Antimicrobial Resistance

 

WHO, FAO, OIE issue urgent call for responsible use of antibiotics in humans and animals

They warn resistance is rising to dangerously high levels worldwide

World Antibiotic Awareness Week was held from 13-9 November with an urgent call for the responsible use of antibiotics in humans and animals to reduce the emergence of antibiotic resistance. The call was made jointly by the Food and Agriculture Organization of the United Nations (FAO), the World Health Organization (WHO) and the World Organisation for Animal Health (OIE).

Antibiotic resistance is rising to dangerously high levels in all parts of the world and threatening the ability to treat common infectious diseases.

Antibiotics are often overprescribed by physicians and veterinarians and overused by the public. Where they can bebought for human or animal use without a prescription, the emergence and spread of resistance is made worse. Examples of misuse include taking antibiotics for viral infections like colds and flu, and using them as animal growth promoters on farms or in aquaculture.

To tackle these problems, WHO, FAO and OIE are leveraging their expertise and working together in a ‘One Health’ approach to promote best practices to reduce the emergence and spread of antibiotic- resistant microbes in both humans and animals.

Dr Tedros Adhanom Ghebreyesus, Director-General of WHO, warns: “Antibiotic resistance is a global crisis that we cannot ignore. If we don’t tackle this threat with strong, coordinated action, antimicrobial resistance will take us back to a time when people feared common infections and risked their lives from minor surgery.”

Commenting on the issue, José Graziano da Silva, Director-General of FAO, notes: “The overuse of antimicrobials blunts their effectiveness, and we must reduce their misuse in food systems. Antimicrobial veterinary medicines are a crucial tool for animal health and welfare and safe food production, but they are by no means the only tool.”

Dr Monique Eloit, Director-General of OIE, added: “Like in human health, veterinary medicine has tremendously progressed thanks to antibiotics. Preserving their effi cacy and availability through their responsible use associated with good husbandry and prevention practices, is therefore essential to preserve animal health and welfare.”

WHO points out that antimicrobial resistance is a complex problem that affects all of society and is driven by many interconnected factors. The organisation notes that single, isolated interventions have limited impact. Coordinated action is required to minimize the emergence and spread of antimicrobial resistance.

All countries need national action plans on antimicrobial resistance, says the WHO. Greater innovation and investment are required in research and development of new antimicrobial medicines, vaccines, and diagnostic tools.

To this end, a political declaration endorsed by Heads of State at the United Nations General Assembly in New York in September 2016 signalled the world’s commitment to taking a broad, coordinated approach to address the root causes of antimicrobial resistance across multiple sectors, especially human health, animal health and agriculture.

 


The current status of antimicrobial resistance

Background
Antibiotics are medicines used to prevent and treat bacterial infections. Antibiotic resistance occurs when bacteria change in response to the use of these medicines.

Antimicrobial resistance happens when microorganisms (such as bacteria, fungi, viruses, and parasites) change when they are exposed to antimicrobial drugs (such as antibiotics, antifungals, antivirals, antimalarials, and anthelmintics). Microorganisms that develop antimicrobial resistance are sometimes referred to as “superbugs”.

As a result, the medicines become ineffective and infections persist in the body, increasing the risk of spread to others.

Antimicrobial resistance occurs naturally over time, usually through genetic changes. However, the misuse and overuse of antimicrobials is accelerating this process. In many places, antibiotics are overused and misused in people and animals, and often given without professional oversight. Examples of misuse include when they are taken by people with viral infections like colds and fl u, and when they are given as growth promoters in animals or used to prevent diseases in healthy animals.

Antimicrobial resistant-microbes are found in people, animals, food, and the environment (in water, soil and air). They can spread between people and animals, including from food of animal origin, and from person to person. Poor infection control, inadequate sanitary conditions and inappropriate food-handling encourage the spread of antimicrobial resistance.

Resistance in bacteria
Antibiotic resistance is present in every country.

Patients with infections caused by drugresistant bacteria are at increased risk of worse clinical outcomes and death, and consume more healthcare resources than patients infected with non-resistant strains of the same bacteria.

