Even before the COVID pandemic, antimicrobial resistance, in which microbes no longer respond to common drugs like antibiotics, was a big concern for public health organizations and healthcare specialists. In 2019, the latest year for which data is available, antimicrobial resistance led to 4.95 million deaths worldwide, making it the third leading cause of death after cardiovascular disease and cancer.
After more than two years of COVID, with widespread and inappropriate use of antibiotics resulting from treatment protocols, public health and health care experts say antimicrobial resistance is dramatically worsening in many countries. This is of concern because bacteria that cause common infections in the blood, lungs, and airways, not to mention the well-known diseases that still exist in low-income countries, such as typhoid and tuberculosis, are increasingly becoming more resistant to existing drugs. At the same time, the pharmaceutical industry is not sufficiently interested in the development of antibiotics, since their market is not lucrative. We risk losing 10 million people every year worldwide by 2050 to diseases we once could treat. Unfortunately, 90% of these deaths will occur in low- and middle-income countries.
Antimicrobial resistance is a long-standing pandemic that has been overlooked. COVID has heightened the urgency to break the culture of liberal antibiotic use. We need to tighten regulations around prescribing these drugs and retrain healthcare providers around the world to be stricter in their use of antibiotics. We need to improve sanitation and hygiene to prevent the spread of disease-causing bacteria. We need better diagnostics and more robust vaccination programs. We are running out of options and the infectious bacteria that afflict so many people in non-Western countries are about to win a battle we once had in our hands.
Take India, the largest consumer of antibiotics in the world, and a place with a deep-rooted culture of antibiotic use. Doctors prescribe an antibiotic for illnesses such as colds or diarrhea and even short fevers. These prescriptions are driven by a variety of factors which include a lack of appropriate knowledge about when to use antibiotics, lack of diagnostics, inability of patients to afford diagnostics, economic incentives, patient demand and fear of clinical failure.
Pharmacists, who also serve as the first stop for health care in many parts of India, do the same since antibiotics are commonly available there without a doctor’s prescription. But these drugs often don’t work, because the majority of these illnesses are viral, not bacterial. Yet, because of these practices, the general public believes they will.
It is therefore not surprising that India, given its population of over a billion people and easy access to antibiotics, is struggling with widespread misuse of antibiotics. The high burden of bacterial infections in the country, where antibiotics are warranted, further complicates the matter. Yet, due to widespread misuse, infectious bacteria develop defenses against these drugs. So, while they are needed, they lose their power.
The COVID pandemic has aggravated this practice of antibiotic misuse. Although COVID is a viral infection with low rates of secondary bacterial infection, the pandemic likely contributed to Indians taking an estimated 216 million excessive doses of antibiotics during the first wave of 2020. This despite advice from the World Health Organization (WHO) and the Indian government’s national treatment guidelines advising against the use of antibiotics, especially for mild and moderate COVID cases. This practice extended to subsequent COVID outbreaks involving the Delta and Omicron variants, and it potentially worsened the resistance problem in the country.
India is not alone. Researchers have observed similar patterns of antibiotic abuse in other non-high-income countries, including Bangladesh, Pakistan, Brazil, and Jordan.
We mentioned several solutions to this problem earlier, but the most important thing we can do is change the culture – the attitudes and approaches of healthcare providers and the general public towards antibiotics in low- and middle-income countries. For example, in these countries, acute upper respiratory infections that are likely viral account for the majority of unnecessary antibiotic prescriptions, but for most healthcare providers, national standard treatment guidelines are not available; even when they are, these guidelines are not user-friendly and do not explain the responsible use of antimicrobials, making them difficult to use in a physician’s daily practice.
To that end, in 2017, the World Health Organization launched the Access, Watch and Reserve (AWaRe) Framework for Antibiotics, which ranks drugs based on the risk of developing resistance. WHO will soon release an Antibiotics Reference Book with simple infographics and a mobile app, which will provide best practices for clinical evaluation, diagnosis and treatment of various infections in outpatients and inpatients using this called a traffic light approach. Recent evidence from China showed that a traffic light approach to clinical guidelines for upper respiratory tract infections reduced antibiotic prescribing by 82% to 40% in the intervention group, compared to 75% in 70% in the control group.
However, changing human behavior and overcoming decades of misaligned practice is a challenge, especially for physicians already in practice, especially practitioners who work in the informal and private health sectors. Studies of mystery shoppers, in which trained people visit establishments in the assumed role of shoppers and then report on their experiences, show a wide gap in know-how in many countries – a gap between what providers say what they would do for a given patient, compared to what they actually do in routine clinical practice.
Governments and health systems will need to do more to prevent over-the-counter sales of restricted drugs and direct sales of drugs by pharmaceutical companies to people without medical training, as well as to help ban drugs irrational fixed-dose combinations and the hard work of preventing counterfeit drugs from entering the market. At the same time, they should help put in place programs to facilitate the responsible use of antimicrobials in hospitals and primary care settings.
India is another example of how regulation helps. The country’s 2018 ban on fixed-dose antimicrobial combinations in India succeeded in reducing antibiotic sales. Similarly, the ban on over-the-counter antibiotic sales has led to reduced antibiotic sales in Brazil and Chile when properly enforced.
Along with continued efforts to improve antibiotic use among existing prescribers, now is the time to prepare next-generation physicians to be better antibiotic stewards. These drugs are a limited resource and greatly affect society if used inappropriately. Additionally, medical schools and training programs need to teach physicians to use standard treatment guidelines when prescribing antibiotics. Focusing on next generation physicians will have a domino effect on the public, pharmacists and informal health care providers. This will protect us from future pandemics of antimicrobial resistance while we deal with the current pandemic.
This is an opinion and analytical article, and the opinions expressed by the author or authors are not necessarily those of American scientist.