Are Developing Countries on the frontline of our war against Antimicrobial Resistance?
Updated: Nov 17, 2017
Happy Antibiotic Awareness Week (13th - 19th November 2017)!
"A whole WEEK?" Well if that sounds excessive, perhaps you didn't realise that Antimicrobial Resistance (AMR) is one of the greatest threats to your health, safety and livelihood?
Concerned? You should be...
What are antibiotics and antimicrobials?
An antibiotic is a medicine designed to "fight" bacteria. Antimicrobial describes any medicine that "fights" a microbe (aka a microorganism). Microorganisms are invisible to the naked eye and include bacteria, viruses, fungi and protozoa. So "antimicrobial" is a collective term for the drugs that help us to overcome these infections i.e. antibiotics, antivirals, antifungals, antiprotozoals etc.
Man vs Microbe
Our bodies provide a potentially warm, comfortable and nutritious environment for microorganisms, so we're a prime target for them. Although we live in peaceful harmony with trillions of them, problems arise if they are pathogenic (cause harm) or if they become overwhelming in number.
Our immune system wages a brutal and daily war against pathogens, keeping us safe from infection. But sometimes a pathogen may outwit our immune system - perhaps because it's particularly virulent, or because we're more vulnerable due to injury, poor health, malnutrition, age, stress and so on. At these times, we're dependent on antimicrobials to fight the war that we can't - to protect us from disease and to allow us to recover.
But this infers that there is, and always will be, an antimicrobial to save the day. Increasingly, this is not the case.
The rise and rise of Antimicrobial Resistance (AMR)?
Our war against germs is not a static one. Microorganisms may rapidly adapt methods to undermine or resist our medicines. Common mechanisms for this include:
pumping the antimicrobial back out of the bacterial cell.
creating proteins that degrade the antimicrobial.
changing or protecting the target site of the antimicrobial.
...all of which renders the antimicrobial ineffective.
As a result, clinicians must turn to another medicine for treatment: one that is sufficiently different in its chemical structure to be unaffected by the type of AMR, but one that is still active against the type of pathogen. In several infectious diseases "multidrug resistance" is becoming increasingly common and a prescriber's options for treating disease are dwindling.
Unsurprisingly AMR increases the likelihood of treatment failure and of mortality. But there are a host of associated hospital costs that further drain the health system:
Increased length of hospital stay... and in more expensive beds (e.g. isolation or intensive care).
Increased use of medical devices and equipment (e.g. ventilators, imaging, laboratory tests, blood screens).
Increased demand for staff, in terms of their number, seniority and speciality.
For the individual, antimicrobial resistance may cause:
Impoverishment, due to loss of earnings and out-of-pocket healthcare costs.
Impaired livelihood or standard of living for self and dependents.
Morbidity (transient or permanent disability) through prolonged ill-health and use of medicines with a poor toxicity profile.
Are those in developing countries at the greatest risk?
The quality and availability of healthcare is not evenly distributed across the globe. Although AMR is a global threat, surely those in low income or "resource poor" countries are at the greatest risk and may be disproportionately affected?
Falsified medicines. A "falsified" medicine is a fake - a spurious substance created by criminals for financial gain. It may contain a small amount of drug in order to fool Quality Control checks, but a falsified medicine will have no therapeutic benefit. Its threat to health is obvious but, in the case of antimicrobials, it can also have a broader public health impact e.g. by undermining "herd immunity", enabling the spread of the pathogen and by encouraging antimicrobial resistance due to sub-therapeutic dosing. National drug regulation, which is designed to protect the population from falsified medicines, is an expensive and highly skilled business. Low income countries lack the resources to regulate their national pharmaceutical markets effectively - and are therefore actively targeted by counterfeiters.
Cost. New drugs, or drug formulations, are protected by a patent for up to 20 years. Whilst patented, the drug company has the exclusive right to market the product - and ordinarily does so at a cost that is prohibitive to most buyers. Many countries have insufficient budget to afford patented "brand" medicines. Equally those living in or near poverty will be unable to purchase medicines privately. These individuals will therefore have fewer therapeutic options - and those that remain are likely to be restricted to older medicines with a greater likelihood of AMR.
Drug development. Pharmaceutical R&D (research and development) is normally focussed on discovering drugs with the potential to generate high revenues, rather than the potential to address the world's greatest health needs. Infectious diseases - particularly those uncommon in the West - do not offer much return and so gain relatively little investment. Did you know that there hasn't been a new class of antibiotic on the market for over 30 years?
Access to effective healthcare. Lack of resources and vulnerability to conflict, disaster or corruption will erode the effectiveness of the health system. Lack of laboratory and diagnostic equipment will make infections harder to identify and treat. Lack of supportive or critical care options, especially for infants, may negate options for intensive therapy or aggressive disease management. Weak prescribing culture and Clinical Governance will result in inappropriate and unrestrained antimicrobial use. Finally, obviously, lack of access to essential medicines will make treatment an altogether a futile endeavour.
Undernutrition. "Undernutrition" is a deficiency of calories and micronutrients in the diet, which impacts health and growth. It's a vicious circle: undernutrition makes an individual more susceptible to disease and, during that infection, their nutritional requirements will increase. Not only this, but chronic undernutrition during childhood may have a permanent effect on the individual. So the undernourished are at greater risk of infection and will have a greater reliance on antimicrobial therapy.
Immunosuppression. HIV, AIDS and TB have a far greater prevalence in developing countries and are less likely to be well-controlled. These illnesses may make a patient more susceptible to concomitant and opportunistic infectious diseases, which - for all of the reasons listed - will be more challenging to treat in developing countries.
What can you do... as a patient?
Only use antimicrobials if prescribed by a healthcare professional.
Don't share your antimicrobials with someone else, even if you think it's the same infection.
Complete the prescribed course of antimicrobials, even when you start to feel better.
Take the antimicrobial as prescribed - following the directions for the right dose, frequency and timing in relation to meals.
Educate your friends and family about being more #AntibioticAware - and remind them that don't treat viral infections.
What can you do... as a healthcare provider?
Don't prescribe antimicrobials unnecessarily - even if your patient pressurises you to do so!
Always follow your antibiotic or antimicrobial treatment protocols - seek advice from your pharmacist or laboratory if you are unsure.
Educate your patient about how to take their antimicrobials safely and effectively.
Become a champion for the appropriate use of antibiotics - help to raise awareness about AMR and good antimicrobial stewardship.
Support the World Health Organisation's "Global Antimicrobial Resistance Surveillance System" (GLASS).
Be especially sparing of parenteral or second and third line antimicrobials - they may be our last line of defence.
So Happy Antibiotic Awareness week... "A whole WEEK?" I agree - it's not enough, let's try to make it last all year.
World Health Organisation, available here: http://www.who.int/campaigns/world-antibiotic-awareness-week/en/
About the author:
Kate's the founder of Global Pharmacy Exchange where she strives to connect and empower the Global Pharmacy Workforce for the sake of #UniversalHealthCoverage ... and because she's a bit of a pharmacy geek.