Concerted efforts are required to advocate sticking to a set of practices, broadly known as antibiotic stewardship, to confine antibiotic use
In 1928, Sir Alexander Fleming observed the bacteria-killing effects of penicillin in his laboratory in London. This was the headstart in the discovery of one of the most important pillars of today’s medicine: the antibiotics. However, Sir Fleming in 1945, during his acceptance speech for the Nobel Prize warned the entire world that misuse of the drug could also result in bacteria becoming resistant to antibiotics.
Although antibiotics have transformed the medical response to bacterial illness and rendered easily treatable many formerly deadly infections, the mishandling and misprescription of these drugs have transformed the bacterial population so that many antibiotics have partially or entirely lost their efficacy.
The Covid-19 pandemic has altered the world, introducing ‘social distancing’ and ‘lockdowns’, globally, as key preventive measures, so far. Above two million lives have been lost, billions are in quarantine, and global economies have shed trillions of dollars. It may seem odd to focus on antibiotics during a viral pandemic. However, bacterial superinfections are often what make pandemics like Covid-19 especially deadly.
There is documented evidence that during the 1918–1920 global influenza pandemic, a large proportion of the patients died not from the virus itself but from secondary bacterial pneumonia that spread easily in the crowded hospital wards among the often malnourished and immune-compromised individuals.
We understand that the ongoing pandemic highlights the critical need for rapid development of vaccines and antiviral treatments to reduce the number of hospitalisations and deaths caused by this dangerous new virus. The scientist from bio-pharmaceutical industry are also responding quickly to develop effective cures. With good luck, we will eventually have some of the critical tools we need to fight this new global living threat.
But there is an even larger threat prowling behind the current pandemic, one that is already killing hundreds of thousands of people around the world and that will complicate the care of many Covid-19 patients. It is the hidden threat from antimicrobial resistance (AMR); bacteria that are not killed by standard antibiotics. Regrettably, the existing pipeline of drugs to manage these deadly infections is nearly exhausted.
Although antimicrobial resistance hasn’t gotten our attention in the same way that SARS-CoV-2 has, AMR bacteria present a growing global hazard. According to the World Health Organisation (WHO), currently, at least 700,000 people die every year due to drug-resistant diseases, though experts fear that the real number is much higher. The so-called superbugs that cause these infections thrive in hospitals and medical facilities, putting all patients, whether they are getting care for a minor illness or major surgery, at risk.
A study published in the Lancet (Volume 395, Issue 10229, P1054-1062, March 28, 2020) of 191 patients in two Wuhan hospitals showed that 50 percent of those who died had tested positive for secondary infections compared to only one of the 137 survivors. In this situation, antibiotics form a critical second line of defense.
Many studies indicate that nearly all severe Covid-19 patients will receive antibiotics as supportive treatment. However, the global crisis of antibiotic resistance, which the WHO declared a worldwide threat to public health in 2014, means this crucial defence is a deteriorating resource. According to researchers, the challenge of antibiotic resistance could become an enormous force of additional sickness and death across our health system as the toll of coronavirus pneumonia stretches critical care units beyond their capacity.
According to microbiologists, in the context of Covid-19, antibiotics should be considered as important as protective gowns or face masks. We should not expect healthcare workers to go into hospital situations without the correct protective equipment. Nor should we expect health care facilities to deliver their tasks without the appropriate antibiotics. This should be considered part of our defence for any pandemic situation. What has happened in response to Covid-19 pandemic is noteworthy. It also raises the question why something similar should not also happen in the face of the global, long-running and much discussed antimicrobial resistance crisis.
These are challenging times globally, given the Covid-19 pandemic and emerging crises. While we all stand united to fight against its spread, Pakistan is continuing efforts in other pertinent domains at the same time. It is a fact, much less known to the general public, and even to the health care providers that antibiotics need to be used in an appropriate manner to prevent the emergence of the resistant bugs.
We need to introduce massive changes to present practice of the use of antimicrobial agents in human, animal and environmental health sectors; collectively under One Health approach. AMR is an integral part of our National Action Plan, and the government of Pakistan is committed to play its part in global disease control programmes most effectively and stand alongside the global community in the effort to reduce AMR burden.
The National Strategic Framework for the Containment of Antimicrobial Resistance was adopted by Pakistan during 2017 as a national action plan to address the growing concern of antibiotic use and resistance. From the work carried out, multiple factors were identified as contributory to the challenge. Firstly, the number of antibiotics available in the Pakistani market is very high. Furthermore, there is a highly prevalent self-medication behaviour and up to 70 percent of patients are prescribed with antibiotics.
Pakistan joined in the international endorsement of the AMR Global Action Plan in 2015. The Ministry of NHSR&C formed an Intersectoral Core Steering Committee to oversee the process of developing a national AMR policy. The commitment led to the development of a National AMR Strategic Framework for Containment of Antimicrobial Resistance (2016) and an operational AMR National Action Plan (2017). The National Institute of Health is designated as national focal point for National International Health Regulation (IHR) and AMR by Ministry of NHSR&C. International partners are also providing technical and financial support to the government of Pakistan to fight AMR to strengthen One-Health AMR surveillance systems, improve laboratory infrastructure and build expertise of senior scientists.
Concerted efforts by all the partners are required to advocate sticking to a set of practices, broadly known as antibiotic stewardship, to confine antibiotic use to when the drugs are really needed. A key principle of stewardship is making sure that the infections a patient is experiencing are identified and lab-confirmed. In this manner, healthcare providers can fit the choice and dose of antibiotic to the pathogen infecting a patient and to any resistance that is already present.
The Covid-19 pandemic evidently shows that dealing with the global health threats of the 21st Century exceeds the capacities of any single nation-state. And like Covid-19, the antimicrobial resistance crisis will only be resolved with collective action. Rather than seeing the two predicaments as independent of each other, both are symptomatic of the challenges of living on an increasingly interconnected planet, and one will aggravate the other. But during this crisis, we are hopeful that the global unity of purpose and research that is tackling Covid-19 become a roadmap for solving one of the most detrimental and long-running crises in global medicine; the issue of increasing antimicrobial resistance and an uncertain pipeline of solutions.
The writer is a senior public health scientist