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Antibiotic overkill – How Pakistanis are putting themselves at risk of antibiotic resistance

Treatment for viral diseases is leading to drug-resistant infections

Antibiotic overkill
We are sitting on the brink of a health disaster. Humans may again reach a stage where even small cuts, minor injuries and seemingly innocuous infections can prove to be killers — all of these are conditions that can be effectively treated by antibiotics. Misuse and overuse of antibiotics is building in our systems resistance to these drugs and a time comes when these medicines are no longer effective in fighting the bacteria and infections they were designed to ward off.

Antibiotic resistance is leading to untreatable infections. Any age group can be affected by it. If care and caution is not exercised in the use of antibiotics, humans could be in serious trouble. We already are, if numbers are to be believed. Self-medication and use of antibiotics without thinking twice is a problem. The fact that Pakistan has, as reported by the Pakistan Medical Association, more than 600,000 quacks who pose as doctors and prescribe antibiotics without any need or deliberation, exacerbates the issue.antibiotic-awareness-poster 1

It is very common practice to go to “pharmacies” which are usually counters in grocery stores, run by people who are not pharmacists, and ask for any random antibiotic that the patient feels “suits” him or her. While it may have been effective the last time you used it, and the time before that, this time it may not work as you have developed resistance to it.

“We see a lot of antibiotic misuse at the hands of general practitioners as well as quacks. The urgency to use antibiotic sometimes also arises from patients demanding that they return with some medication if they have visited a doctor,” says Dr. Nosheen Nasir, Senior Instructor, Adult Infectious Diseases at the Aga Khan University (AKU).

“We see antibiotics being used for viral upper respiratory tract infections and for presumed enteric fever based on typhidot results which are erroneous and misleading.” Dr Nasir adds that antibiotic overuse can lead to increase in drug-resistant infections and significantly increase the risk of morbidity mortality. “Infections which were previously simple to treat now require use of more toxic and expensive antibiotics which are usually given intravenously, leading to unnecessary prolonged hospitalisations.”

World Antibiotic Awareness Week (WAAW), held from November 12 to 18 this year, aims at increasing global awareness of antibiotic resistance, AMR (Antimicrobial resistance) and to encourage best practices. AMR occurs when microbes, such as bacteria, become resistant to the drugs used to treat them. The 2018 WAAW campaign has two key messages: “Think twice. Seek Advice” and “Misuse of Antibiotics puts us all at Risk”.

AMR, as Dr. Nasir adds, refers to resistance among all kinds of micro organisms such as bacteria, fungi, parasites etc. when they are exposed to antimicrobials including antibiotics and antifungals.

She shares an example of antimicrobial resistance that we are facing today in Pakistan. “People get a lot of antibiotics unnecessarily for presumed typhoid fever, also called enteric fever. This has led to a country-wide outbreak of extended drug resistant (XDR) typhoid fever, sensitive to only two antibiotics, one of which can only be given intravenously. This has led to serious life threatening infections particularly in children,” she says.

November 2018 also saw “Call to Action on Antimicrobial Resistance” from November 19 to 20, co-hosted as a second global event by the UN Foundation to help drive action to stop the rise and spread of superbugs. Dr. Fatima Mir, Assistant Professor of Pediatric Infectious Disease at the AKU, explains that “Super bugs are germs which over time have become resistant to common antibiotics through new mechanisms.” She cites some of the lethal super bugs in Pakistan as under:

1.Multidrug resistant gram negative organisms like klebsiella pneumoniae, e.coli and serratia, leading to newborn sepsis.

2.Extended spectrum beta lactamase inhibiting (ESBL) gram negatives like e.coli, klebsiella, enterobactor sp, which can cause gut, abdominal and urine infections in all ages

3.Penicillin resistant streptococcus pneumonia, causing lower respiratory tract infections in all ages

4.Multidrug resistant Typhoid, effecting all ages

5.Multidrug resistant Tuberculosis (TB), affecting all ages

In Dr Mir’s professional experience, Pakistanis generally have a tendency to hurry towards antibiotics, “Especially in cases of Upper Respiratory tract illnesses which are usually viral but also associated with symptoms which make one miserable, like congested nose, throat and body aches, parents feel kids won’t get better without antibiotics, and most physicians succumb to pressure and prescribe antibiotics even for clearly viral illnesses.” She adds that one reason for over prescription is lack of low-cost testing to establish a viral cause. “Usually a full course of antibiotics is cheaper than a test for a single viral antigen, so physicians make a misplaced choice of empiric antibiotics to appease parents (of child patients) in place of expensive testing for an essentially self-resolving viral illness,” she says.antibiotic-awareness-poster 1

The problem of resistance to drugs affects all age groups. The elderly are not spared either. Only tests conducted in the laboratory can confirm whether the cause is viral or bacterial. Lack of mobility of elders to go or be taken to laboratories, plus general caretaker fatigue that sets in when an elderly patient has been dependent for long, means a lot of elderly people end up getting even fewer lab tests run on them than patients of other ages.

The easiest way out is to start them on antibiotics without getting even a simple test done like the “culture” which tells which antibiotics would still be effective for that particular patient. “As older patients may not manifest with typical symptoms of infection, antibiotics are frequently given often causing antibiotic resistance. They often may not have fever, and the infection may only manifest as weakness. This practice can be curbed if investigations are done early to confirm infection prior to starting antibiotic,” says Dr Saniya Sabzwari, Geriatric Specialist at the AKU.

In 2017, a “National Action Plan” was drafted by the Health Ministry in Pakistan to fight antimicrobial resistance, developed in the light of the five strategic objectives listed by the World Health Organisation’s (WHO) Global Action Plan for AMR.

