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June 20, 2017

The unchecked antibiotic


June 20, 2017

The world’s borders are in flux: mass migration has been brought on by an unrelenting war and a general discontent at one’s existing conditions. These factors – compounded by the devastating effects of climate change, famine and water scarcity – have created a humanitarian crisis which has never been seen before.

As governments are under pressure to address these challenges in today’s world, a beast, which has been threatening to rear its head for years, may finally be ready to awaken from its slumber: antimicrobial resistance.

Microbes are ubiquitous: they are found both inside and outside our body. Microbes, which cause severe diseases among certain at-risk populations, usually exist in harmony with our body processes. It is only when one or more of these processes are disrupted that they can cause diseases. These virulent, pathogenic microbes have traditionally been treated by using antibiotics.

The first antibiotic, Sulfanilamide, was developed in Germany in 1932 and ushered in a new era in the research and development of antibiotics. Subsequent decades saw the development of many compounds that were active against the different classes of microbes: bacteria, viruses, fungi and parasites. New modalities in disease therapy greatly improved human health and saved millions of lives. Antibiotics were heralded as the miracle drug. It was believed that the new era of healthcare would eradicate all disease.

However, evolution had other ideas. With the eradication of drug-susceptible microbes, evolutionary pressure to select drug-resistant microbes has increased. Widespread and improper antibiotic use resulted in more of these drug-resistant microbes being selected. This has occurred to the extent that these microbes evolved ingenious tools to help them resist antibiotics to the point that they developed resistance to an entire group or class of antimicrobials.

Fortunately, there were a large number of novel antibiotics at the time to choose from that worked in different ways against the microbes. As a result, if one microbe was resistant to a specific group of antibiotics, it was still susceptible to another. However, evolutionary processes have resulted in microbes developing resistance against multiple classes of antibiotics. A good example is tuberculosis.

No new major types of antibiotics have been developed against bacteria for the past 30 years. Pharmaceutical firms simply do not find it feasible to invest billions into research to develop novel antimicrobials. As the existing arsenal of antimicrobials becomes more and more outdated – coupled with an army of ‘superbugs’, ie multi-drug resistant highly lethal organisms that are already on the horizon – we may again be headed towards a post-antibiotic era in which common infections and minor injuries may prove to be fatal. This writer has witnessed complications arising from relatively simple procedures, such as appendectomies (the removal of the appendix) and a patient suffering life-threatening blood infection from a surgical incision infected by bacteria that do not respond to even the most broadest-spectrum antibiotics.

Health professionals will tell you that they have always feared this day would come. The WHO has been alive to the danger of drug-resistant microbes for a while now. In 2014, the WHO published a detailed report on the challenges of antimicrobial resistance followed by a global action plan on antimicrobial resistance in 2015 that was adopted by the World Health Assembly. The plan proposed the need to increase awareness and education regarding antimicrobial resistance, strengthen the knowledge base through research and surveillance, adopt infection control measures, optimise antibiotic use and invest in researching new antibiotics, vaccines and diagnostic tools.

As far as Pakistan is concerned, the threat of antimicrobial resistance must be dealt with on a priority-basis and poses certain other difficulties. Unlike the Western countries that have a strict policy whereby one cannot obtain antimicrobials without a valid prescription written by a doctor, these – along with just about everything else – are sold over-the-counter in Pakistan.

People seek antibiotics for minor ailments – such as a sore throat – and can easily obtain them as drug sale in the country is mostly unregulated. In addition, those operating these establishments either do not know the health hazard their customers are being exposed to or do not want to deny a customer their wish and thereby risk alienating them. Doctors often readily oblige to the wishes of their patients for a quick fix, where an antibiotic is not indicated. It is better to let the body’s natural immune defences take the fight to the causative organism.

The government must work to draft laws to tackle this looming threat of antimicrobial resistance on an emergency basis. An ‘antimicrobial stewardship’ programme, which involves the active participation of all healthcare professionals in a health facility, is the need of the hour. It incorporates all the facets listed in the WHO plan and aims to implement them in practice. This is a painstaking task, but one that is made easier when all healthcare professionals work in tandem.

Raising public awareness on antimicrobial resistance through advertising on various media will also help curb the unchecked antibiotic use. Finally, the strict monitoring of drug sales and prescribing penalties to those not following government health policies will also help. The WHO has assured world governments their full support in providing expertise and help to combat this menace – provided they are willing to seek it.

Antimicrobial resistance is slowly creeping up the list of problems faced by the world. It is a problem that is not confined to a specific geographical area. It could have implications for the entire world. If it is not handled with utmost urgency, the world stands the risk of being pulled back to the medieval ages of medical practice. The first superbug-driven epidemic may just be around the corner.


The writer tweets @bandaydaputtar


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