Since before Covid-19, infectious diseases experts have been raising the alarm on rising antimicrobial resistance
CLINICAL MATTERS
DR. EDSEL SALVANA
Before the start of the Covid-19 pandemic, infectious diseases experts were already raising the alarm on the threat of antimicrobial resistance. In 2014, the World Health Organization (WHO) released a global report highlighting the very high rates of antibiotic resistance observed in bacteria that cause common healthcare-associated and community-acquired infections in all WHO regions. It warned of the possibility of an apocalyptic post-antibiotic era, where common infections and minor injuries can kill due to the loss of potency of nearly all antimicrobials. Increasing resistance is not only limited to bacteria. It is also increasing in fungi (e.g. Candida auris), parasites (e.g. malaria), and viruses (e.g. HIV). The newest SARS-CoV-2 variants have already developed resistance to most of the monoclonal antibodies that have been used for treatment because of continuing mutation and recombination.
Antimicrobial resistance is at least as old as our antibiotics. When penicillin was first mass-produced for human use in the 1940s, penicillin-resistant bacteria were discovered shortly thereafter. Bacteria, having been around on our planet two billion years longer than humans, are the ultimate survivors. An arms race between humans and bugs ensued, with new antibiotics being developed at a fast pace and the bacteria catching up quickly. Unfortunately, due to widespread misuse, poor antibiotic stewardship has rapidly accelerated the development of resistance.
Agricultural, non-therapeutic use of antibiotics, which are routinely added to animal feed to increase yield and survival of animals, has become widespread. This has resulted in many animals harboring antibiotic-resistant bacteria, which have made their way to humans. Unregulated use of antibiotics in humans to inappropriately treat viral illness is a notorious cause of resistance. Poor adherence to recommended doses and a shortened duration of treatment have all contributed to the loss of efficacy of many antibiotic classes. Amoxicillin, which is by far the most abused antibiotic in the Philippines, is now practically useless in treating infections caused by E. coli. The latest antimicrobial surveillance data shows that nearly 80 percent of E. coli have become resistant to amoxicillin and ampicillin. E. coli is also nearly 50 percent resistant to ciprofloxacin, an antibiotic, which is frequently prescribed for urinary tract infections without the benefit of proper urine culture data, resulting in treatment failure.
One scary bacterium that is rapidly becoming resistant to our last line of our antibiotics is Klebsiella pneumoniae. Klebsiella is typically found in the respiratory and urinary tract. What makes Klebsiella scary is that it easily develops resistance to multiple antibiotics and on top of that, it can pass these resistance genes to other bacteria such as E. coli. The resistance of Klebsiella to strong antibiotics like cephalosporins in the Philippines is already at 50 percent, necessitating the use of last-line antibiotics like carbapenems as first-line instead. With increasing carbapenem use, Klebsiella are now about 15 percent resistant to these drugs of last resort, and there aren’t many treatment options left.
One of my long-term patients whom we treated with multiple antibiotics due to recurrent UTIs recently had a scary urine culture result. It showed a Klebsiella that had become resistant to all antibiotics, and we had nothing to treat him with. Fortunately, he responded to a complex combination of antibiotics. The regimen we used was quite expensive and was not guaranteed to work. Treatment of these increasingly resistant infections is best undertaken in consultation with an infectious diseases specialist to optimize whatever antibiotics may still have some activity. While this is something that subspecialists do on a regular basis, we would rather not have to do this in the first place. Preventing the emergence of a superbug, such as this, is by far the most cost-effective pathway. His antibiogram is shown below.
As a signatory to the United Nations and WHO conventions, the Philippines is obligated to respond to the global threat of antimicrobial resistance. Antimicrobial stewardship programs have been adopted by the Department of Health in most hospitals to address rising resistance. Unfortunately, not everyone is on board with these initiatives. Efforts at restricting inappropriate antibiotic prescription are seen by some healthcare providers as an unwelcome imposition on their right to autonomously determine patient care. Some people continue to demand inappropriate antibiotics despite being told they have a viral infection. Inappropriate antibiotic use harms patients, and severely limits treatment options for future infections. We must avoid a scenario where we lose a life-saving tool because of irrational and unscientific medical practices. There is no more time to waste, and we must act before it is too late.
Industrial players, particularly in the agricultural livestock sector, need to decrease their use of antibiotics for non-therapeutic purposes. Organic and antibiotic-free products are already seen as desirable commodities that command premium prices. Rather than being niche products, with hoe these will become the norm and the agricultural sector realizes that it is part of a much bigger ecosystem that affects us all.
Government and industry cannot do it alone. Antimicrobial stewardship and rational use of antibiotics is everyone’s responsibility. There are many things that lay persons can do to decrease their risk of drug-resistant infections. Here are some of them.
- Only take antibiotics upon proper consultation with a qualified healthcare professional.
- Once an antibiotic course is started, take the required doses consistently and finish the prescribed course unless your doctor tells you to stop.
- Do not pressure your doctor to prescribe antibiotics “just in case,” especially when what you have is a viral illness.
- Never share your leftover antibiotics with your relatives or friends without proper consultation with a healthcare professional.
- Educate yourself about antimicrobial resistance and do your part in further reducing the risk.
The antibiotic era that started in the 1940s has ushered in a golden age , when highly fatal diseases such as tuberculosis and other severe infections could be tamed with safe and effective treatments. It is imperative that we preserve these essential tools of progress. The alternative will usher in a new dark age, where we will once again be helpless in the face of pathogens that should have already been history.