A unique combination of factors, including overprescription of antibiotics and poor infection control practices, has led to the GCC countries becoming a hub for antibiotic-resistant bacteria or, as they’re more commonly known, superbugs.
A single-pronged strategy simply won’t be enough to address an issue that’s putting healthcare professionals’ ability to treat common infections at risk; what’s needed is urgent, coordinated action encompassing education and antibiotic stewardship programmes, better and faster diagnostic tests, and widespread surveillance. Otherwise, these superbugs will spread even further, creating a potential scenario WHO has described as “a post-antibiotic era, in which infections and minor injuries that have been treatable for decades can once again kill”.
Research carried out over the past few years by scientists at the University of Queensland (UQ) has found that the Gulf states are facing a rapid rise in superbug prevalence. Acinetobacter baumannii, a bacterium well known for being antibiotic-resistant and associated with dangerous hospital-acquired infections, for example, has been found in Saudi Arabia, the UAE, Kuwait, Qatar, Oman and Bahrain.
Furthermore the researchers discovered that the prevalence of a strain of potentially deadly superbugs called carbapenem-resistant bacteria, that kill up to half of infected patients has increased by up to 90% over the past two decades. They were even able to identify and describe, for the first time, one member of this superbug family, Klebsiella pneumoniae, that is pan-resistant; in other words, it can’t be treated by any commercially available antibiotics.
The new normal
The prevalence of bacteria that are not only immune to antibiotics but are also, in some cases, cloaking themselves in genetic material to avoid detection has led to a situation where patients in the region are at risk of dying from common, normally treatable, conditions such as urinary tract infections because they harbour these superbugs.
Even more worryingly, superbugs aren’t only being transmitted between patients within hospitals – they’re spreading much more widely, as evidenced by the fact that bacteria with identical genetic fingerprints are scattered across the entire Arabian Peninsula.
“We know that the last things infectious diseases respect are borders,” says Hosam Zowawi, a Saudi Arabian-born PhD student at the UQ Centre for Clinical Research who played a key role in setting up the region-wide collaborative study on superbugs in the GCC. “If such a monster [pan-resistant K. pneumoniae] exists, it will find its way to other parts of the world, no matter what.”
According to Zowawi, improper use of antibiotics is one key reason the current situation has arisen; not only are antibiotics available over the counter in many GCC countries but doctors are also prescribing too many on a trial-and-error basis because they don’t have the ability to identify the correct antibiotic for each patient when treatment is urgent. Most existing diagnostic tests take 48–72 hours to detect resistant bacteria.
On top of this, Zowawi believes infection control practices in the GCC need to be strengthened. “There is a lot of evidence that infection control is quite unoptimised in some hospitals, and that is how bacteria are being transmitted from one patient to another, or from the health worker to the patient or vice versa,” he notes. “It’s very important to develop stronger precautions to limit the spread of superbugs.”
Finally, two other factors external to the healthcare setting make the GCC particularly susceptible to superbug spread: travel patterns and the current geopolitical situation in the region.
“Travel is one of the main ways infectious diseases are spread,” Zowawi says. “Not only do the Gulf countries, particularly Saudi Arabia, receive a lot of international visits during the Hajj pilgrimage season, but the UAE, particularly Dubai, also receives a lot of international travellers going through Dubai to their ultimate destinations. This increases the ‘fluidity’ of exchanging bacteria, including antibiotic-resistant bacteria.”
War is another factor that encourages the transmission of infectious diseases. “Superbugs are well known to excel during wartime, so the issue of the Syrian refugees, for example, is a serious one,” Zowawi stresses. “A study we undertook with our colleagues in Jordan found antibiotic-resistant bacteria among Syrian refugees
settling in Jordanian cities.”
Networked response
There are a number of positive signs that suggest progress is under way to start to combat the spread of superbugs in the GCC, however, even if it is slow. Antimicrobial stewardship programmes (ASPs) designed to limit the overuse and misuse of antibiotics, for example, are becoming much more widespread as hospitals in the GCC follow the example of their colleagues in the US.
