Even before Covid, antimicrobial resistance, in which microbes no longer respond to common drugs such as antibiotics, was a major concern of public health organizations and healthcare professionals.
In 2019, the latest year for which data is available, antimicrobial resistance killed 95.4 million people worldwide, making it the third leading cause of death after cardiovascular disease and cancer.
Experts say that after more than two years of Covid, as a result of the widespread and inappropriate use of antibiotics caused by treatment protocols, antimicrobial resistance is worsening significantly in many countries.
This is worrisome because, in addition to the germs that cause well-known diseases such as typhoid and tuberculosis, which are still prevalent in low-income countries, bacteria that cause common blood, lung, and urinary tract infections are also gaining resistance to existing drugs. Meanwhile, the pharmaceutical industry is not interested enough in making antibiotics because their market is not lucrative.
According to predictions, by 2050, 10 million people worldwide will die each year from diseases that we could once treat. Unfortunately, 90% of these deaths will occur in low and middle income countries.
Antimicrobial resistance in itself has been a long-term, neglected phenomenon. Covid-19 has highlighted the need to abandon the culture of liberal consumption of antibiotics.
We need to tighten regulations on prescribing these drugs and teach healthcare providers around the world to be more rigorous in their use of antibiotics. We should also increase the level of hygiene in order to prevent the spread of disease-causing bacteria. We need better diagnosis and stronger vaccination programs.
We are running out of options, and the infectious bacteria that infect so many people in non-Western countries are on the verge of winning a battle that was once within our control.
Consider, for example, India, which is the world’s largest consumer of antibiotics and where the culture of antibiotic consumption is deeply rooted. Doctors prescribe antibiotics for diseases such as colds or diarrhea and even short-term fevers.
Many factors cause these prescriptions; Such as lack of proper knowledge about when to use antibiotics, lack of diagnosis, inability of patients to pay for diagnostic tests, economic incentives, patient demand and fear of worsening of the patient’s condition.
Pharmacists, who serve as the first stop of healthcare in many parts of India, do the same, as antibiotics are usually available without a doctor’s prescription.
But antibiotics are often not effective because most of these diseases are viral and not bacterial. However, because of their widespread prescription, the general public believes that they are effective. Therefore, it is not surprising that India, considering the population of more than one billion and easy access to antibiotics, is heavily involved in the inappropriate use of this class of drugs.
More puzzling is the high burden of bacterial infections in India, where antibiotics are widely prescribed. However, due to the widespread misuse of these drugs, infectious bacteria are developing defenses against these drugs. So, while they are needed, they are losing their power.
The globalization of covid has intensified the inappropriate use of antibiotics. Even though Covid is a viral infection and the rate of secondary bacterial infections is low, this trend probably caused Indians to take about 216 million extra doses of antibiotics in the first wave of the disease in 2020. This is despite the fact that according to the guidelines of the World Health Organization and even the national health guidelines of the Indian government, antibiotics should not be used for mild and moderate cases of Covid.
The practice of inappropriate use of antibiotics spread to subsequent waves of covid, which included delta and amicron strains, and probably exacerbated the problem of antimicrobial resistance in this country.
Of course, India is not alone. Researchers in other low-income countries, including Bangladesh, Pakistan, Brazil, and Jordan, have observed similar patterns of antibiotic misuse.
Several solutions to this problem have already been mentioned, but the most important thing we can do is to change the culture, that is, to change the attitude and approach of health care providers and the general public towards antibiotics in low- and middle-income countries.
For example, in India, acute upper respiratory tract infections, possibly viral, account for the majority of unnecessary antibiotic prescriptions, yet national standard treatment guidelines are not readily available to most health care providers. On the other hand, even when these guidelines exist, they are not user-friendly and do not explain the responsible use of antimicrobials, and the physician cannot easily use them.
In this regard, in 2017, the World Health Organization developed the AWaRe (Access, Surveillance and Precaution) framework for antibiotics, which classifies drugs based on the risk of developing resistance.
The World Health Organization will soon publish a book on antibiotics with simple data entry, as well as a mobile app that provides best practices in the assessment, diagnosis and treatment of various infections in outpatients and in-hospital patients using a beacon approach.
Recent evidence from China has shown that the guiding light approach to clinical guidelines for upper respiratory tract infections reduced the amount of antibiotic prescription in the intervention group from 82% to 40%, while in the control group, antibiotic prescription decreased from 75% to 70%. did
However, it is challenging to change human behavior and overcome several decades of abnormal practice, especially among practicing doctors who work in private and informal sectors.
Formative client studies, in which trained individuals go to health care facilities in the role of hypothetical clients and then report their experiences, suggest that there is a gap between what health care providers claim to do for a particular illness and what they actually do in routine clinical practice. They give, there is a difference.
Governments and health care systems should do more to prevent the over-the-counter sale of restricted drugs and the direct sale of drugs by pharmaceutical companies to people without medical training, and to help ban unreasonable fixed-dose combination drugs. The entry of fake drugs into the market. At the same time, they should help develop programs to facilitate the responsible use of antimicrobials in hospitals and primary care settings.
India is another example of how regulation can be useful. The 2018 ban on fixed-dose antimicrobial drug combinations has succeeded in reducing sales of antibiotics in India. Similarly, over-the-counter antibiotic bans in Chile and Brazil have led to a decrease in antibiotic sales.
In addition to ongoing efforts to improve antibiotic use among current prescribers, it is time to prepare future physicians to become better at prescribing antibiotics.
Antibiotics are a limited resource and if used inappropriately, they have a great impact on society. Medical schools and training programs should train physicians to use standard treatment guidelines when prescribing antibiotics. The focus on future doctors will have a domino effect among the public, pharmacists and health care providers who work informally. Doing so, while dealing with the current outbreak, will protect us against future outbreaks of antimicrobial resistance.