Superbug central: unauthorised antibiotics

The effects of over-reliance on antibiotics have been well documented. The body’s processes are affected and the natural bacteria levels present begin to change, leading to reduced or even complete elimination of the effectiveness of drugs, chemicals or other agents designed to cure or prevent infections. Bacteria survive and continue to multiply, causing more harm.

This means that, eventually, no antibiotics will work on the patient and, from there, it spirals into a tale of superbugs, antibiotic-resistant populations and deaths in hospitals. Deaths then begin to occur in the outside world when simple illnesses that could once have been treated with antibiotics get out of control. We then get mass plagues and, by the end of the scenario, we have reached the sort of dystopian nightmare usually reserved for B-grade horror films.

Popping pills

Unfortunately, the population in the MENA region, particularly the residents of the Gulf Cooperation Council (GCC) states, are notorious for their love of antibiotics. Researchers have realised that part of the problem lies with ease of access, thanks to lax regulation and lack of public knowledge of the dangers. Studies published by researcher Hosam Zowawi show that 68% of pharmacies in Abu Dhabi and 78% in the Saudi capital of Riyadh sell antibiotics without a prescription. This is despite the fact that it is illegal to sell antibiotics in this fashion in the GCC states. In Saudi Arabia, Zowawi’s research team individually checked 88 pharmacies and found all but one dispensing antibiotics illegally.

Zowawi, who is Saudi by birth, is based at the University of Queensland Centre for Clinical Research in Australia, where he co-authored the study on the rise of antibiotics and other studies on different aspects of infection control. According to those involved, these studies show that the trend is only getting worse. It is becoming a ‘hot potato’ for healthcare experts in the region, who are urging patients to get wise to what is happening.

Antibiotic education

Dr Laila al-Dabal, head of the infectious diseases unit at Rashid Hospital in Dubai, believes physicians are prescribing antibiotics wrongly or under pressure from patients. In 2016, she told the Khaleej Times that the situation was even scarier with drug-resistant hospitals.

“Admitted patients have more serious illnesses,” she said. “In these patients, a simple pneumonia or urinary tract infection can be a terminal event if we lack the proper antibiotic that can control the infection as early as possible. This can be complicated further if an outbreak of infection with these bacteria takes place in the hospital.”

Dabal’s message reveals a dangerous precedent that is at risk of developing in the GCC states. One of the main factors in its emergence is a lack of education about how antibiotics work and the responsibility that patients are under when they should be prescribed them.

“One common mistake is taking incomplete courses of antibiotics; the patient might take two or three doses and as soon as they feel better, they stop the antibiotic without going back to the prescribing physician,” she says. “This will obviously lead to the creation of drug resistance and there is a cumulative risk every time an antibiotic is used or prescribed inappropriately.”

Research in the past decade has showed that if a patient fails to complete a course of antibiotics, some of the bacteria causing the infection may survive – and these will be the ones with greatest resistance to the antibiotic. As the surviving bacteria reproduce, the resulting infection will no longer be treatable with the same antibiotic.

However, many members of the healthcare sector controversially say this is untrue. Some physicians say that for otherwise-healthy people, taking most, though not all, of a course of antibiotics will significantly reduce the infecting bacteria but not necessarily eliminate it. This allows the body’s natural defences to take over and kill off the remaining bacteria.

“There are some special circumstances when it’s important to kill all the bacteria – when the patient’s normal defences are damaged for any reason, for instance, or when the infection is in a site that’s relatively inaccessible to antibiotics and the white blood cells that kill bacteria,” says Lyn Gilbert, a clinical professor in medicine and infectious diseases at the University of Sydney who has published work on this topic.

“This can be in the middle of an abscess or cavity filled with pus, as in tuberculosis infection; on a foreign body, such as a prosthetic heart valve; or in dead tissue that can’t be removed, as in osteomyelitis or infection of the bone.

“Obviously, stopping antibiotics before a serious infection is cured will risk a relapse,” she says. She disagrees, however, with the type of arguments that these doctors are making.

