The experts warn

'Antimicrobial resistance: Global report on surveillance' by WHO: "A post-antibiotic era—in which common infections and minor injuries can kill—far from being an apocalyptic fantasy, is instead a very real possibility for the 21st century."

Dr. Abdul Ghafur K: When we are called to manage patients with severe infections due to pan resistant bugs, we do really wonder whether we are living in pre-Alexander Fleming years without antibiotics and then with a shock, but no surprise, realise that we have reached the end of antibiotic era. Still, the Indian medical community remains in a state of denial. We have not yet taken the issue of antibiotic resistance seriously. We believe that Dr. Fleming has discovered penicillin only early this morning and consider antibiotic resistance a problem of next century where in fact antibiotics are dead and the foul smell of decay is already around us. You may call me a pessimist, but I sincerely believe that it is too late to save antibiotics; unless you have divine powers to bring the dead back to the life.

Cesar A. Arias and Barbara E. Murray: It is more difficult than ever to eradicate infections caused by antibiotic-resistant “superbugs,” and the problem is exacerbated by a dry pipeline for new antimicrobials with bactericidal activity against gram-negative bacteria and enterococci. A concerted effort on the part of academic researchers and their institutions, industry, and government is crucial if humans are to maintain the upper hand in this battle against bacteria — a fight with global consequences.

Tuesday, December 23, 2014

Antibiotic abuse: How we are losing the most potent arsenal of modern medicine


(First published in Republica Daily on Dec 23, 2014)
Antibiotics are one of the marvels of medical science. Commercial availability of antibiotics in 1940s put an end to relentless suffering of mankind from bacterial infections.

Sir Alexander Fleming, the discoverer of antibiotics, had made the following cautionary statements on June 26, 1945, in The New York Times, “The microbes are educated to resist penicillin and a host of penicillin-fast organisms is bred out. In such cases the thoughtless person playing with penicillin is morally responsible for the death of the man who finally succumbs to infection with the penicillin-resistant organism. I hope this evil can be averted.” But the evil is still being perpetrated after all these years. Deaths out of infections resistant to all available antibiotics are increasingly being reported these days. 

Our whole environment is permeated with bacteria and other microbes. Within minutes to hours of coming into this world a baby is covered by millions of bacteria. Thankfully, except for a few, bacteria are harmless or rather helpful in some contexts. When infection occurs, only one or two types of the pathogenic bacteria are responsible. The standard practice in treating these infections is to ascertain the bacterial infection, prescribe a supposedly effective antibiotic and at the same time investigate for exact bacterial etiology and antibiotic sensitivity. But often in common practice, antibiotics are used without confirming the bacterial infection and without the guidance of antibiotic susceptibility reports. 

Doctors usually prescribe antibiotics based on non-specific signs and symptoms of a probable bacterial infection. In our country antibiotics are also commonly used on the recommendation of pharmacists or by patients themselves based on their prior experience. These practices lead to overuse of antibiotics. When we use antibiotics, by no means can we target the specific bacteria that are causing the infection; all the bacteria that are susceptible to the antibiotics will die out and the resistant bacteria will be left behind. 

These bacteria then get carried and transmitted here and there. Every time we use antibiotics we clear grounds for resistant bacteria to flourish.

Bacteria are a very dynamic population. Since they divide rapidly and are present in very high numbers there is high opportunity for rapid genetic changes in response to external stimuli. This is the reason why common bacteria and their antibiotic sensitivity patterns can differ among two localities, two hospitals in a locality and two units within the same hospital at the same time. Antibiotic therapy should thus be based on current local microbiological data. 

The science of microbiology, heavily invested upon by the brilliant scientists and medical practitioners of the time, had produced antibiotics that is one of the greatest gifts to mankind. Ironically, the science itself was shadowed by its own product. In most areas of the world clinical microbiology never flourished. Antibiotics, the mere profit earning novel products for the business world, were aggressively marketed to every nook and corner of the world but the need for microbiological laboratories were never felt. In many countries, including ours, antibiotics can be bought in pharmacies without prescription and used arbitrarily. For many years the world willfully wallowed with the antibiotics. Eventually, what was feared followed, the reign of antibiotic resistant microbes.

Because of the high antibiotic pressure from the rampant antibiotic use, antibiotic susceptible bacteria died out and resistant bacteria took their place. In day to day life, many of us have heard people describe how simple antibiotics stopped working for them and that they use stronger antibiotics now. Especially in hospitals, bacteria have become highly drug resistant with often one or two antibiotic choices and these last resorts are usually very expensive and toxic. The problem of antibiotic resistance is multifaceted; facts are scary, current scenarios disturbing and the path ahead starkly arduous.

It is already too late to take initiatives against antibiotic resistance but nothing considerable has been done. Questions have been raised but seldom answered. Not only the patients and the antibiotic sellers but many clinical practitioners themselves do not realize the depth of the problem and the real danger building up. Time has come for all the stakeholders to identify the root causes of antibiotic misuse, discourage them and lay the foundation to support proper antibiotic use.

Over-the-counter buying and selling of antibiotics without prescription should be completely stopped. In places where doctors are not available, authority can be transferred to those with highest level of training. We have seen that distribution of sedatives has been fairly regulated in this country and there is no reason why the same cannot be done with antibiotics. Clinical practitioners should be updated and medical students and residents should be adequately educated on proper antibiotic use. 

Antibiotic use should always be supported by adequate and up-to-date microbiological evidence. For this, microbiology laboratories should be developed in adequate numbers throughout the country. Exaggeration of symptoms, bargaining with the doctor for strong remedies or guaranteed treatment encourages antibiotic use thus the patients are advised to keep calm with the common infections. Most of these are viral in origin or self limiting and do not require antibiotic use. It is the antibiotic user who pays all the prices. General public should make themselves aware about the different aspects of antibiotic use, misuse and the consequences. 

Thanks to the dynamism of the bacterial population, the problem of antibiotic resistance is not an irreversible one. Some antibiotics which were no longer used owing to the resistance are now found to be effective. Most of the developed countries have successfully implemented measures to bring down the problem of antibiotic resistance. Most of us were born in the world with effective antibiotics and no fear of dying out of a bacterial infection. It will be a shame to be alleged in history as the generation who wasted all the antibiotics. Moreover, it will be painful to see our loved ones die in lack of antibiotics we wasted.

The author is a Resident at the Department of Medical Microbiology, Tribhuvan University Teaching Hospital. 

This article has been carried here in public interest for purely non-commercial purpose. With gratitude to Republica. 

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