Health experts have expressed concerns regarding growing  misuse of antibiotics, as it is threatening to outpace the ability of medicines to cure infections. They warn that the misuse of antibiotics could pose a high risk for pandemics of infections. 

Infection with drug resistant microbes increases the morbidity, mortality, length of hospitalization and treatment cost of patients.

The World Health Organization has also warned that if people do not change the way antibiotics are used now, the new antibiotics will suffer the same fate as the current ones and become ineffective. 

What is antimicrobial resistance?

Antimicrobial Resistance (AMR) occurs when bacteria, viruses, fungi and parasites change over time and no longer respond to medicines making infections harder to treat and increasing the risk of disease spread, severe illness and death. 

As a result of drug resistance, antibiotics and other antimicrobial medicines become ineffective and infections become increasingly difficult or impossible to treat. That means the germs are not killed and continue to grow. Resistant infections can be difficult, and sometimes impossible, to treat.

AMR is an urgent global public health threat, killing at least 1.27m people worldwide and associated with nearly five million deaths in 2019, according to the Centers for Disease Control and Prevention of the United States of America.

Antibiotic resistance can affect anyone and will lead to a situation when there are no antibiotics because the antibiotics which we have will not work. It will affect agricultural products and their livestock too as there has been a wide use of antibiotics in livestock as well. 

The WHO has declared AMR among the top 10 global health threats. It can no longer be addressed by single, isolated interventions with limited impact. 

Factors associated with antimicrobial resistance 

Self-medication, unnecessary use, incomplete dose, inadequate awareness, public preferences, economic condition, professional ethics, unavailability of antibiotics prescribers, unclear law/policies, easy accessibility of antibiotics in pharmacies/medical shops and lack of antimicrobial resistance surveillance are some of the factors causing antibiotic resistance in Nepal. 

Similarly, no evidence-based practices for antibiotic prescriptions, unregistered pharmacies, inadequate laboratory facilities for culture and susceptibility, less motivated health workers for service delivery, over-prescription of antibiotics, and patients not finishing the treatment play an important role in causing antibiotic resistance in Nepal. 

“Multiple pregnancies, abortion and unhygienic birthing centers are some of the risk factors for antimicrobial resistance in females as antibiotics are used during pregnancy,” says Dr Bibeka Shrestha, an expert working in antimicrobial resistance. 

A cross-sectional survey with 516 samples of clinicians, private drug dispensers, patients, laboratories, public health centers and livestock and poultry farmers, conducted by KR Rijal and team in 2017, showed that 79 percent of respondents purchased antibiotics directly over the counter.

Section 17 of the Drugs Act states that no person shall sell or distribute such drugs without prescription of a doctor as categorized not to be sold or distributed without such prescription. 

Condition in Nepal 

Nepal experiences an extremely huge burden of infectious diseases such as respiratory tract infections, enteric fever (typhoid, paratyphoid fever), urinary tract infections and other bacterial infections. Researchers have reported a high burden of drug resistant/multidrug resistant bacteria in the country. 

In a research conducted by Dr Anup Bastola and his team in Sukraraj Tropical and Infectious Disease hospital between 2015 and 2019, Salmonella spp and Shigella spp bacteria were mostly resistant to ampicillin/amoxicillin, cotrimoxazole and chloramphenicol. 

In the research Assessment of Antibiotics Use and its Resistance in Nepal conducted by Nepal Health Research Council recently among 1,079 doctors/health workers, only 32 percent of the doctors/health workers have access to laboratory facility for Antibiotic Susceptibility Testing (AST). Among them, only 49 percent recommend antibiotic susceptibility testing before prescribing antibiotics which is a significant reason for influencing rational prescriptions of antibiotics.

