Countering Antibiotic Resistance- Learning from the world
In our previous post, we discussed the numerous problems posed by the antibiotic resistance to the entire world. As we mentioned, the situation is severe in BRIC countries-Brazil, Russia, India and China- but other developing countries are not better off. In fact, in some places, the ‘post-antibiotic’ era which we talked about has already arrived. In Nigeria, for instance, some studies suggest that as many as 88% of Staphylococcus aureus infections, which cause diseases in the respiratory tract, cannot be treated with methicillin — once a potent weapon against the microbe. It is imperative to find the underlying cause for this problem in developing economies. A recent appeal by British Prime Minister David Cameron on July 2 highlights the need to stay away from the ‘dark ages of medicine.’
Resistance on the rise
Research carried out by medicine experts of Cardiff University, UK suggests that in the Indian subcontinent itself, up to 95% of adults in India and Pakistan carry bacteria that are resistant to ‘last resort’ antibiotics such as carbapenems. By comparison, only 10% of adults in the Queens area of New York carry such bacteria. This spread in the Indian subcontinent has been unprecedented. However, the harsh reality is that researchers have been unable to pin point a particular cause for this epidemic-like situation.
One likely culprit is lack of sanitation. In many areas, waste water from hospitals is poorly filtered, allowing the antibiotic-resistant bacteria that flourish there to escape into waterways. If people drink this contaminated water or practice poor hygiene, the bacteria can spread. Bacteria develop in these wastes and soon develop resistance to potent drugs due to genetic alteration in hospital waste. When these bacteria end up in the human body, they can create havoc. This bio magnification- the process due to which a simple bug becomes deadly after being passed through several stages of the food chain- has been well documented. Since filtering out the antibiotic residue from medical waste is largely dependent on infrastructure, it is clear why the problem is so common in developing countries. Healthcare is often the most neglected domain in developing economies and this has been one of the greatest perpetrators.
Over prescribing or unregulated use of antibiotics is one of the greatest culprits. In China, for instance, hospitals and clinics receive financial incentives for prescribing which leads to an overuse of antibiotics. Some countries even allow pharmacies to sell antibiotics without prescription and people buy them even for diseases that antibiotics cannot treat, such as malaria. Clearly, lack of awareness and education, along with indiscriminate prescriptions has added to the untimely arrival of the post antibiotic era. In many places, patients don’t trust their doctors and force them to prescribe antibiotics. This is prevalent In India and if such reports are to be believed, then the buck doesn’t stop with doctors.
Limited access to basic medical care is one reason for the overuse of carbapenems and other second-line antibiotics. About 70% of India’s 1.2 billion citizens live in rural areas, where, despite government efforts, hospitals are often under-staffed and lack basic equipment and medication. Rather than relying on physicians, many rural patients turn to local pharmacists and whatever drugs they have in stock.
An explanation for trans-oceanic spread of superbugs lies in human migration. Patients from developing countries migrate to developed countries such as USA and the UK, which has led to an even wider base of antibiotic resistant bacteria. Antibiotic resistance exists in these developed countries too, but the spread of superbugs such as the aforementioned NDM-1 can be attributed largely to the migration of people. In most cases, the migrants don’t even know they are infected. In fact, some cases reported in the UK showed that a few patients who contracted infections due to superbugs had just shook hands with people returning from the Indian subcontinent. This is a disturbing revelation.
It is for these reasons why researchers do not know what factors have caused resistance to grow so rapidly in developing nations. Another possible cause might be the use of antibiotics for growth promotion in livestock, although it remains controversial. Solving these problems clearly requires better monitoring of drug resistance. The WHO report proposes a new global surveillance network, although it is not clear who would pay for it.
What has the world done to counter the Resistance?
In September 2012, Indian physicians moved a step closer to their goal of countering the threat of antibiotic resistance when India’s drug regulators announced a plan that would put tight restrictions on the sale of antibiotics. Carbapenems and many other antibiotics are already on a list of 536 drugs in India that require a prescription. Studies had shown that such drugs were easy to purchase at retail pharmacies without a physician’s signature. However, under the new regulations, carbapenems and other antibiotics with declining efficacy would be treated as a special category of prescription drugs. They would carry prominent red labels, and surprise inspections by the regulator would check whether pharmacies were selling them over the counter.
In 2010, India’s government created a task force to develop a national antibiotic policy. But the task force’s recommendations to ban over-the-counter sales of antibiotics and prohibit the use of carbapenems and other second-line antibiotics except in major hospitals were rejected by the Indian health minister, Ghulam Nabi Azad in 2011. Azad argued that the bans could have a devastating effect on health in rural areas.
Taking cue from the above mentioned directive by the WHO, some other countries are trying to take those lessons on board. Hospitals in Israel now practise ‘active surveillance’, meaning that if a new patient has been to any other health-care institution in the past six months they are checked for potential superbugs. Anyone who tests positive for such bacteria is flagged as a carrier in national-health records, which are accessible to hospitals, nursing homes and community physicians. France and the United Kingdom follow similar rules, but unfortunately many countries do not. It is high time developing countries adopted these rules to monitor the spread of these superbugs.
Meanwhile, lab-detection methods have also improved. Labs are now required to use whole-genome sequencing instead of genome sequencing to avoid missing out on superbugs. This means that the complete DNA sequence of an organism’s genome at a single time is analysed and additional information on genetic relationships, origin or susceptibility to specific diseases is pointed out.
The harsh truth is that new drugs will not be available in the market any time soon. Perversely, the rapid advance of resistance and the consequent need to use these drugs sparingly has convinced pharmaceutical companies that antibiotics are not worth the investment. In fact, even if the world sees new types of antibiotics, they might not offer the help that is expected of them. They are likely to be expensive and unaffordable in the developing world. More importantly it is all but inevitable that new drugs will eventually lose their potency, too.
Consequently, awareness needs to be created, especially in rural areas of developing countries. Antibiotics need to be consumed for the entire course and reckless use needs to be stopped. Antibiotic soaps available in USA and the UK have helped and need to be introduced in developing countries as well. However, it is of utmost importance that governments of developing countries show more interest in their countries’ healthcare. Recent protests by Brazilians during the FIFA World Cup have highlighted the apathetic state of their healthcare. The situation is the same in India and China. Better infrastructure is needed with which we can filter out harmful waste before getting rid of it. With a growing rural population, infrastructure, mass intimation and development of cheap antibiotics are important, but the most important thing is sensible and cautious use of antibiotics.