Antibiotic resistance growing

Manzur H Maswood | Published: 00:01, Mar 15,2019 | Updated: 00:02, Mar 15,2019


People buy drugs at a pharmacy at Segunbagicha in the capital. — Sony Ramany

A growing trend of antibiotic resistance has put the health of Bangladeshis under serious threats.
The surge in antibiotic resistance, mostly caused by high rates of antibiotic use and misuse, has become a matter of great concern as the rate of new antibiotic development is declining.
Antibiotic resistance poses a big risk in terms of mortality and economic burden worldwide.
Different studies show that developing countries like Bangladesh are more affected because of the widespread misuse of antibiotics, non-human antibiotic use, poor quality of drugs, inadequate surveillance and factors associated with individual and national poverty indicators like poor healthcare standards, malnutrition, chronic and repeated infections, unaffordability of more effective and costly drugs.
Furthermore, scarcity of newer drugs has made it imperative to contain antibiotic resistance before all options to battle the diseases caused by bacteria are exhausted.
According to the 2014 World Health Organisation report on global surveillance of antimicrobial resistance, significant gaps in surveillance prevail along with a lack of standards for methodology, data sharing and coordination.
The Southeast Asia, African, and Eastern Mediterranean regions have been identified as having major gaps and Bangladesh, a developing country of Southeast Asia with a high degree of antibiotic resistance, poses a regional and global threat.
The antibiotic resistance has turned so alarming that antibiotics for common diseases are getting resistant.
In a study performed in Chittagong in 2003, typhoid patients were found to be unresponsive to the second-line therapy (ciprofloxacin). The first-line therapy was not even attempted because of the existing resistance. Therapeutic failures like this are not rare at all, the study says.
Furthermore, multiple studies have demonstrated irrational antibiotic prescribing by physicians, a habit of self-medication among patients, and indiscriminate use of antibiotics in agriculture and farming in different parts of the country.
Despite the fact that many studies have been performed on the prevalence of antibiotic resistance in Bangladesh, no attempts have yet been made to systematically unify them.
A study published in the March issue of International Journal of Infectious Diseases shows a horrific picture of antibiotic resistance against many common bacteria in Bangladesh.
The study titled ‘Antibiotic resistance in Bangladesh: A systematic review’ analysed 46 studies carried out between 2004 and 2018 on antibiotic resistance in Bangladesh.
The review says antibiotic resistance is a worldwide problem and Bangladesh is a major contributor to this owing to its poor healthcare standards, along with the misuse and overuse of antibiotics.
According to the review, forty-six articles were included in this systematic review. Antimicrobial susceptibility testing was performed by disk diffusion method in 82.6 per cent of studies, while the Clinical and Laboratory Standards Institute guidelines were followed in 78.3 per cent.
The review says a high prevalence of resistance was detected in most tested pathogens, and many of the common first-line drugs were mostly ineffective.
Resistance to carbapenems was low in most cases. The presence of extended-spectrum beta-lactamase producing organisms was indicated by the high resistance to beta-lactams.
Methicillin-resistant Staphylococcus aureus was identified in four studies in the review. Three studies reported vancomycin susceptibility of enterococci, and the median susceptibility was 100 per cent. Streptococcus pneumoniae exhibited high susceptibility to penicillin. Resistance data were available from only six out of the 64 districts of Bangladesh.
Talking to New Age, doctors warned that a health catastrophe was in the making in Bangladesh because of antibiotic resistance caused by high rates of antibiotic use and misuse.
Once a bacteria becomes resistant to antibiotics, treating infection caused by the bacteria becomes difficult and in some cases, medically impossible. Untreated, bacterial infections can spread rapidly and may cause a health catastrophe, they say.
Because of widespread use of antibiotics, infectious bacteria develop the ability to survive the antibiotics designed to kill them or stop their growth and become resistant to the antibiotics.
The more antibiotics are used, the more resistant the bacteria can become as sensitive bacteria are killed, but stronger germs resist the treatment and grow and multiply. Repeated and improper use of antibiotics contributes to this process, they note.
Bangabandhu Sheikh Mujib Medical University hospital ICU physician AKM Habibullah told New Age that about 20 to 25 per cent of the patients admitted to the ICU were found with antibiotic resistant.
Many patients are even resistant to all the antibiotics available in Bangladesh and some patients are found sensitive to only one antibiotic, Colistin Sulphate, the latest generation antibiotic in the world.
In a recent visit to the BSMMU hospital ICU, New Age found two patients resistant to all but one antibiotic, Colistin Sulphate.
Bangabandhu Sheikh Mujib Medical University pharmacology chairman Sayedur Rahman said that Colistin Sulphate was the latest antibiotic developed in the world.
He said in the next seven years, only one antibiotic was in the pipeline.
‘If anyone is suffering from infection caused by any bacteria resistant to the Colistin Sulphate, they have hardly any hope of being cured,’ he said.
The study published in the March issue of International Journal of Infectious Diseases, analysing studies from 2004 and 2018 on antibiotic resistance in Bangladesh, found that bacteria which caused common ailments like urinary tract infection, pneumonia and ear infection were becoming resistant to most of the antibiotics in Bangladesh.
