An ominous future: common infections can kill us

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While recent health crises, such as the deadly Ebola outbreak in West Africa, have caused much human and economic devastation in the affected countries and tested the resolve of the international community, the past hundred years have witnessed dramatic improvements in human health not seen in previous centuries when life was in most cases “poor, nasty, brutish and short” as Thomas Hobbes, the English philosopher, observed in the 17th Century.

A quick glance at the main causes of death over time makes this crystal clear. While infectious diseases such as tuberculosis, pneumonia and diarrhea, which were major killers in the first part of the 20th Century, have experience a rapid decline, non-communicable chronic diseases --heart disease, cancer, diabetes, and others, now account for nearly two out of every three deaths worldwide. The dramatic reduction in mortality due to infectious diseases was achieved by advances in scientific and medical knowledge that improved our understanding of how contagion of infectious disease occurred and the application of that knowledge through basic public health practices, sanitation and hygiene, and investments in safe water. The discovery and introduction of medicines that kill microbes in the early 1930s, beginning with sulfa drugs and penicillin, revolutionized medical care and contributed to further health improvements. 

In spite of the health benefits brought by penicillin, Sir Alexander Fleming, who isolated the penicillin fungus, warned in his 1945 Nobel Laureate speech that the widespread use of antimicrobials (AMs) for curing diseases risked making bacteria resistant to these new medicines. Indeed, he foresaw the looming AMR crisis facing the world today, observing that “…the time may come when penicillin can be bought by anyone in the shops. Then there is the danger that the ignorant man may easily underdose himself and by exposing his microbes to non-lethal quantities of the drug make them resistant.”

While AMR is the natural self-defense mechanism of microbes against attacks that threaten their survival, such as from antibiotics, we humans have done our part in aggravating this condition and its impact.  Indeed, one of the most important causes of AMR is inappropriate use of antibiotics in the health system.

As a contribution to a new World Bank report on AMRs launched during the United Nations General Assembly last week, our team conducted a systematic review of the literature and prepared case studies in six low-and middle income countries (Botswana, Croatia, Georgia, Ghana, Nicaragua, and Peru) to provide a cross-country “snapshot” of factors that contribute to AMR.  The analysis focused on the market offer and consumption of antibiotics in the public health system, use of antibiotics in health facilities, availability of antibiotics without prescription in pharmacies (via a self-referred patient that simulated having an urinary tract infection), as well as characteristics of multidrug-resistant tuberculosis and hospital-acquired infections that are usually produced by multi-resistant microbes.

The findings highlight the need for multifaceted action to prevent failures along the therapeutic chain which increase the risk of AMR, including: 

  • Systematic reviews of the type and number of antibiotics available in the market for use in countries. This information is of critical importance for helping develop policy measures to control irrational use of antibiotics; for example, use of fixed-dose antibiotics that include two or more active pharmaceutical ingredients combined in a single dosage form, but without any clear therapeutic advantage over individual ingredients available separately. Also, having this knowledge in low-and middle income countries could help reduce the use of antibiotics already withdrawn from the market in high-income countries due to safety and inefficacy risks, and of redundant brand name drugs with the same antimicrobial, which only confuses prescribers and patients.
  • Formulation, adaptation and incentivized use of treatment norms and hospital protocols to guide appropriate prescription and utilization of antibiotics in the health system. The use of guidance based on scientific and clinical evidence is critical to develop a “cautious prescription and use culture” of antibiotics and other drugs.
  • Education campaigns about the risks associated with the misuse of antibiotics.  These are important for raising awareness of the problem among health professionals, patients and the general population.   
  • Enactment and enforcement of regulatory measures to monitor and control the procurement of antibiotics without a prescription in pharmacies.  This is common practice in low- and middle-income countries, which needs to be strictly regulated and enforced to prevent the indiscriminate use of antibiotics and the risk of AMR. 
  • Infection prevention and control measures at health facilities.  As we saw during the Ebola outbreak, these measures are of critical importance to reduce hospital-acquired infections (HAI), including those caused by drug-resistant pathogens.
  • Measures to support patient compliance with treatment regimens. Since the emergence of numerous cases of drug-resistant pathogens can be traced to poor adherence to the recommendations made by physicians or pharmacists, ensuring treatment compliance is important for controlling MDR.  This is of particular importance in the case of conditions such as tuberculosis (TB) to prevent the onset of MDR-TB and Extensively drug-resistant tuberculosis (XDR-TB), which require extensive, high-cost, treatment for up to two years.  
In moving forward, we have to be clear that in the same way as uncontrolled outbreaks of infectious diseases of animal origin can spread with impunity across national boundaries, AMR can negatively impact rich and poor countries alike, because patients who remain infectious for a longer period of time pose an increased risk of spreading drug-resistant microorganisms to others.  A concerted global effort, with clear goals and targets, needs therefore to be implemented at the country level by governments and   international organizations, including the World Bank Group, to avoid returning to a time when simple infections can kill us.
 
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Authors

Patricio V. Marquez

Lead Health Specialist, Health, Nutrition and Population Global Practice, The World Bank

Albert Figueras

Associate Professor of Pharmacology, Universitat Autònoma de Barcelona and Director of the Fundació Institut Català de Farmacologia (FICF)

Join the Conversation

Ishani Premaratne
October 08, 2016

Thank you for highlighting this important discussion. Your note that one of the most important causes of AMR is inappropriate use of antibiotics within health systems strikes me as especially important for physicians-in-training and medical students who can take heed and advocate for reform within the systems where they are being educated.