Controlling Antimicrobial resistance …
Human and animal body including the environment, water, soil, and air, is home to tens of millions of tiny living organisms called microbes. They cover from bacteria to viruses including parasites, fungi, mycoplasma, chlamydia, and rickettsia. They cause diseases. Since the inception of the disease, human beings were almost always active to combat all kinds of diseases by different kinds of drugs or medicines, called antimicrobials (AM).Recently, many cases are found where the drugs are not effective even in cases of the drugs that were once highly effective. Antimicrobial resistance (AMR) is a condition where the disease-causing microorganisms do not respond to the antimicrobials drugs or medicine as it was applied for. Resistant microbes are termed as 'superbugs'. It is the microbes, not the human or animal, who gain resistance against antimicrobials. The impact of AMR affects everyone irrespective of age, gender and territory. Human is thought to be the first line of the sufferer. Animals are also equally affected including the wildlife. Also, the environment, soil, water and air, are not free from the consequences.
AMR is an old issue. After the discovery of penicillin in 1928 and commercially released in 1941, penicillin-resistant Staphylococcus aureus was found in the immediate next year. In some cases, AMR was found in the same year of marketing the medicines. At present, bacteria arethe most widely spread resistant microorganisms. Escherichia coli and Klebsiella pneumonia, considered as reference bacteria for AMR, showed resistance against ciprofloxacin, one of the most recommended antibiotics for UTI (Urinary Tract Infection), up to 27.02% and 72.22% respectively.The virus affects the immune system and lowers activity. Resistance is found in most antiviral medicines along with the antiretroviral agents.
COVID-19 pandemic pointed the finger at the global perception ofthe treatment of diseases. It emphasizes more focus on the prevention by vaccination and other means. During this pandemic, the rate of prescribing antibiotics and antivirals are 95% and 21%, respectively, in two hospitals of Wuhan. On the other hand, another study found that only 5.6% of patients had bacteremia. So, the overuse and misuse of antibiotics will make the present AMR condition more fatal.
Bangladesh: Health system and AMR
Unfortunately, the area, Southeast Asia, covering Bangladesh is the riskiest territory in the globe. Though there are rules and regulations, the implementation rate is poor in this region. For instance, antibiotics are readily available and can be purchased as over-the-counter (OTC) medicines here in Bangladesh. Sharing the antibiotics to others, taking the remaining medicines for the next illness without the prescription of a physician, unethical medical practices such as by the medical assistant who is not authorized to prescribe are common. The health system in Bangladesh is not monistic, rather is pluralistic. In this country the connectedness among the bodies and regulatory control is weak. It aggravates the unethical practice and unfair means. Following that, inadequate surveillance, lack of data sharing, malnutrition, random use of non-human antibiotics, chronic and repeated infections and individual and national poverty are contributing to the development of AMR.
Emergence and spread in AMR
AMR occurs naturally. When antibiotics are applied to kill the infections, some of the bacteria are smarter to skip the effect. Then, the organisms multiply rapidly, spread and infect in a new horizon. Mutation, gene transfer, enzyme production and phenotypic change are common to achieve the resistance.
Wrong prescriptions during viral infection, substandard medicine, and inaccurate diagnosis, poor preventive measures such as vaccination, sanitation, hygiene, and lack of proper surveillance are contributing to a significant level. Globalization moved people, animalsand plants easily. By these means, resistant organisms spread throughout the world more easily even there are customs regulations.
Effect of antimicrobial resistance
Presently, AMR takes 700,000 lives per year around the globe which could reach 10,000,000 by 2050 if remain uncontrolled. AMR results in longer hospital stay, intensive care units with isolation beds and economic loss. The major surgical procedures such as organ transplantation, joint replacement, cesarean section and many more face critical challenges. Also, blood infections, asthma, rheumatoid arthritis, diabetes and other chronic diseases treatment will be difficult if AMR sustains. Out of the stated 17 Goals of Sustainable Development Goals (SDG), 6 are particularly relevant and are not achievable without the proper address of the AMR.
Way forward to combat AMR
AMR is a worldwide public health critical concern. So, all the nations should come forward and contribute proportionately. The One Health system should be followed to include human, terrestrial and aquatic animals, plants and the environment. Prevention through discovery or innovation and implementation of vaccination should focus more than to control by the antimicrobials. Already, Antimicrobial Resistance Multi-Partner Trust Fund (AMR MPTF), the Global Antibiotic Research & Development Partnership (GARDP), AMR Action Fund is working on it.
World Antimicrobial Awareness Week (WAAW), 18-24 November 2020, is being observedglobally for the first time with the slogan, "Antimicrobials: Handle with Care". The date will be the same for the upcoming years This year the WAAW has more responsibility to the aware mass population abouttaking antimicrobials during the pandemic of COVID-19 and to the conscious selection of medicines by the doctors.
Initiatives in Bangladesh
Keeping the national limitations into consideration, Bangladesh is trying to take care of the AMR issue. The country started the journey by signing the "Jaipur Declaration-2011" to control antibiotic resistance. Then, the National Steering Committee (NSC), National Technical Committee (NTC) and National Working Group (NWG) were formed in 2012 at a different level.
AMR has extensively been focused on the National Action Plan for Health Security (NAPHS). Bangladesh Livestock Research Institute (BLRI) has launched a laboratory this year for AMR detection in Bangladesh. BARA (Bangladesh AMR Response Alliance) brought together the physicians and veterinarians in a platform to mitigate the resistance. Also, the members of Platform, a voluntary organization of physicians and dentists, are contributing from their position.
Immediate action should be taken to limit the random use of antimicrobial in this pandemic period. Also, the proper and strict policy should be taken to maintain the second wave of COVID-19 in the winter season as Bangladesh is a country with one of the highest population densities and hotspots of AMR. Bangladesh has enough policy but we are weak in implementation. All the AMR related policies such as antibiotic treatment policy should be followed strictly by all the relevant stakeholders.
Recent research showed that vaccination can greatly combat AMR. There are many more vaccines including the one for COVID-19 is in pipeline. Application of particular light, photodynamic therapy, in effect for the treatment of many diseases or deformities. Multiple drug therapy, application of bacteriophage virus, and regular probiotic ingestion can contribute to limit the infection.
The stakeholders should contribute sincerely to mitigate this public health concern. The world should update the blueprint of peace and development, SDGs, and also emphasize on the responsible use of antimicrobial medicines. Also, coordinated action among the stakeholders and alternative therapies to avoid antimicrobial usage for combating the infection are necessary.
Md Abdul Wares, PhD is a Veterinary Surgeon (VS), Department of Livestock Services, Dhaka