Dr. Shyam P Lohani

IT is not uncommon that a patient with once commonly treatable infection succumbs to death in an intensive care unit (ICU) and the health professional increasingly becoming helpless. This is the situation frequent in hospitals throughout the world including Nepal. Once a miracle drug, antibiotics have revolutionised modern medicine and have saved millions of lives. The invention of penicillin transformed infectious disease management in the early 20th century. Within a century, it has turned into one of the greatest medical challenges.
Antibiotics are the group of drugs used to prevent and treat infections caused by bacteria. These drugs either stop the multiplication of bacteria or kill them. Due to various reasons, these drugs once highly effective to treat even serious life-threatening infections caused by bacteria are increasingly becoming resistant.

Effectiveness
Antibiotics are becoming ineffective as drug resistance spreads globally leading to more difficulties in treating infections and death. The reasons for bugs to gain resistance are multiple ranging from underuse, overuse to inappropriate use. Antimicrobial resistance (AMR) is now a global threat. Its emergence rests on antimicrobial overuse and/or underuse in humans and food-producing animals; globalisation and suboptimal infection control measures facilitate its spread.
The antibiotic-resistant infections are currently implicated in 700,000 deaths each year and the costs incurred to some $100 trillion. By 2050, drug-resistant infections will kill an additional 10 million people a year worldwide of which 4.7 million in Asia alone. Common infections such as pneumonia, gonorrhea, tuberculosis, typhoid and food-borne diseases are becoming resistant to common first-line antibiotics and are harder to treat and sometimes even impossible to treat. The situation has already indicated that we are running out of effective antibiotics. The list of resistant bugs is ever increasing globally. The emergence and spread of resistance need to be taken as a global public health emergency. The situation is even worse in countries where the prescription is not necessary and antibiotics are sold over the counter in pharmacies.
A lack of infection control policies and treatment guidelines largely result in over prescription as well as inappropriate use by consumers. Large percentages of prescriptions are unwarranted even in countries where a prescription is mandatory for antibiotics. Moreover, the emergence and spread of antibiotics resistance pathogens invariably limit our ability to treat common infections.
Antibiotic resistance refers to bacterial strains which are changed or are not effectively controlled by first-line antibiotics. In other words, antibiotic resistance is the ability of bacteria to survive the effects of an antibiotic. This occurs naturally i.e., the development of resistance is a normal evolutionary process for microorganisms but misuse in humans, animals, and agriculture often leads to acceleration of the development of resistance.
Other aspects of antibiotic use are also responsible for the rapid emergence of antibiotic resistance. Banned in many countries, antibiotics are still used as a growth promoter in food animals, suboptimal use in the poultry industry; aquaculture and beekeeping have accelerated development of resistance and resulted in the faster spread.
Antibiotic resistance is surely a global threat as it crosses boundaries owing to the increased movement of people across the borders. Infections caused by resistance bacteria not only result in longer hospital stay, increase the cost of treatment, need for more expensive antibiotics but also cause negative clinical outcomes and of course increase the number of death.
At this time, about seven per cent of deaths are due to infections and it may reach 40 per cent as it was in the pre-antibiotic era. Moreover, if prompt action is not taken now, we will find ourselves in an almost pre-antibiotic era where people die from infections resulting from routine surgical procedures. Standard surgical procedures would become far riskier and treatments that suppress the immune system, such as chemotherapy and organ transplants would become almost impossible. Civil war, armed violence, famine, and natural disasters aggravate the situation and scale up the infections in vulnerable areas. Multidrug-resistant bacteria are causing more deaths worldwide.

Approaches
Discoveries of new antibiotics are lagging behind considerably despite the fact that antibiotic resistance is sure to become one of the global public health emergencies. The main reason is that it is not considered a wise investment for pharmaceutical industries. On one hand, antibiotics are used for relatively short periods and are often curative. They are not as profitable as drugs that treat chronic conditions such as diabetes, psychiatric disorders, asthma, and hypertension. On the other hand, the development of resistance is inevitable once the antibiotic is used against pathogenic bacteria causing infection.
The second approach is to use and manage our current antibiotics reservoir judiciously so that they remain effective for a much longer period of time. Judicious use of antibiotics to reduce the global burden of antibiotic resistance is the key. This can be achieved by categorising antibiotics for different levels of facilities and health care professionals and also place few antibiotics on the restricted use list.
Another way of combating drug resistance is to prevent infections. This can be done by simple approaches such as hand washing by healthcare workers, and isolation of patients colonised by multidrug-resistant bacteria, but newer approaches such as disinfection of air by UV are promising, too. As prevention is always better than treating infections, vaccine-based approaches to combat resistance problems are of considerable interest as well.
Our responsibility in combating antibiotic resistance includes but not limited to use antimicrobial drugs only when needed, complete the full prescribed course even if the symptoms have subsided, never share antimicrobials with others or using leftover drugs from previous prescriptions, and not ask healthcare professionals into prescribing antimicrobials when they are not necessary. Good hygiene practices, including washing hands and disinfecting hospitals to prevent the spread of microbes, should be followed. Last but not the least, getting recommended vaccinations to reduce the risk of infection will reduce the need for antibiotics.

(Professor Lohani is the founder and academic director at Nobel College. lohanis@gmail.com)