Illustrative image. Experts say some doctors
added to the problem of antibiotics resistance by prescribing antibiotics
unduly. — VNA/VNS Photo Hiền Hạnh
There are
times when there’s bad news and even worse news.
One such
time is dealing with the problem of drug-resistant diseases in Việt Nam and
elsewhere .
A couple of case studies:
Trung
(not real name) was hospitalised a month ago after showing symptoms of
pneumonia. After four days of treatment, however, his condition did not improve
and he lost consciousness. Doctors at the National Hospital for Tropical
Diseases in Hà Nội had to resort to endotracheal intubation (an emergency
procedure) to keep him alive.
Susceptibility
testing showed that he was resistant to all types of antibiotics except for
colistin - a toxic antibiotic used to treat only the worst drug-resistant
infections. After a month on endotracheal intubation, he regained consciousness
and his condition has stabilised.
Thanh,
64, another patient who was taken to Vạn Hạnh Hospital in HCM City early last
month, was not so lucky. Thanh resisted the strongest of antibiotics and was
only sensitive to colistin and polymycin B. Three weeks after treatment, his
condition worsened. His family took him home last week to await his demise.
Dr Dương
Minh Tuấn said Thanh was the fifth such patient in a month that he’d seen,
resistant to almost all types of antibiotics.
“We now
have overwhelming evidence of rampant antibiotic resistance in most hospitals
across the country, and it’s very worrying….” he paused, about to drop the
bombshell.
“Because
it means anyone of us can develop this resistance to antibiotics.”
Let that sink in, first.
“When one
takes any type of antibiotics, naturally resistant bacteria will develop in his
or her gut. These bacteria can be spread from him or her to anyone in contact,
whether at home or in the community. If he is treated at a hospital, the bacteria
can spread directly to other patients.
“Basically,
it means that even if you don’t take antibiotics, when other people around you
take antibiotics and develop resistant bacteria in their bodies, there’s a
chance that you get those as well.”
This problem
has been brewing worldwide for decades, but has not hit public consciousness in
the country in a big way, although the World Health Organisation last year
listed Việt Nam among countries with the highest antibiotic-resistant
infections.
Nguyễn Vũ
Trung, deputy director of the Central Tropical Diseases Hospital, said that the
resistance rate to carbapenems, the strongest group of antibiotics, has risen
to 50 per cent, mostly from gram-negative bacteria that have an impenetrable
cell wall.
Resistance
to third-generation cephalosporins, another powerful group of drugs, has surged
to more than 60 per cent in the country, he said.
Recent
individual studies have shown that Việt Nam has the highest prevalence of
penicillin-resistance (71.4 per cent) and erythromycin resistance (92.1 per
cent).
“This
means that when treating a patient with antibiotics resistance, we will face
many difficulties, including lesser choices of drugs, longer treatment time,
higher costs, and sometimes, sadly, we can’t save the patients because no drug
helps,” Trung said.
Two weeks
ago, on September 21, the UN General Assembly held a high-level meeting to
discuss how antibiotics have become less useful when treating human illnesses
caused by bacteria. For the fourth time in its 70-year history, the UN elevated
a health issue to crisis level, the previous occasions being HIV, the rise of
non-communicable diseases such as heart disease, and Ebola.
The
recognition by international agencies that antibiotic resistance is a global
problem has come a bit late in the day, and it marks an acknowledgement that
some of the miracles of modern medicine, including penicillin, could have run
their course.
Antibiotics
have been central to modern medicine, treating and preventing infections,
protecting patients from pre and post surgical complication, the side-effects
of cancer treatments, helping people with compromised immune systems, and
treating and preventing diseases in livestock and other animals used as food.
This is how antibiotic
resistance spreads. — Photo www.me-med.com
Widespread abuse
However,
widespread abuse of these drugs for many, many years now has borne fruit in a
pandemic with horrifying implications.
Trung of
the Central Tropical Diseases Hospital, who co-authored a 2013 report titled “Antibiotic
use and resistance in emerging economies: a situation analysis for Việt Nam,”
said overuse of antibiotics in human medicine as well as agriculture and
livestock production was the main reason behind the growing problem.
The
report, commissioned by Việt Nam’s Ministry of Health in collaboration with the
Global Antibiotic Resistance Partnership and Oxford University Clinical
Research Unit, studied 15 hospitals nationwide.
It said
that in 2008-2009, antibiotics constituted an average 36 per cent of hospital
treatment expenditure, and almost 40 per cent of this was accounted for by the
third generation cephalosporin contributed a major part – 39.5 per cent. By value, the average antibiotic expenditure
per hospital in 2008 was US$1.75 million. The highest spending on antibiotics
($6.74 million) was at the Chợ Rẫy Hospital in HCM City, followed by the Bạch
Mai Hospital in Hà Nội, with $5.5 million.
Total
drug sales in Việt Nam nearly tripled in value between 2001 and 2008, from $500
million to $1.4 billion. The report said no separate figures were available,
but antibiotics were among the most widely used drugs.
