Get ready for a long term battle with bugs
View(s):Humans have been continuously battling thousands of different bacteria throughout history with outbreaks, fear, economic loss and death. Despite being armed with all our sophisticated medical knowledge and antibiotics, we still struggle to win the war. It is surprising how fast the bacteria learn to develop resistance to even newly developed antibiotics and it is a real challenge to treat infections caused by multi drug resistant (MDR) bacteria.
Since the discovery of penicillin by Alexander Fleming in 1928, then identification of penicillin resistant Staphylococcus aureus in 1942, we have now come to an era of MDR common bacterial pathogens such as Typhoid bacilli, Streptococcus pneumoniae (causing pneumonia, and meningitis), Neisseria gonorrhoeae (gonorrhoea), Shigella (food poisoning), and Mycobacterium tuberculosis and pan drug resistant hospital superbugs such as Acinetobacter, MRSA, Pseudomonas and coliforms. Successful treatment of the infections caused by these bugs needs expensive and broad spectrum antibiotics, prolonged hospital stay with ICU care and a multi-disciplinary team of specialists which will cost the state millions of rupees and even after weeks or months you cannot always expect the outcome to be good.
What causes antimicrobial resistance? Irrational or inappropriate antibiotic use and prescription has been a topic for extensive discussion among clinicians without very favourable results due to several reasons. Many people still believe that antibiotics can cure or reduce their common cold or flu which is not true; in fact it may prolong the suffering as the antibiotic would kill the friendly bacteria living on our upper respiratory tract, suppressing the invading viruses causing common cold and flu. Many people may demand an antibiotic for their flu at the visit to the general practitioner. Many think the longer the list of medicines prescribed, the better the outcome, but this will cause a lot of side effects needing more and more drugs to relieve them.
Another major problem is over-the-counter antibiotic availability without a doctor’s prescription. Use of antibiotics such as tetracycline, chloramphenicol, ciprofloxacin and amoxicillin in animal husbandry, aquariums, farming and sometimes agriculture has caused them to be added to our food chain making our gut associated bacteria multi-drug resistant. Some patients present with infections by MDR bacteria without any prior antibiotic treatment or hospitalization. That can be linked to the resistance passed through the food chain.
The availability of cheap, poor quality antibiotics in the market, poor surveillance systems, poor infection control practices and limited facilities for a quicker and reliable diagnosis are the other major factors causing emergence of drug resistance.
Hence, now it is the time for action. How can we combat antibiotic resistance? There are several steps which can be taken at the state level, hospital level, and the individual level.
Awareness programmes, articles and posters for the general public on correct antibiotic use will reduce the demand and make people aware of their side effects, of the suffering related to the infections by resistant pathogens and the cost they have to pay with money and lives. All doctors should also be aware of correct indications for antibiotic prescription and not issue them to satisfy the patient. Further, they should be aware of the correct dosage, frequency, administration and the correct duration for each and every antibiotic as these are also critical in reducing the resistance and yielding successful outcome.
Political involvement in development of a national policy on antibiotics is crucial in combating resistance. Banning the use of antibiotics in animals and agriculture and rational use in humans should be implemented. The government should enforce the existing law against over-the-counter antibiotic issue and should arrange campaigns to encourage rational antibiotic use and infection control with adequate funding.
A good example of government involvement is American President Barrack Obama’s 1.2 billion dollar plan for a broad attack on resistance in 2015. He stated, “the evolution of antibiotic resistance is now occurring at an alarming rate and is outpacing the development of new counter-measures capable of thwarting infections in humans” which shows how he has understood the magnitude of the problem. Some US medical societies have even published guidelines against antibiotic treatment: e.g. “watchful waiting” for patients with sinusitis regardless of severity and no antibiotics for asymptomatic bacteriuria. Further, the US has now taken measures that their hospitals should have an antibiotic stewardship program as a condition for payment.
In Sri Lanka, a set of antibiotic guidelines prepared by the Sri Lanka College of Microbiologists (SLCM) in collaboration with other relevant professional colleges was issued as Health Ministry circulars in 2015. SLCM is also conducting a multi-centre, prospective antimicrobial resistance surveillance project (ARSP) fulfilling a long term need for a proper data base on the subject with awareness programmes conducted throughout the country for all health care workers. All microbiologists provide a 24-hour service for opinion on antibiotics and infection control issues in health care settings islandwide.
- Improving point-of-care diagnostic testing of an infection will reduce unnecessary antibiotic use for each and every infection on admission to a hospital. Rapid diagnostic kits can be introduced which are cost-effective and easy to use.
- Every hospital should have a good infection prevention and control team which will make policies and guidelines on infection control, conduct surveillance for multi-drug resistant pathogens and hospital acquired infections, be involved in outbreak management, arrange awareness programmes for health care workers, and conduct evaluation and appreciation of the good practices. Controlling infections will certainly alleviate the problem of emerging resistance.
Antibiotic resistance has only little motivated the pharmaceutical industry to make new broad spectrum antibiotics for several reasons. Since the 1970s, only a few new antibiotics had been issued to the market till 2000. The relatively short duration of therapy with antibiotics especially compared with anti-diabetics or anti-hypertensives, is seen by many companies as less profitable, and often they have a strong competition from low priced generics in the market.
Further making the situation worse for them, many antibiotics would last only till the bugs develop resistance and many expensive drugs will be used by the clinicians as the last resort failing more affordable drugs. Many companies are reluctant to go in for developing new antibiotics spending millions of dollars in clinical trials and going through unfriendly regulations for the authorization, achieving only little in the end.
- Vaccines play a critical role in prevention of several serious infections such as meningitis, pneumonia, influenza and many others; hence it is a way of escaping from resistant pathogens. Improvement of existing antibiotic classes to overcome the resistant barriers and to find alternatives for antibiotics in treatment for infections are also being considered as potential solutions.
Making bacteria a MDR pathogen is extremely easy but infections caused by such bacteria will often result in huge costs, fear, suffering and loss of valuable human life. Unless we act today, there will be no tomorrow for mankind. Therefore it is the responsibility of every person to support the long-term battle with the bugs and to combat antibiotic resistance.
(The writer is a Consultant Microbiologist, Head of the Department of Microbiology and Infection Prevention and Control, Teaching Hospital Karapitiya. This article is based on a lecture given by her at the annual academic sessions of the Galle Medical Association in October 2015)