By Dr Karim Wanga
As the World marks the end of antimicrobial awareness week (WAAW)18th -24th November, we are all reminded that we have responsibility to do something to prevent emergence of new resistance or prevent and / or slowdown the spread of existing resistance.
Antimicrobial resistance affects human, animal and food security because it threatens the very core of modern medicine, and the sustainability of effective global public health response to the enduring threat from infectious diseases.
The drivers of AMR include indiscriminate use, misuse and overuse of antimicrobials in humans, animals, crop sectors and aquaculture. In addition, poor disposal practices and presence of antimicrobials in the environment, water bodies and water streams.
Antimicrobial resistance (AMR) is the ability of microorganisms (such as bacteria, fungi, viruses and parasites) to change over time and no longer respond to medicines used to treat them (such as antibiotics, antifungals, antiviral agents, antimalarials) making it harder to treat these infections.
All microorganisms can develop resistance to medicines used to treat infectious pathogens and the phenomena is referred to as antimicrobial resistance (AMR).
Antimicrobials are grouped according to the organisms they act primarily against, whether bacteria, viruses, fungi or parasites. The antimicrobials that treat bacterial infections are referred to as antibacterial agents and the majority are antibiotics. Those medicines used for treatment fungal infections are antifungals, parasites e.g., protozoa, worms are treated by anti-parasitic agents and anti-viral agents are used for treatment of viral infections. Most antimicrobials are antibiotics but NOT all antimicrobials are antibiotics.
Antimicrobials are medicines that either kill microorganisms or stop their growth. They may be derived from multiple sources including microorganisms (antibiotics), plants, animals, synthetic and semi-synthetic sources.
Bacteria may have inherent (natural) resistance to antibiotics. For example, an organism may lack a transport system for an antibiotic or organism may lack the target molecule for binding of the antibiotic or as in the case of gram-negative bacteria, the cell wall is covered with an outer membrane that serves as a barrier to permeability against some antibiotics.
Several mechanisms are developed by bacteria in order to acquire resistance. They require either modification of genetic material or acquisition of new genetic material.
It is estimated that about 214000 neonatal deaths occur annually from neonatal sepsis at global level, and they are attributed directly to drug resistant bacteria. Approximately 106 million individuals are infected annually with drug resistant pathogens and gonorrhea is one of the most common infections. Some gonorrhea infections have become untreatable because of resistance to last resort antibiotics.
The low- and middle-income counties (LMICs) are faced with the triple burden of HIV, ineffective healthcare delivery systems and COVID 19 pandemic. The Low- and Middle-Income Countries (LMICs) are also greatly affected by AMR due to the widespread availability and familiarity, generally low cost, and relative safety of antimicrobials agents.
The widespread use of antibiotics has caused a huge increase in the rate and number of resistant bacteria. The strains of resistant bacteria have become widespread. The multi-drug resistant bacteria have reached the proportions that virtually no antibiotics are available for treatment e.g., extreme drug resistant (XDR) TB, enteric fevers and some strains of bacteria that causes cholera (Vibrio cholerae).
Attention should also be paid to emerging resistance to antimicrobials used for treatment for HIV, TB and Malaria. In the case of TB, about 500000 individuals developed multi-drug resistant (MDR) TB in 2014, with an estimated mortality of 210000 that was directly linked to MDR TB. Extensive drug resistant (XDR) TB has been reported by 100 countries across the world. In 2019, 4.95 million deaths were attributed to drug-resistant bacterial infections and 1.27 million deaths occurred in the Africa region.
The health and economic impact of AMR is enormous. The annual deaths from drug-resistant infections are projected to increase from the current 700,000 to 10 million globally by 2050 if nothing is done to intervene on containment of AMR. The global economic cost of AMR is projected to increase to $100 trillion by 2050. The major concern is emergence and spread of multi-drug resistant bacteria, where it seems we are running out of treatment options
Effective antimicrobials are needed for both preventive and curative health services. When used appropriately, antimicrobials could protect patients from potentially fatal infections and improve patient outcomes in complex procedures such as surgery and in the administration of chemotherapy in immunocompromised individuals.
Policy highlights in AMR
Currently several global and national efforts and strategies have been initiated geared towards containment of AMR.
For example, Kenya has put up policies and regulation such as patients and public should only use antibiotics when prescribed by duly qualified and licensed healthcare professionals, take as instructed and finish prescriptions of antimicrobials even when they feel better.