The scary
part is this: just 20 per cent of the country’s antibiotics use is from
hospitals, and the rest happens outside, and most of this is “inappropriate,”
according to doctors.
“Mothers
often treat sick children without consulting a proper healthcare provider, and
children with coughs and colds are given antibiotics,” Trung said.
A 2007
study had found that general knowledge on antibiotics was poor among the
community. Self-treatment was common, as was incorrect dosage or duration. To
this day, antibiotics can be purchased over the counter at pharmacies without
the legally-required prescription. Trung said some doctors added to the problem
by prescribing antibiotics unduly.
The 2013
report said that in rural and urban pharmacies in the country, 88 to 91 per
cent of all antibiotic sales (sample taken in 2010) were without prescription.
A pharmacist in Hà Nội who insisted on anonymity said while he was aware of the
law, he had to keep his customers.
"First,
I can’t compete with other drug stores if I ask for a prescription. Secondly,
if I don’t give them antibiotics and their illness symptoms don’t go away, they
would not return the next time."
Even less
reassuring was a 2009 study’s finding that just 27 per cent of pharmacy staff
had correct knowledge of antibiotic use and resistance.
No oversight
Cao Hưng
Thái, deputy director of the Examination and Treatment Department under the
Ministry of Health, blamed the abuse of antibiotics on lax management of
antibiotics and mild penalties.
“People
keep joking that they can buy antibiotics as easily as buying vegetables,” he
said.
“While we
do have adequate regulations on the sale of antibiotics, according to which
certain types of antibiotics can only be purchased with prescription, it’s
obvious that enforcement is not effective," he said.
Thái said
a motely inspection force with the health ministry has to oversee more than
30,000 healthcare institutions and more than 30,000 drugstores and pharmacies
in the country. Furthermore, most clinics and hospitals lack the equipment and
human resources to carry out susceptibility tests and determine which type of
antibiotic can be administered to a patient.
“At the
grassroots level, doctors often prescribe antibiotics based on their
experience, which is also limited. This also leads to inappropriate use of
antibiotics," Thái said.
Experts say overuse of
antibiotics leads to more antibiotic-resistant infections. — VNA/AFP Photo
Antibiotics in agriculture
Significant
amounts of antibiotics used by people and animals eventually find their way
into the environment, particularly in surface and ground water and in the soil.
Antibiotics-resistant bacteria arise and spread in animals and in the
environment, and, sometimes, to humans through several ways.
In Việt
Nam, the use of antibiotics in livestock breeding has been increasing over the
last several decades.
The 2013
study estimated that 70 per cent of pharmaceuticals used in animals are
antibiotics. Many antibiotics used to treat human diseases are used in
agriculture and farmers often do not comply with regulations requiring them to
stop the use of these drugs before harvesting their products.
Dr. Soccoro Escalante, Health System
Development Coordinator of the WHO, confirmed this.
“In the animal sector, inappropriate use of
antibiotics in animal husbandry and aquaculture drive antimicrobial resistance.
This will in effect have dangerous impacts on human health, through the
transmission of antimicrobial resistant organisms and the existence of
antibiotic residues in the food chain,” she said.
Environmental
contamination is also a big factor as resistant bacteria from human and animal
waste can be spreaded out via unsafe waste disposal from hospitals and poor
sewerage systems add to the problem. Antibiotic residues in water and soil can
also compound the emergence of resistant bacteria in the environment.
Small improvements
The
ministry launched in 2013 an action plan to deal with antibiotics resistance.
The plan
called on hospitals to improve consultancy on medicines as well as management
of infections. It introduced stricter regulations on the use of antibiotics and
advanced equipment.
Since
then, “doctors and pharmacists have become better aware of the importance of
proper use of antibiotics as well as the seriousness of antibiotics
resistance," said Trung from the National Hospital for Tropical Diseases.
In June
2015, WHO supported the Government in convening a high level inter-sectoral
meeting, during which an Aide Memoire for Multi-sectoral Action to Combat AMR
was signed.
“WHO
strongly recommends that Việt Nam pursue this high-level multi-sectoral
commitment, ensuring that policies and regulations at the national level are
strong, while at the same time, advocating and monitoring for local actions at
all levels, at the provinces, districts and communities,” Soccoro said.-
Elephants in the room
Amidst
all the analysis of antimicrobial resistance, some fundamental causes are
rarely mentioned or highlighted, and these elephants in the room could well end
up trampling all efforts to deal with the problem.
Poverty
has been cited by the WHO itself as a major force driving antimicrobial
resistance. In developing countries, inadequate access to effective drugs
worsens unregulated dispensing and manufacture of antimicrobials, and
“truncated antimicrobial therapy because of cost are contributing to the
development of multidrug-resistant organisms."
In 2007 a
study by Dr Margaret Planta noted this: "Poverty-stricken patients may
forgo the cost of a physician consultation and self-medicate. They may be more
likely to purchase the least expensive (and possibly least potent drug) under
the assumption that they are all bioequivalent. Furthermore, these people may
only complete a truncated course of therapy because of their inability to pay
for the full course of medications."
No comments:
Post a Comment