- by Dr. Naseem Salahuddin

The crisis of antibiotic resistance has been a rising storm the world over for several decades, but has become a burning issue in recent years. The global problem has become our problem and this battle has arrived at our doorstep.

As healthcare givers we have become acutely aware of the rising trend of drug- resistant microorganisms (DRMOs). Today, we can no longer treat typhoid or urinary tract infections with oral antibiotics as we once did with the confidence that the infection will be eradicated, and the patient cured. Hospital acquired infections are on the rise with highly DRMOs that either do not respond at all to antibiotics, or do so at the expense of high cost of drugs and prolonged hospital stay. Hospital acquired bacteria are generally different from community acquired bacteria. They are more aggressive and spread easily in hospitalised patients via contaminated hands of patients, nurses or doctors, or equipment used on patients. As a consequence, the germs residing within the crucibles of the human body exchange resistance genes within their own species, and cause outbreaks of drug resistant infections

Multidrug resistant TB (MDR) is proving to be our most feared enemy. Even twenty-four months’ use of toxic drugs does not guarantee cure, while the use of extensively drug resistant TB (XDR) leaves little or no hope of cure, and at the same time transmits relentlessly into the community.

Here are some reasons why this may become a valid prediction- unless we sit up and take note of this prophecy:

There is a dramatic increase in the prevalence of superbugs, and there is equally a drop in the number of available antibiotics. Bugs have developed their own weaponry to fight chemicals; there are no new antibiotics on the horizon. We are simply recycling old drugs, or re-naming them, while deluding us into the belief that increasing dosages, combining several antibiotics, or rethinking pharmacokinetics and pharmacodynamics, will kill bacteria. Indeed they may, but at the cost of wiping out normal friendly flora, which leads to super infection, prolongation of hospital stay, financial drain, side effects and sometimes will not even produce the cure. Medical journals are replete with instances of mortality due to DRMOs. Physicians have become helpless onlookers as deaths in our hospitals from untreatable bacteria are on the rise.

We have overused antibiotics in the community. A scratchy throat, a cold, or a bout of diarrhea, are almost always of viral origin, and yet the sufferer is prescribed an antibiotic or two plus a bagful of multivitamins, antipyretics and probiotics. The antibiotics do nothing more than create side effects, destroy normal body flora and escalate expenses.Doctors try to convince themselves that the patient demands antibiotics. Most patients would be happy with only supportive care and explanation with a dose of sympathy.

There is no control on dispensing of antibiotics. One can walk into a grocery store and verbally demand a cephalosporin, a quinolone or a glycopeptide, and a semi literate shopkeeper will hand you anything that you ask for. There is no legislative policy to stop the sale of over the counter drugs of any kind.

There is no effective infection control in our hospitals. Cleanliness on our streets, premises, homes, work places and hospitals is not one of our virtues. Hospital waste lies strewn, infected needles and syringes are discarded and reused, invasive procedures are performed without regard to hygiene. Most hospitals do not have central sterile services departments (CSSD), and so surgeons believe in using strange cocktails of antibiotics for days at end, in the mistaken belief that these will protect from infection.

“Bad prescriptions” actually originate from bad diagnoses. Not all fevers are caused by infection. The unfortunate fact is that most doctors do not keep abreast of medical literature;rather, they are under selective pressure from pharmaceutical detail persons for prescribing their products. Their students and observers replicate their bad practices. Diagnosing fever cannot be done in a hurry, one must take at the very least,a detailed history and examination before considering management. 

MDR and XDR TB are monsters of our own creation. Anti TB drugs are often incorrectly prescribed, improperly taken or substandard drugs are consumed. The result is selective drug pressure and emergence of resistance. Not only is it dangerous for the patient,but also transmission of MDR TB to the community is a grave public health hazard

Many substandard laboratories churn out substandard or fake reports. Certain blood tests for typhoid or TB are of no diagnostic value, and yet they are widely used in almost all commercial labs in the country. Diagnosis should be evidence-based through correctly ordered lab and radiology tests. Often, the poorly educated doctor prescribes antibiotics or anti TB drugs for weeks or months, where none was even required.  Not only is the real diagnosis of fever obscured, the extended use of an antibiotic selects for drug resistance.

Antibiotics are fed to livestocks for fattening animals.Unsuspecting humans indirectly consume small amounts of antibiotics in tikkas and kababs. Antibiotics from the meat of animals are absorbed into the human body and can create drug resistance as well as possible allergic reactions.

So what is to be done? How do we revert to the good old days when bugs could be killed easily without fuss? What can hospitals, pharmacies, communities, professional societies, or individuals do to control drug resistance? I believe there are solutions. And we hold them in our hands, but only if we believe in the importance of antibiotic control.

“Antibiotic Stewardship”(AS) has become a buzzword in health care all over the world, and it encourages the prudent use of antibiotics, and discourages their random and irrational uses. The Medical Microbiology and Infectious Disease Society of Pakistan (MMIDSP) has pledged to take the issue seriously, and to spread the notion nationally. It may already be late, but it is better late than never. It is suggested to apply a two -pronged approach: institution- based and community- based.  

The concept of institution-based control is to introduce AS in as many hospitals across the country as would be willing to participate. Training is imparted through workshops, conferences and lectures to train doctors on prudent selection of antibiotics for prevention and treatment of hospital-acquired infections and for prophylaxis before surgery. Ideally, every institution should have adequate lab facilities for microbiology, trained nurses in infection control, pharmacists with expertise in antimicrobials, and infectious disease consultants. Most hospitals in Pakistan probably do not have this quorum, but one can make a beginning. The most important factor is to get agreement and support of the administration. 

The second arm is to raise awareness in the community among doctors and general public about the harm created by irrational use of antibiotics. The two most common conditions of misuse are in respiratory illnesses and acute diarrheas where only symptomatic treatment suffices. Simply restricting antibiotics in these two ailments would reduce misuse by over half. Advocacy, teaching and convincing doctors and the common man is a challenge, but one hopes to publicise with the help of guided lectures, pamphlets, posters, and print and television media.

Other issues have to be taken up with pharmaceutical industry and pharmacists, as corporate businesses are involved.Other channels would be: restriction of over-the -counter prescriptions, encouraging training of microbiologists and high calibre laboratories, and most importantly, to make AS part of medical curricula, and mandatory continuing medical education for established clinicians. These are difficult challenges in our prevailing cauldron of other health problems. To advocate major shifts in practices of veteran clinicians is unrealistic through a lone voice. It needs strong support and endorsement from professional societies, medical colleges, WHO, Ministries of Health, Drug Regulatory Authority, Research Councils and others, to make this transformation that will lead to better patient care.

The unregulated, unchecked and irrational use of this double-edged sword is bound to create serious health problems and incurable infections. The onus is on each one of us to protect our environment and ourselves from the terror of drug resistant bacteria. Otherwise we might become helpless victims in another kind of war.

Bacteria are living, dynamic and evolving organisms. Just like human beings, they become defensive when threatened. When challenged, they fight their own battle for survival.

Dr. Naseem Salahuddin is Prof of Medicine and Head Department of Infectious Diseases, The Indus Hospital Karachi