One initiative Zowawi cites as being particularly effective is the University of Pittsburgh Medical Center’s interactive telephone approval service. For a number of restricted antimicrobials, the requested product is reviewed by an infectious disease specialist before being prescribed. If it’s not the right drug for the patient, an alternative will be provided in the context of the clinical situation.
“These kinds of programmes are being replicated and implemented across the GCC, as well as in Australia and around the world,” he says. “There is a huge movement in the infectious diseases world towards implementing ASPs in hospitals, although I personally think more needs to be done in the community setting too. Community medical centres are not as well regulated as hospitals and this is one of the main issues.”
Surveillance is another area in which progress is undoubtedly being made, with Zowawi and his colleagues at UQ at the helm. Indeed, the statistics cited earlier were just a few examples of the insight to have come out of the collaborative network they established in late 2011 to monitor the emergence and spread of superbugs in the region. Currently, seven hospitals in six Gulf states – Bahrain, Kuwait, Oman, Qatar, Saudi Arabia and the UAE – are sharing data and samples of antibiotic-resistant bacteria via the network.
Alongside this, Zowawi, who became the first scientist in the Middle East to win the prestigious Young Laureates prize at the Rolex Awards for Enterprise in 2014, has also been working behind the scenes to develop diagnostic tests that work much faster than current ones.
“The test we have developed can characterise and identify the genetic characteristics of bacteria in a couple of hours instead of days,” he explains, adding that this will help clinicians apply targeted treatment and implement infection control precautions more quickly.
Education the key
It is still early days, however, and on several fronts – most notably education, technology development and monitoring the spread of superbugs – much more needs to be done. For Zowawi, education must be the region’s biggest priority.
“We have to develop tailored education programmes on infection control and antimicrobial resistance to raise all stakeholders’ awareness – the public and healthcare professionals, as well as people in the agriculture industry,” he says. Antibiotic use in agriculture could also be contributing to antibiotic resistance, although Zowawi points out that there is no evidence to support this in the GCC yet.
“What’s most important is to create an awareness campaign that is designed from the bottom up – someone needs to observe exactly what the public and the community needs, and develop a campaign to fit those needs.”
Zowawi hopes to be that someone. “There’s an obvious need to develop an education programme, and that’s what I’d like to base my next six to 12 months on,” he says. “I would do formative research to understand what the culture knows and then design an education programme based on that.
“My aim is not just to raise awareness – it’s to change behaviour, which will result in reducing the issue of antimicrobial resistance.”
And that’s not all the award-winning scientist has planned. Not satisfied with just a GCC surveillance network, he hopes to expand what he and his colleagues have already put in place across the whole MENA region.
“I would love more hospitals in Jordan to join us, and I’m in contact with Médecins Sans Frontières, which will hopefully be able to give us some access to the refugee camps in Jordan and other neighbouring countries to study the spread of superbugs,” he explains. “I’d also love to collaborate with hospitals in Lebanon and Egypt in order to get a better understanding of the issue of antimicrobial resistance in the whole MENA region.”
The collaborative network the team has developed up until this point has already resulted in the creation of a document designed to help individual countries develop national plans to reduce antimicrobial resistance.
Finally, better diagnostic technology will be essential in the effort to effectively combat the spread of superbugs, and this is one area that Zowawi isn’t alone in pinpointing.
Indeed, while he is working on a diagnostic tool that is more suitable for clinical situations than the one he has already designed, the UK’s Nesta Foundation and the White House have launched award schemes, worth £10 million and $20 million respectively, to reward scientists that can come up with cheap point-of-care tests for bacterial infections.
Zowawi and his colleagues’ work is clearly only the tip of the iceberg, but it does offer one very important lesson to healthcare stakeholders in the GCC: the only way to get close to solving what has become an incredibly troubling problem for the region will be through a joined-up approach, encompassing improved surveillance, education, technology and antibiotic stewardship.
Otherwise, there will be little to stop the superbugs that are becoming increasingly resistant to all known antibiotics spreading even further afield.