Patients are advised to never use left-over antimicrobials, never share antibiotics with others (friends, relatives, workmates, schoolmates), avoid self-medication, avoid over the counter use of antimicrobials, prevent infections by implementing effective hand washing and hygiene practices, avoiding unnecessary contact with sick people and ensuring up to date vaccinations.
Policy implementation Challenges surrounding AMR
In summary, the threat of AMR is real and it is right here with us. The mechanisms of AMR are now known and explained.
However, the awareness among policy makers at national and county level, local and healthcare facility managers and the general public is inadequate.
The awareness and sensitization on AMR should be strengthened among the key stakeholders and the national action plans, strategies on containment of AMR should be widely disseminated among the communities of practice in all sectors i.e., the human health, animal health, crop sector, aquaculture and the environment.
Kenya has developed and published several guidance on containment of AMR, however these guidelines are not efficiently disseminated and they are not effectively utilized.
The policy makers and the political leadership can contribute to containment of AMR by ensuring development and implementation of legal and regulatory framework targeted at strategic interventions to combat AMR.
They should ensure robust national action plans (NAP) for containment of AMR, implementation of enhanced surveillance systems for resistance, antimicrobial use (AMU) and antimicrobial consumption (AMC), strengthen policies and implementation of infection, prevention and control measures, regulate and promote the appropriate use and safe disposal of antimicrobial medicines and creating awareness on the impact of antimicrobial resistance.
There is insufficient utilization of laboratory data and diagnostics to guide antibiotic prescribing and monitoring of antibiotics treatment. There is limited capacity of laboratory (microbiology) capacity in the country, especially in performing antibiotic susceptibility testing. This is mainly due to the cost implication of susceptibility testing, inadequate laboratory facilities and normalcy in empirical treatment of infections.
The one health Approach to combat AMR
The prospect of the world entering a “post-antibiotic era” where common infections can no longer be treated is a real possibility if pragmatic steps from one health approach are not taken to address the threat of AMR.
Emphasis should be placed on one health and pragmatic approaches that entails structured coordination and collaboration of human health, animal health, crop sector, aquaculture and the environment. Antimicrobials are public good; we should handle them with care!
The healthcare workers can contribute to containment of AMR through prevention of infections by ensuring hand washing, cleaning of instruments and the environment in the healthcare facilities. They should keep the clients’ vaccinations up to date, stop dispensing of antimicrobials without prescriptions, utilize laboratory testing before prescribing of antimicrobials, only prescribe and dispense antibiotics when they are truly needed, prescribe and dispense the right antibiotic at the right dose and frequency for the right duration of treatment.
The communities of practice in the animal sector also have a major role to play in prevention and containment of AMR. They should ensure that antibiotics given to animals including food producing and companion animals are only used to control and treat infectious diseases and they should be given under the supervision of a qualified and licensed veterinary practitioner. They should advocate and participate in the vaccination of animals to reduce the need for use of antibiotics and thus prevent AMR.
Antibiotics are given to food producing animals to treat infections. The animals may develop drug resistant bacteria in the gut. The drug resistant bacteria may then be passed on to humans through food, the environment (water, soil) or by direct human-animal contact. Then there is human to human transmission of resistant bacteria, healthcare associated resistant infections (HAI) where infection is passed on from one patient to another, poor hygiene and lack of adequate infection prevention and control practices (IPC) at our healthcare facilities and the cycle continues.
Promotion and implementation of good husbandry practices and biosecurity measures at farm level is critical in prevention and control of infectious diseases thus reduction in the use of antimicrobial agents. In addition, promotion and application of good practices at all steps of production and processing of foods from animals and plant sources aids in prevention of infections transmission.
The practitioners in agriculture sector should also adopt sustainable systems with improved hygiene, biosecurity and stress-free handling of animals as well as adoption of international standards for appropriate use of antibiotics and the guidelines set out by Food and Agriculture Organization (FAO) and World Organization for Animal Health (WOAH).
The practitioners in the environment sector also have a role to play through protection of water sources from contamination with antimicrobial residues by regulating and enforcing the quantities of antimicrobial residues that are discharged into the environment.
The lack of access to clean water, sanitation and Hygiene (WASH) is another driver of infection transmission which in turn causes an increase in the use of antimicrobials and resistance. The policy makers have little guidance to understand and determine the best management options and approaches to tackle the threat of AMR.
In addition, effective treatment of effluents and wastes from industries, farms, healthcare facilities, slaughter houses and other sources. These activities will reduce spread of genes of resistance antimicrobials in the environment and eliminate residual antimicrobials.
Dr Karim Wanga is the chief principal regulatory officer, Products Safety, at the Pharmacy and Poisons Board (PPB)