Resistance in Klebsiella pneumoniae – common intestinal bacteria that can cause lifethreatening infections – to a last resort treatment (carbapenem antibiotics) has spread to all regions of the world. K. pneumoniae is a major cause of hospital-acquired infections such as pneumonia, bloodstream infections, and infections in newborns and intensive-care unit patients. In some countries, because of resistance, carbapenem antibiotics do not work in more than half of people treated for K. pneumoniae infections.

Resistance in E. coli to one of the most widely used medicines for the treatment of urinary tract infections (fluoroquinolone antibiotics) is very widespread. There are countries in many parts of the world where this treatment is now ineffective in more than half of patients.

Treatment failure to the last resort of medicine for gonorrhoea (third generation cephalosporin antibiotics) has been confi rmed in at least 10 countries (Australia, Austria, Canada, France, Japan, Norway, Slovenia, South Africa, Sweden and the United Kingdom and Northern Ireland).

WHO recently updated the treatment guidelines for gonorrhoea to address emerging resistance. The new WHO guidelines do not recommend quinolones (a class of antibiotic) for the treatment of gonorrhoea due to widespread high levels of resistance. In addition, treatment guidelines for chlamydial infections and syphilis were also updated.

Resistance to fi rst-line drugs to treat infections caused by Staphlylococcus aureus – a common cause of severe infections in health facilities and the community – is widespread. People with MRSA (methicillin-resistant Staphylococcus aureus) are estimated to be 64% more likely to die than people with a non-resistant form of the infection.

Colistin is the last resort treatment for lifethreatening infections caused by Enterobacteriaceae which are resistant to carbapenems. Resistance to colistin has recently been detected in several countries and regions, making infections caused by such bacteria untreatable.

Resistance in tuberculosis (TB)
WHO estimates that, in 2014, there were about 480,000 new cases of multidrug-resistant tuberculosis (MDR-TB), a form of tuberculosis that is resistant to the 2 most powerful anti-TB drugs. Only about a quarter of these (123,000 cases) were detected and reported. MDR-TB requires treatment courses that are much longer and less effective than those for nonresistant TB. Globally, only half of MDR-TB patients were successfully treated in 2014.

Among new TB cases in 2014, an estimated 3.3% were multidrug-resistant. The proportion is higher among people previously treated for TB, at 20%.

Extensively drug-resistant tuberculosis (XDRTB), a form of tuberculosis that is resistant to at least 4 of the core anti-TB drugs, has been identifi ed in 105 countries. An estimated 9.7% of people with MDR-TB have XDR-TB.

Resistance in malaria
As of July 2016, resistance to the fi rst-line treatment for P. falciparum malaria (artemisinin-based combination therapies, also known as ACTs) has been confi rmed in 5 countries of the Greater Mekong subregion (Cambodia, the Lao People’s Democratic Republic, Myanmar, Thailand and Vietnam). In most places, patients with artemisininresistant infections recover fully after treatment, provided that they are treated with an ACT containing an effective partner drug. However, along the Cambodia-Thailand border, P. falciparum has become resistant to almost all available antimalarial medicines, making treatment more challenging and requiring close monitoring. There is a real risk that multidrug resistance will soon emerge in other parts of the subregion as well. The spread of resistant strains to other parts of the world could pose a major public health challenge and jeopardize important recent gains in malaria control.

Resistance in HIV
In 2010, an estimated 7% of people starting antiretroviral therapy (ART) in developing countries had drug-resistant HIV. In developed countries, the same fi gure was 10-20%. Some countries have recently reported levels at or above 15% amongst those starting HIV treatment, and up to 40% among people re-starting treatment. Who stresses that this requires urgent attention.

Increasing levels of resistance have important economic implications as second and third-line regimens are 3 times and 18 times more expensive, respectively, than first-line drugs.

Since September 2015, WHO has recommended that everyone living with HIV start on antiretroviral treatment. Greater use of ART is expected to further increase ART resistance in all regions of the world. To maximize the long-term effectiveness of fi rstline ART regimens, and to ensure that people are taking the most effective regimen, it is essential to continue monitoring resistance and to minimize its further emergence and spread. In consultation with countries, partners and stakeholders, WHO is currently developing a new “Global Action Plan for HIV Drug Resistance (2017-2021)”.

