We know that antimicrobial resistance (AMR) is a global problem, but how is it seen and experienced in different regions of the world? Cultures asked some of our ASM Country Ambassadors and Young Ambassadors to share their personal observations of AMR in their home countries so that we can get a glimpse of what AMR looks like, from Thailand to Afghanistan.
Suthat Saengchoowong – Thailand: Responsible prescription of antibiotics to animals
In Thailand, inappropriate uses of antibiotics are commonly found in vet practices, in both companion and food-producing animals. For instance, some veterinarians prescribe antibiotics for viral infections, and most use these drugs empirically, ignoring the importance of antibiotic sensitivity testing.
To address this problem, schools in Thailand currently urge and educate vet practitioners and students to be aware of this crisis. For food-producing animals, the governmental authorities have launched laws and regulations towards a withdrawal period. Despite these regulations and education programs, the lack of awareness at the public level is still a major hindrance to addressing proper antibiotic use.
Edgard Lafia – Benin: Self-medication
According to studies, self-medication is a common practice in most African countries, and Benin in particular. The three determining factors are free sale of most drugs in drugstores without prescriptions, sale of imitation drugs in markets and sometimes on the street, and the low purchasing power of the people. The ministry of health tries to raise public awareness against counterfeit drugs, mainly through radio and TV spots.
Ghazal Hassan – Morocco: Growing E.coli resistance
Nosocomial infections from resistant E. coli in Moroccan hospitals are increasing in prevalence. A lack of resources in Moroccan hospitals leads to a lack of proper hygiene, which is the main cause of the spread of nosocomial infections. Poor-quality toilets and the lack of maintenance of sanitary facilities are also major factors.
In order for health workers to properly identify E. coli strains in Moroccan hospitals, they must search for pathogenic germs in every infection. The problem is that neither the hospital nor the patients can afford these investigations. This results in prioritization of patient treatment over the identification of the germ and its serotype. We believe that this attitude toward treatment is an important factor in the development of resistance in bacteria.
Bernardo Elias Correa Soares – Brazil: Best practices are key
Biosafety in veterinary facilities is very important for preventing the spread of resistance. A comprehensive antimicrobial monitoring system is in place at most food-animal facilities. One of the key measures to lessen resistance is lowering the use of important antimicrobials in food animals.
Naturally, poorly equipped facilities may be a port of entry for germs. At the same time, resistance control programs depend upon reliable methods to diagnose infections and test antibiotic susceptibility. These basic principles must never be neglected. More importantly, rigorous observance of biosafety norms, hygiene, and cleanliness in the work place, according to infection control best practices, is paramount, be it GLP (laboratory) or GCP (clinical) practices).
Gnatoulma Katawa – Togo: House pharmacies
In our system there are many instances of self-medication as a result of poverty and corrupt government policies. For example, there are many nonprofessional practitioners who have private clinics in their homes; they prescribe a lot of antibiotics. This is made possible due to pharmacies failing to verify prescribers and the pharmacies’ motivation to sell more of their products. Compounding this problem is not only the quality of the drugs, but also the conditions in which these products are stored. People are often drawn to these “home pharmacies,” as they cannot afford hospital visits. There they are also able to obtain drugs immediately, further increasing the appeal of avoiding the hospital. This situation is widespread and visible.
Rama Chaudry – India: Rising metronidazole resistance
Antibiotic resistance increases the risk of sepsis in India, which is currently the leading cause of morbidity and mortality in Indian neonates.
Members of the Bacteroides fragilis group are the most commonly isolated anaerobic pathogens in humans. Metronidazole has been the drug of choice for preventing and treating such infections for 40 years. Although B. fragilis has the broadest spectrum of recognized resistance to antimicrobial agents among anaerobes, the worldwide rate of metronidazole resistance remains low, <5%.
I was a member of the group that reported the first metronidazole-resistant strain of B. fragilis from India. A 34-year-old man was admitted to my hospital with bleeding gums, myalgia, and general malaise. Over the course of four months in the hospital, his condition started to deteriorate. Postmortem blood cultures grew B. fragilis, and showed resistance to a host of antibiotics used to treat the patient, including metronidazole.
Because antimicrobial sensitivity testing of anaerobes is not being done in most laboratories around the world, it is difficult to estimate the precise incidence of resistance to metronidazole. The acquisition of metronidazole resistance by B. fragilis, reported here, emphasizes the need for a study to more accurately assess susceptibilities of clinical isolates. Diagnostic microbiology laboratories and clinicians should be more aware of the incidence of metronidazole resistance.
Maria Alexandra Garcia Amado – Venezuela: Environmental reservoirs of resistance
I have cultured feces from the wild and observed growth of gram-positive bacteria in culture media with antibiotics. Additionally, I have found antibiotic resistance in Vibrio isolates from marine waters. These findings tell me that wildlife can be reservoirs of bacteria with antibiotic resistance, but more studies are needed to determine resistance mechanisms.
In my country, antibiotics are sold by prescription only. However, in my opinion, the problem lies in getting medical, veterinary, and dental professionals to give prescriptions only in specific cases. Venezuela is now experiencing a difficult economic situation, and we do not have access to medicines, including antibiotics.
Riika Ihalin - Finland: Cautious use has good results
A recent study (in 2014) by the National Institute of Health and Welfare shows that antibiotic resistance is not a big problem in Finland, and in some cases the prevalence of antibiotic-resistant bacterial strains has even decreased. I think this is because the National Institute of Health and Welfare monitors the AMR situation in Finnish hospitals regularly. Moreover, we use antibiotics with caution both in food production and in outpatient treatment.
MDs in Finland inform their patients about the potential risks of unnecessary courses of antibiotics. However, people should be reminded about the possible risks of the introduction of resistant strains from other countries.. For example, after the tsunami in Thailand, several patients that were transported from Thailand to be treated in Finland brought resistant strains
Abdul Hakim Aziz – Afghanistan: Problematic imported medicines
The problem of antibiotic resistance in Afghanistan, beside other reasons related to the microbes themselves, is due to: illegal/nonqualified medicine, especially antibiotic imports; lack of quality control labs in provinces; irrational use of medicine; and lack of culture and antibiogram facilities in many provinces.
Illegal medicine: Many medicine-importing companies in Afghanistan have close ties to powerful people and parliament members, and they import substandard medicine illegally for profit. 98% of the medicine in Afghanistan is imported from other countries: 60%from Pakistan; 30% from India, China, and Iran combined; and the remaining 10% from other countries. Many of these medicines are imported without taxes or quality control, and they are low-quality medicine; some are even labeled “for export only.”
Lack of quality control labs: We have just one quality control lab in Kabul, one in Herat (Iran border) and one in Nangrahar (Pakistan border).These labs solely control the physical quality of medicine, such as production date, expiration date, batch numbers, packing shape, color of medicine, and chemical quantity and quality. Sampling practices are not qualified either, as they are not representative of all imported medicine.
Irrational prescription of medicine/antibiotics: Different studies in Afghanistan show that up to 60-70% of prescriptions contain antibiotics, 70-85% of them lack appropriate dose and duration , and irrational combinations of antibiotics are common in public and private health sectors of Afghanistan due to lack of trust of the quality of medicine/antibiotics.
Poor knowledge and training of medical staff and poor public awareness of misuse of antibiotics without a prescription further complicate the situation.
Read the latest issue of Cultures to hear more perspectives on AMR, from scientists, policymakers, economists and food producers.