Between the years 2000 and 2010, global consumption of antibiotics has increased by 30 per cent. Some 700,000 people die every year from infections that don’t respond to antibiotics. If this is not controlled, AMR could cause 10 million deaths each year by 2050; this number would be more than the deaths caused by cancer.

While over-dosage leads to antibiotic resistance and other serious side effects, under-dosing is a problem too. “This means that the drug, even if chosen correctly, is ineffective because it cannot reach effective concentration in blood. Incorrect dosage is one of the main contributors to antibiotic resistance in addition to incorrect usage,” says Dr. Mir.

Treating tuberculosis with the food basket incentive

By Farahnaz ZahidiPublished: March 23, 2014

world tb day

A day ahead of the World TB Day, we look at the difficulty level of treating the disease.
Faces all around you are covered by masks, even your own, because the moment you enter the area you are handed a mask.
All you can see is eyes. Some red and tired, swollen after hours of coughing and staying awake. Others more hopeful and healthier, obviously recuperating from a disease that can kill but can be easily avoided. One way of avoiding it is this simple face mask that wards off communicable diseases like tuberculosis (TB).
The environment is airy and sunny. It has been designed in a way that germs will have a tough time surviving here. Scores of patients are waiting for their turn. Some are seen standing in queues and others napping on benches.
This is the TB clinic at Indus Hospital Karachi. Muhammad Zaheer is currently under treatment for DR-TB here (drug-resistant TB). Despite months of treatment and counselling, he still repeats out loud the myth he believes in. “Ye hamari khandani beemari hai. It is a familial disease. My father died of it. Lots of my relatives have it,” he says in a matter-of-fact way. The middle-aged carpenter knew he had TB even before he got married, but never exercised any precaution. His wife’s family never thought it dangerous she would be marrying someone who has TB. His four children have never been tested for TB.
Thus, lack of awareness remains a major challenge in the treatment of TB. “There are an estimated 300,000 cases of TB detected in Pakistan every year. Almost 20 per cent (58,000-60,000 kids) are children under the age of 15,” says Dr Ghulam Nabi Qazi, a public health scientist from WHO.
The WHO website cites a higher number, stating that approximately 420, 000 new TB cases emerge every year and half of these are sputum smear positive. Pakistan is also estimated to have the fourth highest prevalence of multidrug-resistant TB (MDR-TB) globally. Pakistan ranks fifth amongst TB high-burden countries worldwide.
“TB is common in both rural and urban areas, as it is a communicable airborne disease. Urban areas are crowded, leading to spread of TB. In rural areas there is more poverty; people can’t afford timely medical checkups and medicines and end up becoming victims of the disease,” says Dr Qazi.
Clinical psychologist Zainab Bari is one of the first people TB patients meet at the Indus Hospital’s TB clinic. “Lack of awareness is a major problem. Unless people understand their disease, controlling it becomes very difficult,” says Bari. At the clinic she sensitises patients about how to avoid catching the TB germs. TB, contrary to myth, is not a genetic disease. It is an airborne, highly contagious droplet infection. Bari informs patients about facts like mothers with TB can breastfeed their babies, so long as their faces are covered by masks to avoid infecting the children.
The same holds true for physical contact between couples, because TB is not a sexually transmitted disease. Counselling is also needed because of the stigma and discrimination against people with TB. People avoid TB patients, and sometimes the stigma leads to severe consequences like isolation and divorce.
Encouraging results
Yet, Pakistan’s progress in the control of DR-TB in particular is seen as something of a success story compared to many other regions of the world.
Over the six years that the TB programme has been running at the Indus Hospital, a cumulative number of approximately 10,000 patients have registered for treatment here, of which 8,000 have been treated, shares research associate Rubab Batool of the Indus Hospital. “We have treated around 600 patients successfully for DR-TB until now. Currently, 264 patients are enrolled with us for DR-TB.”
The food factor
“We somehow see a lot of female patients here,” says Dr Sana Adnan, who is one of the doctors at Indus Hospital treating TB patients. In Dr Adnan’s opinion, the reason is that women are generally not nutritionally well-fed in our patriarchal set-up and are hence more susceptible to catching TB due to low resistance. “TB is very directly related to food and a strong immune system. The doctors working with TB patients are advised not to come in contact with patients on an empty stomach, because if they have been eating enough, their chances of catching the germs are reduced.” The doctors here call it an informed decision to work with patients of this highly infectious disease. “At least we are aware of what we are working with and can take precautions. One could catch the TB germ anywhere in an enclosed space where people come in close contact, even at a shop you go to for shopping,” says Dr Adnan from behind her mask.
Doctors estimate that most Pakistanis have been exposed to TB germs, but our immune system stops it from becoming full-blown TB.
TB remains more common in the lower socio-economic groups. In easier words, it is a disease of the poor, very directly related to malnutrition and food insecurity. “One reason why patients willingly keep coming to us for regular treatment is because we provide food baskets to many of them, as well as vouchers for transport so that they can come to us even from far flung areas. This acts as an incentive. They are getting treated and their families are not going hungry,” says Dr Maria Jaswal, assistant clinical coordinator of the Susceptible TB Programme at Indus Hospital.
Missed cases
Dr Amanullah Ansari, provincial technical officer for TB Control, Global Fund, shows guarded optimism when it comes to MDR TB in Pakistan. “Some 200,000 cases of MDR TB are still not in our fold and are undiagnosed in Pakistan; there are an estimated 55,000 in Sindh alone. But yes, there is success, because we have begun detaining MDR TB cases, and treating them. But till people keep going to quacks for treatment due to lack of awareness, our challenge remains,” says Dr Ansari.
More than 30 per cent which is a whopping three million cases of TB remain undiagnosed worldwide. The WHO’s slogan currently is to reach these missed cases.
Published in The Express Tribune, March 23rd, 2014.