Imagine a world without any effective antibiotics.
Imagine a time when a mild bacterial infection is non-responsive to most or all of the available antibiotics, and a patient develops sepsis and then eventually dies.
This is what experts are terming ‘the post-antibiotic era‘.
Antibiotic resistance is a significant problem in the world at large, cutting across both developed and developing countries.
Antibiotic resistance can simply be explained as the ability of bacteria to become resistant to concentrations/doses of antibiotic, which they would normally have been sensitive to. As a result, antibiotics become ineffective in the prevention and treatment of infections.
Apart from the burden antibiotic resistance poses to the human race- in terms of deaths from infections due to resistant organisms- antibiotic resistance also leads to huge financial burdens to health care systems. This could be as a result of the costs spent on purchasing much more effective and potentially more expensive antibiotics for increasingly resistant infections, or due to increased lengths of stay in the hospital, loss of productivity in the workplace and consequent negative effects on the economy of the country.
While antibiotic resistance rates are rising, the development of new antibiotics is growing at a slow pace. The costs associated with research, production of new antibiotics among other factors are some reasons for this slow rate of development. And imagine if after pharmaceutical companies invest so much in developing new antibiotics, and by the time the antibiotics are released into the market, resistance to them has developed
In the year 2015, Public Health England launched an Antibiotic Guardian Campaign to raise awareness about the imminent effects of antibiotic resistance and to encourage people to be proactive about preventing antibiotic resistance. As part of this campaign, people (healthcare professionals, students and members of the public) were encouraged to make pledges towards measures they would take or things they would do to help in combating antibiotic resistance.
Causes of Antibiotic Resistance
Antibiotic resistance occurs when bacteria become ‘smarter’, mutate, and the antibiotics used against them become less effective.
There are a number of factors that are responsible for the development of resistance to antibiotics. Key among them is inappropriate prescribing of antibiotics, misuse/irrational use of antibiotics; taking antibiotics when they are not needed, not taking them for the prescribed duration/course or taking them inappropriately. Antibiotic resistance can also occur due to improper use of antibiotics in animals. This is an aspect of antibiotic resistance that is not commonly discussed. In seeking to proffer solutions to the problem, in addition to engaging key stakeholders, the veterinary sector needs to be engaged and educated on the dangers of misuse of antibiotics and the danger of antibiotic resistance.
Antibiotic Use in Nigeria
There is a high rate of antibiotic misuse in Nigeria. In developed nations like the UK, antibiotics are only sold when a prescription is tendered and such prescription is only written when proper testing has been carried and the General Practioner (GP) ascertains a need for that antibiotic. In Nigeria, one can easily walk into a pharmacy and ask for an antibiotic over the counter for conditions where an antibiotic would not logically be indicated.
The absence of policies with respect to antibiotic use and sale in Nigeria is a big factor in its current misuse.
Solving the Problem of Antibiotic Resistance
There is no quick-fix solution to the problem of antibiotic resistance. Resistance among bacteria is inevitable as it is part of their evolutionary development. Bacteria existed before humans themselves and so the only way we can solve the problem of antibiotic resistance is by employing measures that prevent infection, preventing inappropriate use of antibiotics, restricting easy access to antibiotics (by implementing policies and ensuring compliance with them) and the use of persuasive methods such as education
Infection prevention and control strategies are key in reducing the development of infection and preventing the propagation of resistant bacteria. Simple hand hygiene practices in the community, workplaces and in hospitals are very important.
Antimicrobial stewardship involves coordinated activities and efforts that are carried out to ensure the proper use of antibiotics, through the collaboration of a multidisciplinary team. Antimicrobial stewardship teams commonly exist in hospitals in developed countries, and could also exist in the community.
An antimicrobial stewardship team consists of an infectious disease physician, an antimicrobial pharmacist/clinical pharmacist, microbiologist(s), nurses and hospital management (and may include other key members of the healthcare team).
The team is responsible for the drawing up of guidelines on the use of antibiotics, implementing strategies for rational use of antibiotics, education of hospital staff, and quality assurance of antimicrobial stewardship activities.
Implementing antimicrobial stewardship activities in a relatively resource-poor setting like Nigeria will be faced with many challenges, ranging from the lack of awareness about the dangers of antibiotic resistance to inadequate qualified health personnel. Lack of funding, lack of equipment in some settings (particularly laboratory diagnostic equipment), and poor infrastructure are also other challenges that will be encountered.
We need action from the governments at all levels to implement policies that guide the development of national antimicrobial stewardship teams and site-specific antimicrobial stewardship teams. Staff need to be trained and antimicrobial stewardship should be implemented in all hospitals. Infection prevention and control practices should be enforced and the general public and healthcare staff should be educated. Monitoring of activities should be done at all levels, by the local, the State and the federal government, with the Nigeria Centre for Disease Control suitably spearheading the fight against antibiotic resistance in Nigeria.
The Role of Pharmacists
As pharmacists- medicines experts and custodians of medicines, we should be placard carrying antibiotic guardians! Antibiotic misuse and concurrent antibiotic resistance is a big issue. Every antibiotic we dispense should serve a rational purpose. When a simple solution can be provided to a patient’s condition, let us desist from offering antibiotics first. Wisdom is also needed in knowing when to refer cases to a physician especially when practising in the community. We should as much as possible let our clinical decisions be guided by a strong evidence base.
It is sometimes saddening to find out that even pharmacists/pharmacy staff can be players in the irrational use and ‘irrational sale’ of antibiotics. Regardless of the fact that we have no policies in place in our country- on the offering of antibiotics over the counter without a prescription- we pharmacists should utilize the knowledge we have and constantly educate ourselves. When clients come to ask for antibiotics, let us take the proper history from them and ascertain whether or not an antibiotic is really needed at that point in time, and then refer them to get a laboratory test done (some community pharmacies in Nigeria have diagnostic centers in their premise or close to their establishment) or refer them to a doctor. Avoid the temptation of offering an antibiotic for the common cold, for example.
Let us be educators on the importance of the rational use of antibiotics whatever setting we find ourselves.
So next time a lovely client walks into your community pharmacy and immediately requests a specific antibiotic, do the proper thing, take the appropriate history and think ‘rational use’ over making a sale. It is also very important not to leave pharmacy assistants to handle clients like this.
Let us take charge of our role as medicines expert, antibiotic guardian, and life-saver (literally), and play a part in ensuring that we save our antibiotics, and improve the health of the world at large.