The study showed that Escherichia coli, a bacteria available even in jar water or street food in Dhaka and the most common causative organism of urinary tract infection, was studied in 21 articles and found high resistance to commonly used antibiotics — ampicillin in 94.6–100 per cent cases, amoxiclav in 67.1–85.5 per cent cases, ciprofloxacin in 65.2–80.5 per cent cases and co-trimoxazole in 72–82.2 per cent cases.
Resistance to ampicillin, amoxiclav, ciprofloxacin and co-trimoxazole was 100 per cent, 58 per cent and 67.4 per cent and 72.7 per cent respectively in Klebsiella bacteria that cause pneumonia.
Co-trimoxazole was ineffective against 86.6 to 98.7 per cent cases of tested Pseudomonas bacteria, which causes ear infection, and 87.5 to 100 per cent ineffective against Enterococcus bacteria, common among people who lacked the practice of hand washing after defecation.
Sayedur Rahman said that as there was a shortage of new antibiotics, it was of utmost importance that the existing ones were used cautiously.
‘Rampant taking of antibiotic, without maintaining due time, and not fulfilling course of antibiotic are the major reasons for the growing trend of antibiotic resistance,’ he said.
The pharmacologist said that antibiotics were available at drug stores across the country and anyone seeking a prompt cure from a simple viral infection like fever, cold and diarrhoea, which needed no antibiotic to cure them at all, used to buy antibiotics from the drug stores and take them whimsically.
Unregulated pharmacies and quacks are also contributing to the antibiotic resistance, he said.
‘There are about 2.3 lakh pharmacies and 4 lakh quacks in the country and they sell or prescribe antibiotics rampantly,’ said the pharmacology professor.
Another reason for antibiotic resistance was that antibiotics were rampantly used in livestock which ended up in the environment and directly went to humans through consumption of meat, he said.
Bangladesh Agricultural University microbiology and hygiene professor Tanvir Rahman said that the use of antibiotic in livestock could happen for some real causes when the animals got ill.
But the concern was that in the husbandry of livestock, antibiotics are used to a batch of animal when one got ill, he said.
There are antibiotic uses of sub-therapeutic doses in animal feed and water to promote growth and improve feed efficiency, he mentioned.
‘There is no option but to stop these practice to avoid antibiotic resistance,’ Tanvir said.
In case of animal getting ill, he said, the specific animal must be given antibiotic if needed, but the unnecessarily use of antibiotic to a batch of animals should be stopped.
Tanvir said there were measures which could be effective for the animals.
He said in case of getting ill, the particular animal should be isolated, instead of providing antibiotics to all the animals.
And if there are any suspected animal getting ill but they are still fine, the animals should be taken in quarantine. After some days, they could be given antibiotics or needed no antibiotics, but it would help stopping random use of antibiotics to a batch of animal.
Sayedur Rahman said controlled and lowered use of antibiotics could prevent resistance and this could be achieved by implementing strict regulations on antibiotic use, as well as by educating health professionals and the public, as irrational antibiotic use was common in Bangladesh through prescription and self-medication.
Different reports and studies also show that multidrug-resistant tuberculosis appeared to be a cause of concern in Bangladesh.
According to the World Health Organisation’s latest report on TB, which is caused by Mycobacterium tuberculosis bacteria, the annual incidence of multidrug-resistant TB in Bangladesh is 8,400.
In 2017, according to WHO, at least 5,800 cases of multidrug-resistant TB were found.
It also says that 29 per cent of the multidrug-resistant TB patients took TB treatment in the past but they grew resistant.
Besides, among the newly identified TB patients, 1.6 per cent of them were already multidrug
More worryingly, at least 22 per cent of the multidrug-resistant TB patients do not get treatment in their life.
The multidrug-resistant patients are resistant to the most powerful first-line drugs for TB treatment — rifampicin and isoniazid and rifampicin, according to WHO.
WHO says in Bangladesh, multidrug-resistant TB is becoming an emerging public health problem.
It has identified 27 high burden countries for multidrug-resistant TB, where Bangladesh is the sixth in rank. Four of those high burdened countries, including Bangladesh, belong to the South-East Asian region.
Doctors say that as the antibiotic business is profitable, pharmaceutical companies are eager to produce and market more antibiotics, a reason responsible for the misuse of antibiotics.
According to Drug Administration officials, the antibiotic was the second best-selling drug in Bangladesh.
According to a review on the pharmaceutical industry business in Bangladesh by LankaBangla, the sale of antibiotic was Tk 1,687.61 crore in 2018, the second most sold medicines after acidity drugs.
Bangladesh Association of Pharmaceutical Industries secretary general SM Shafiuzzaman said that they produced medicines on market demands.
‘We don’t prescribe antibiotics and don’t promote selling those without prescription, but we do business upon market demand,’ he said.
Drug Administration director Ruhul Amin said that they were aware of the growing trend of antibiotic resistance and taking measures, including awareness campaign and drive against sale of antibiotic without prescription, but those were not adequate.
He said a drug act which was drafted already proposed a punitive measure for selling antibiotics without a prescription.

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