Anti Bacterial Drug Resistance: Time to Act

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 Anti Bacterial Drug Resistance: Time to Act

Prof. Emeritus Lt. Gen. Mahmud Ahmad Akhtar
Former Surgeon General Pak Army

The rapid rise of bacterial drug resistance has become a global problem. Keeping in view the seriousness of this problem, on 21st Sep 2016 the United Nation’s General Assembly discussed this issue and agreed to develop national action plans to help shore up the effectiveness of the life-saving anti-bacterial drugs in people and animals. They pledged to strengthen regulation and to improve reporting system that track how antibacterial drugs are used. It is feared immensely that due to the loss of anti-bacterial drugs, people may lose life due to simple infections and surgical procedures may not be possible. The problem is further compounded due to lack of development of novel anti-biotic.

The bacteria are very mobile and spread all over the places. The overuse of anti-bacterial in pig-production in China has spawned resistant bacteria that have surfaced in the USA and Europe. Jim-O’Neil, chairman of the British review on anti-bacterial resistance, estimates that 700,000 persons a year die from drug-resistant infections.

In Pakistan the problem is very grave and wide-spread. The bomb in fact, has already exploded. Pakistan being a resource-poor country, also lacking in public literacy, needs to adopt effective measures on emergency basis to tackle the problem-in fact declare anti-bacterial drug resistance emergency. Pakistan has the highest death toll in all age groups starting from still births, newborns, maternal to adult barring a few Sub Saharan countries.

First and foremost Pakistan should set its priorities right. Health and literacy should be accorded top priority and not the lowest which it is accorded presently. Elitist projects like metros, orange-line etc., and serving tiny minorities of the urban population are receiving over-all priority, neglecting health and education of the masses. Even in the health-sector, primary cum secondary health care comprising over 90% of the health-care system, is accorded the least priority while non-cost-effective luxurious tertiary projects receive undue priority. Prevention and health promotion should be the main pillar of the National health policy. Public awareness should be created among the population through all means like media, educational institutions -health being part of curriculum/syllabi, NGOs, INGOs, political institutions, prayer leaders etc.

Taking an example of tuberculosis which is seriously affecting Pakistan’s population. Pulmonary tuberculosis is a common infection in Pakistan. It is easily treatable due to the production of a large number of very effective anti-tuberculosis drugs at very affordable prices- thanks to Herculean work of the western scientists. A patients suffering from pulmonary tuberculosis, if diagnosed in early stage, treated with appropriate combination of anti-tuberculosis drugs in adequate doses for an adequate period (6 months) rapidly becomes non-infectious and is cured. But if not treated properly, the bacteria become resistant, need second line of very expensive and toxic drugs for prolonged periods, i.e. years. The spread of resistant bacteria also causes resistant type of tuberculosis compounding the problem.  In order to prevent it, doctors must educate and motivate patients to adhere strictly to the treatment schedule. Doctors and the team members should regularly check the adherence or in difficult circumstances DOTS regime under supervision should be used.

Misuse of anti-bacterial drugs is a major cause of development of bacterial resistance. In Pakistan, anti-bacterial drugs are sold without prescriptions at many places. There is wide-spread self-medication and misuses indulged by practicing quacks also. Viral infections commonly of respiratory tract are treated with anti-bacterial. Diarrheas, dietetic and bacterial, without significant systemic effect and loose motions without blood/pus are treated with anti-bacterial. Simple skin infection like boils etc. is treated with systemic anti-bacterial. For ordinary simple bacterial infections needing anti-bacterial, first line narrow spectrum antibiotic penicillin V should be used and for uncomplicated urinary tract infections like cystitis, nitrofurantoin should be used. For resistant staphylococcal infections, cloxacillin/fluocloxacillin should be used.  Unfortunately these essential affordable life-saving anti-bacterial are not available in Pakistan because Pakistan is not implementing the World Health Organization “Essential Drugs List” system. The reason is Pakistan’s problem of corruption and lust for money. Due to the non- availability of the 1st line anti-bacterial drugs, 2nd and 3rd line anti-bacterial are misused causing the problem of drug-resistance and high mortality because many patients cannot afford very high cost of 3rd line anti-bacterial. This is the major cause of Pakistan’s heavy toll of deaths in the World and in all age-groups.

Pharmaceutical companies are aggressively promoting anti-bacterial drugs for irrational uses which should be strictly controlled. Sales of fake and date expired anti-bacterials should be tackled effectively. Prevention of infections should be given utmost importance. Water-borne infections are very common, responsible for over 40% of hospital admissions and deaths.

Hygienic measures like hand-washing with soap, not with antibacterials and sanitizers, clean food, proper sanitation, avoiding open defecation should be practiced. Potable water should be made available. Water should be boiled before drinking etc. Respiratory infections should be prevented by preventing atmospheric pollution and taking effective preventive measures. Hospital infections should be effectively controlled- cross infections avoided. Strict sterilization done in the operation theaters and other departments. Unfortunately in Pakistan hospital infections with resistant bacteria are very high causing enormous morbidities and fatalities. Surgical prophylaxis: For clean operations and clean dental procedures, for infection prone operations anti-bacterial injections may be used during the operations for short duration. Timely immunization should be done antibacterials should not be used. Healthy life style measures should be observed to boost body’s immunological system. There should be restriction on the use of anti-bacterials, for animals which has become a common cause of development of bacterial resistance. It has been recently found that copper based fixtures have 98% less bacterial contamination- these should be used in the buildings fixtures.

In the medical institutions there should be departments of clinical pharmacology/ clinical therapeutics like the departments of cardiology, pulmonology, gastroenterology etc. These departments job is to formulate drug policies/ anti-biotic policies, guide-lines on rational uses of antibacterials and to carry out therapeutic audits and clinical trials. Anti-bacterial drugs should be judiciously chosen, used in proper dosage and for adequate periods, therapeutic audits and in association with microbiology department, carry out sensitivity tests-educate medical personnel on the uses and misuses of anti-bacterial drugs. If adequate measures are taken, the problems of anti-bacterial drug resistance can be tackled and lives can be saved.

From the Centers of excellence the information passed on regularly to the doctors and the public. Every hospital/institution should have anti-bacterial therapy guidelines based on clinical conditions and sensitivity tests. There should also be antibiotic policies at the Provincial and Federal levels. If adequate measures are taken not only morbidity/mortality will be minimized but also scarcely available funds will be saved.

WHO has issued a fresh warning on Feb 27th that a dozen super bugs pose an enormous threat to human health and urged hospital infection control experts and researchers to focus on fighting the most dangerous pathogens first- the top priority. It further pointed out that we are fast running out of treatment options and if we leave to market forces alone the new antibiotics we must urgently need are not going to develop in time. Britain’s chief medical officer described drug resistant pathogens as a national security threat equivalent to terrorism. Dr Thomas R Frieden, the recently retired director of the disease control and prevention called them one of our most serious health threat. A recent study has revealed that drug resistant infections in children had increased seven folds in eight years.

The WHO report rated research on three pathogens as “critical priority”. They are carbapenem- resistant Acinetobacter baummannii and Pseudomonas aeruginosa along with all members of enterobacteriaceae family resistant to both carbapenems and third generation cephalosporins. The medicine priority is given to drug resistant versions of strep pneumonia, haemophilus influenzae and shigella, all of them cause common infections in children. For developing countries tuberculosis is also a major problem.