Resistance in influenza
Antiviral drugs are important for treatment of epidemic and pandemic infl uenza. So far, virtually all infl uenza A viruses circulating in humans were resistant to one category of antiviral drugs – M2 Inhibitors (amantadine and rimantadine). However, the frequency of resistance to the neuraminidase inhibitor oseltamivir remains low (1-2%). Antiviral susceptibility is constantly monitored through the WHO Global Infl uenza Surveillance and Response System.


Pharmacist takes the lead in spreading awareness in Syria

Many pharmacists in the Syrian Arab Republic admit dispensing antibiotics without asking for prescriptions. Three pharmacy graduates decided to launch a campaign to inform fellow pharmacists of their role in preventing antibiotic resistance.

Hanaya Raad is a Syrian pharmacist who has dedicated herself to spreading awareness on antibiotic resistance in her home country. A topic not covered in her out-dated university curriculum, Raad first heard about antibiotic resistance after she graduated when it was mentioned in a practical course for pharmacists. On hearing about this mounting threat, Raad and two of her fellow graduates Sarah Safadi and Nour Allahham took it upon themselves to take action.

After digging further into the topic and educating themselves on the best course of action for pharmacists, Raad and her colleagues approached the Syrian Pharmacists Association.

“We met the head of the Syrian Pharmacists’ Association and the head of the Scientifi c Committee and explained the problem and the concerns in Syria,” she says. “In Syria, antibiotics are purchased in pharmacies and healthcare centres without the need to show a prescription, and lots of patients in Syria don’t go to doctors to take advice if they get sick. They consider the pharmacists as the fi rst people to go to, to ask for antibiotics.”

The Syrian Pharmacists’ Association threw their support behind the graduates and Raad and her colleagues were able to launch an awareness campaign targeting antibiotic-prescribing habits among pharmacists and antibiotic misuse in the population, starting in the capital city of Damascus

“The campaign aimed to target pharmacists around Damascus, with the plan to cover other Syrian cities in the future,” says Raad. “We were able to reach 413 pharmacies, which is roughly half of the pharmacies in Damascus.”

The materials developed by these inspired graduates were delivered not only to pharmacies, but also to healthcare centres and hospitals. This was made possible by 19 volunteers who travelled around Damascus, providing advice and talking to pharmacists about the danger of dispensing antibiotics without a prescription from a doctor. They also created small cards for the pharmacists to give to their patients when they buy antibiotics, with instructions on how to use them.

In addition, they created a Facebook page to reach as many Syrians as possible, as the instability made it difficult to cover certain areas in the region. Several lectures and presentations were also held for pharmacists, students, and the general public.

The key messages in these materials and activities highlighted the magnitude of the antibiotic resistance problem and the role of pharmacists in decreasing antibiotic resistance among Syrians. “It was important that they should know that they cannot give antibiotics without making sure that the patient has a bacterial infection, not a viral infection,” says Raad.

The campaign had to navigate various hurdles along the way, including travel restrictions, lack of experience, and reluctance of pharmacists due to economic problems and insecurity in the country.

Yet, despite all the challenges, the campaign received very positive reactions, especially amongst the younger generations of pharmacists.

“It was a big achievement because there hasn’t been any initiative about this problem in Syria,” says Raad.

The team have also used the campaign to conduct some preliminary research on the knowledge and attitudes around antibiotic resistance in the Syrian Arab Republic.

“We have a bit of an idea that the problem is big in Syria and it is not something that we can just ignore,” says Raad. “Now I am trying to collaborate with the universities in London to do a real research project on this and to assess how big the problem is.”

Raad did her Masters of Public Health at London Imperial College in 2016 and is now based in London along with one of the other colleagues who started the campaign, working on improving the campaign strategy. They will continue the campaign with high hopes to expand into even more regions.

 

 

 

Date of upload: 22nd Jan 2018

                                  
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