Over the top

“Superbugs are born and grow from the irrational use of antibiotics, and it’s clear from our research that active guidelines must be implemented to restrict their use in the region,” writes Zowawi in a study published in 2016 in Clinical Microbiology Reviews. He says that the unnecessary use of antibiotics has been identified as a major cause in the spread of hospital and community-acquired infections across the GCC states.

This echoes a WHO report from 2011 that says that inappropriate use of antimicrobials drives the development of drug resistance.

“Overuse, underuse and misuse of medicines contribute to the problem,” Zowawi adds, saying that intervention is needed to battle “the medical disaster facing the GCC states. Improving basic infection control precautions like hand hygiene, and prohibiting the availability of antibiotics without a prescription should also be mandatory, particularly in conjunction with a mass education campaign about antibiotic use.”

Professor David Paterson, who worked on the study with Zowawi, says the research team has developed the first regional network of collaborating hospitals and institutes to study superbugs in the region. They hope the network will eventually develop continuing surveillance for antibioticresistant bacteria.

Government action

The real question that remains is how the GCC governments and healthcare watchdogs can manage the sale and use of antibiotics in the region to avoid population-wide resistance to these drugs. Most believe it is important to establish a region-wide surveillance system to monitor the emergence and spread of antibiotic resistance across borders. Zowawi works as part of a project in which hospitals in the Gulf states collaborate to share data and samples of antibiotic-resistant bacteria.

But more needs to be done. Many, if not most, of the GCC states do not have clear guidelines for antimicrobial use, and lack policies for restricting and auditing antimicrobial prescriptions. A study by researchers from the King Abdullah International Medical Research Center in Riyadh notes that there are no guidelines for the use of antimicrobials in the animal industries in the GCC wider region.

“It is, therefore, not surprising that antimicrobial resistance has emerged in these countries,” the study’s authors write. “There are few reports studying prevalence rates of resistance among the different pathogens and mechanisms of resistance at the national level. Most GCC countries lack the presence of antimicrobial stewardship programmes, especially in the inpatient setting where broad spectrum antimicrobial agents are used.

“Most hospitals’ architectural designs are old, and many harbour two and four-bedded rooms, which do not allow proper isolation of infected and colonised patients with multidrug-resistant organisms.”

Infrastructure demands

The report lists other shortcomings in the region such as the lack of strong infection-control programmes and properly trained infectious-disease specialists or clinical pharmacists in the field of infectious diseases. One of its main criticisms is the lack of properly trained staff – something that might have a bearing on the prevalence of over-the-counter antibiotic sales.

“The lack of clinical pharmacists and infectious disease specialists may be a major contributor to the current emergence of resistance,” the authors write.

“Multidisciplinary teams including infectious-disease specialists, surgeons, pulmonologists, emergencyroom specialists and clinical pharmacists may be needed to enhance the use of antibiotics, and play an important role in recommending the appropriate antimicrobial regimens and proper guidance on treatment and de-escalation.”

It’s clear that the GCC’s experts realise there is an issue and that more needs to be done. But this does not seem to break through to the wider population. Like many aspects of declining healthcare rates in the GCC, the issue comes down to a lack of proper monitoring of official channels for the distribution. More should be done to police and monitor the sale of the drugs, and to fine and shut down businesses that break the rules.

The second, and perhaps more important, aspect is to introduce a wide-scale public education programme that covers all aspects of antibiotic protocol and safety, and shows patients how to correctly use antibiotics.

In many Western nations, patients are given a sympathetic look and told to drink more fluids when they present at a doctor’s office with a request for antibiotics, so prevalent has the fear of resistance become. GCC pharmacists and doctors must draw the line, too. A government-funded education campaign on the dangers of antibiotic overuse must be enacted in the GCC. Given the gravitas of the situation, such an education programme will be valuable in curbing not just the number of pharmacies that are selling antibiotics but also the high numbers of customers asking for them.