Among the 521 pharmacies, the majority of the drug dispensers (43.4 percent) dispense antibiotics without a doctor’s/health worker’s prescription. Azithromycin (24.5 percent), Amoxicillin/Amoxyclav (20.5 percent), Cefixime (14.8 percent), Ciprofloxacin (14.1 percent), and Metronidazole (nine percent) were the most commonly dispensed antibiotics without prescriptions from doctors and health workers.

Of the 2,122 outpatients, 22 percent did not consume a full course of antibiotics. Similarly, about 10 percent and eight percent of the outpatients consume antibiotics as prophylaxis and consume double dose antibiotics for fastest recovery respectively. Around 22 percent of them save residual antibiotics for treating similar symptoms in future. Additionally, around 28 percent of the outpatients mentioned that they buy antibiotics without doctor’s/health worker’s prescriptions.

About 85 percent of health workers/doctors did not prescribe antibiotics by their generic name. Similarly, more than one-third i.e. 37.8 percent of prescribed medicines were antibiotics which is higher than the WHO set standard. 

In a cross-sectional study conducted by Karuna Kayastha and team at International Friendship Children’s Hospital Kathmandu from August 2017 to 2018 in among 1,443 samples that included urine, pus, wound swab, endotracheal tip, catheter tip, and blood were collected from pediatric patients below 15 years  extended-spectrum β-lactamase (ESBL) production in Escherichia coli and Klebsiella species E. coli (n = 79), Klebsiella pneumoniae (n = 18), and Klebsiella oxytoca (n = 6) were isolated from different clinical specimens. Of which, 64 (62.1 percent) exhibited multidrug resistance.

Among the total of 103 bacterial isolates, 62.1 percent (64/103) were found to be multi drug resistant; the highest multidrug resistant strains were detected in K. pneumoniae (88.9 percent; 16/18), followed by E. coli (57 percent; 44/79) and K. oxytoca (50 percent; 3/6)

“Nepal is one of the major contributors to the growing burden of antimicrobial resistance due to widespread use of antibiotics,” says Dr Santosh Dulal, health expert working on antimicrobial resistance.  

According to the National Tuberculosis Control Centre 350 to 450 multidrug resistant tuberculosis are notified annually. 

Multidrug-resistant TB is caused by a TB germ that is resistant to at least isoniazid and rifampin, the two most potent TB drugs. These drugs are used to treat all persons with TB disease, the center says. 

“There must be rational use of antibiotics. The government must train the health workers on prescribing the antibiotics,” says Dr Bastola, communicable, infectious and tropical disease health expert. 

Nepal has a high prevalence of infectious and communicable diseases that contribute to higher morbidity and mortality. The infectious disease with the highest contribution to premature mortality in Nepal in 2019 were lower respiratory infections, diarrheal diseases and typhoid fever as per the Nepal Burden of Disease 2019. “When there is antibiotic resistance then it poses risk on the treatment of these diseases,” says Dr Dulal. 

Though the government has made a national action plan for antimicrobial resistance (2021-2026), it has yet not been endorsed by the government. 

Methods of prevention

Irrational use of antibiotics and illegal import of medicines need to be strictly controlled. Immunization and vaccination program to prevent and surveillance initiatives on antimicrobial use as antimicrobial resistance involving government agencies, medical personnel, veterinarians, livestock producers/farmers is needed. 

Unless the infection prevention is done there remains the risk for antimicrobial resistance. This is why the government must work to prevent infections. 

There is also a need for strict monitoring and regulations to prevent dispensing of antibiotics, (Colistin for animals) or reserve group of antibiotics from pharmacies without prescriptions.

Mind it

• Do not distribute antibiotics and consume it 
• Pay attention on cleanliness and maintain distance with patients 
• Take all the necessary vaccines
• Follow medical advice 
• Only prescribe medicines upon laboratory reports 
• Properly manage hospital waste 
• Surveillance, monitoring and research
• Coordinate at different levels
• Keep AMR on curriculum of schools and colleges
• Strict punishment for violating regulations
• Make treatment guidelines available to clinicians and health workers