Subash Subedi
Antimicrobial resistance occurs when bacteria mutate and become resistant to antibiotics used to treat the infections they cause. It is one of the biggest global public health challenges. As of present at least 700,000 people die each year due to drug-resistant diseases, including 230,000 people who die from multidrug-resistant tuberculosis alone. It is also estimated that the failure to address the problem of antibiotic resistance could result in 10 million deaths by 2050 costing 66 trillion euros. Bacteria are developing antimicrobial resistance up to the point that few among innumerable bacteria are resistant to all the currently available antibiotics. It is hard to imagine a world without antibiotics and harder without an efficacious one.
Numerous accidental discoveries have proven to be a miracle for humankind that revolutionized the entire world of medicine. One of them is the discovery of Penicillin in 1928 by Sir Alexander Fleming that marked the beginning of the antibiotic era. Before the discovery of antibiotics, Bloodletting was used as one of the medical therapy for infections which was done by making an incision on a vein/artery or using leeches. A minor paper-cut or anything that leads to infection could result in death easily. The average life expectancy at birth was 47 years in the pre-antibiotic era which rose to 78.8 years in the antibiotic era. Antibiotics have transformed our healthcare system radically but we tend to forget that it was discovered less than a century ago.
Alexandar Fleming back then also warned that bacterial resistance had the potential to ruin the miracle of antibiotics and this biggest fear is turning into reality considering the current scenario of antibiotic resistance. Bacteria develops antibiotic resistance mainly via antibiotic modification i.e. enzymatic breakdown of antibiotic making it inactive, alteration in primary site of action by structural change in molecule, production of an alternative target that is resistant to inhibition by the antibiotic and by preventing the antibiotic from entering the cell or pumping it out faster than it can flow in.
A growing number of infections such as pneumonia and tuberculosis are becoming harder to treat as the antibiotics used to treat them has become significantly less effective thereby increasing recovery time, hospital stay and eventually death rate. So, is this the beginning of the end of the antibiotic era? Maybe. We could be on the verge of the antibiotic pandemic if the increasing rate of resistance goes unchecked.
Antibiotic resistance occurs naturally, but the misuse of antibiotics in humans and animals is accelerating the process. With a high incidence of infectious diseases, poor healthcare system, inappropriate use of antibiotics in treatment and lack of proper infection control and preventive measures, Nepal is becoming one of the major contributors to the increasing global burden of AMR.
Widespread irrational use of antibiotics is one of the prime reasons for the growing burden of antibiotic resistance. Due to the low number of physicians to population (1:1724) and uneven distribution of doctors in the country, most Nepalese are obliged to visit the pharmacist and health assistant for primary health care services. This situation has favored empirical therapy as a method of treatment which leads to unnecessary and overprescribing of antibiotic.
Self-medication is another common practice that contributes to resistance against antibiotics. Most of the people take antibiotics without prescription of the doctor based on their past experience of self-medication. There is a widespread practice among the commoners where the medication is stopped after 2–3 days when symptoms start to subside. As a result, compliance with the treatment prescribed by physicians is reduced and thus there is absolute failure to follow a full course of treatment. Most of the individuals also then store leftover medicines for future self-medication. These ignorant behaviors not only prolong the duration of illness but also contributes to the emergence of antibiotic resistance bacteria. So, antibiotics should be consumed strictly as per the prescription of a doctor only.
Antibiotic resistance is also caused partly by excessive antibiotic prescribing. Several studies of antibiotic prescribing patterns in Nepal have shown most patients were unnecessarily prescribed more than one antibiotic concurrently without confirmation of bacterial infection or susceptibility testing. Overprescribing including for viral infection upon which antibiotics have no effect is also increasing which reflects our behavior of prescribing antibiotics without proper indication. One of the common problems faced by physicians all around the world is that the patients insist them to prescribe antibiotics. This practice has further enhanced the unnecessary use of antibiotics as well. According to the study, it is shown that 97% of the patient do not accept antibiotic prescription if explained thoroughly by doctors. So, proper patient counseling will help a lot to cut down antibiotic usage if not necessary.
Most of us as well as medical professionals are aware of the antibiotic resistance but not about the gravity of the issue. So it is of utmost importance to provide training and education to medical practitioners as in general, medical professionals are likely to alter their practice patterns only when their knowledge, beliefs, attitudes, and skills are aligned with the intention of reducing antibiotic resistance. Since most of the Nepalese are provided primary health care services by health assistants and pharmacists, it is equally important to make them aware because they prescribe antibiotics as much as the physicians if not more. The trend of prescribing an unnecessary antibiotics is so deep-rooted in our clinical practice, we will definitely be having difficulties in controlling this behavior. It is also challenging to optimize the use of antibiotics maintaining the quality of treatment but is not impossible.
Another major reason for the emergence of drug-resistance superbugs is an extreme abuse of antibiotics in cattle, pigs and poultry as growth promoters and to minimize production losses. Antibiotics must be given to animals under veterinary supervision and avoided for growth promotion or to prevent diseases.
But the good news is that although the development of new antibiotic has slowed down in recent years, World Health Organization has made it a priority to develop novel treatments. The Program on the Global Action Plan on Antimicrobial Resistance by the World Health Organization (WHO) is working with the mission of reducing the wave of antibiotic resistance. Scientists are working on the possibility of Phage Therapy (use of virus to treat bacterial infection) as an alternative to antibiotics to kill resistant bacteria which could be a promising new avenue to combat bacterial infections. There are also several projects going on for the development of vaccines for common infections that can help prevent the disease in the first place.
While we are progressing forward because of scientific advancement and technologies in health care, are we stuck or leaping backward at the same time as modern medicine could become obsolete without urgent action against antibiotic resistance?
Not every infection requires antibiotics. As Dr. Tom Frieden accurately mentioned that If we use antibiotics when not needed, we may not have them when they are most needed. So when not required, Take Care Not Antibiotics.
(Subedi is medical student at Chitwan Medical College Teaching Hospital.)
