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War declared on the ‘superbugs’

Several initiatives are under way to stop the abuse of antibiotics.

“South Africans love antibiotics,” according to Adrian Brink, a clinical microbiologist and co-chairperson of the South African Antimicrobial Stewardship Programme, which advocates the proper use of antibiotics to counter bacteria’s growing resistance to the drugs.

“‘Mummy’s going to take you to the doctor; he will give you an antibiotic and then you’re going to feel much better’ – this is what we hear growing up. From a young age we believe antibiotics will cure any illness. Doctors are to blame too; they are the prescribers,” says Brink, who is part of a growing movement in the medical fraternity to change this mind-set or at least mitigate its consequences.

Global research, including studies published in the New England Journal of Medicine and by the United States’ Centres for Disease Control and Prevention, shows that more than 50% of all antibiotics prescribed are unnecessary, but Adriano Duse from the infectious diseases department at the University of the Witwatersrand (Wits) says the figure is closer to between 70% and 90%.

According to researchers, the overuse and inappropriate use of antibiotics, coupled with poor infection control, has led to a global threat from “superbugs” – bacteria resistant to common antibiotics.

How do bacteria become resistant?

Resistance develops when bacteria are exposed to an antibiotic and, for a variety of complex reasons, a small number don’t die, according to Marc Mendelson, the second co-chairperson of the South African Antimicrobial Stewardship Programme and head of infectious diseases at Groote Schuur Hospital.

“The bacteria that survive have developed ways to evade the mechanism of the antibiotics and become resistant,” he said.

Therefore, the more antibiotics a person uses, the higher the chance they have of acquiring bacterial resistance, he said. Antibiotics taken for the wrong length of time and the incorrect prescription of drugs contribute to resistance.

A World Health Organisation report released in April on antimicrobial resistance raised alarm bells around the world. The report said that cases of the sexually transmitted infection, gonorrhoea, resistant to all available drugs had been reported from South Africa. 

In Europe, an estimated 25?000 people die each year from drug-resistant infections, according to the European Centre for Disease Prevention and Control.

Mendelson warned that “we are at the tipping point of entering a post-antibiotic era”. Without any anti­biotics left to treat infections, simple medical procedures could become fatal and complex operations such as organ transplants impossible.

How bad is it?

He said the scope of the problem in South Africa was difficult to establish because the country did not have a national system in place to monitor antibacterial resistance, but resistant bacteria were increasingly being reported from hospitals in both the public and private sectors.

“Now we’re going back to using an antibiotic from the 1960s called colistin to treat some patients with certain resistant infections as a last line of defence,” he said.

But the drug can have severe side effects, particularly for the kidneys, and is not registered for use in South Africa. Gavin Steel, from the health department, said: “Access to this medicine is, therefore, through the section 21 permit process that allows for the importation of unregistered medicines for use in approved patients.”

Clinicians wanting to prescribe the drug must write to the director general of health, who can approve its use on a case-by-case basis.

“The number of approvals for colistin more than doubled between 2011 and 2013 – from 544 patients to 1?164,” he said.

This year so far, 657 patients have been approved to use the drug “and this is likely to increase during the year”, according to Steel.

Pipe-line drying up

Resistance to antibiotics is not new and has happened since Alexander Fleming first discovered penicillin in 1928.

“But a company would always produce a new antibiotic which would be efficacious against the resistant organisms,” Guy Richards, an intensive care specialist and a researcher at Wits, said.

But only now that the new-drug pipeline is drying up and very few new antibiotics are being developed is the world taking notice.

Part of the reason for this, he said, is that there is little money in it for the pharmaceutical companies that research and develop these medicines.

“It’s a long development period with a short time [that] the drug remains on patent. Antibiotics are also only used for a short period. If you develop an antidepressant, which someone might use for the rest of their life, it’s much more profitable.”

Preserve effectiveness of current drugs

Instead of relying on new drugs, experts are trying to preserve the effectiveness of those currently available.

In South Africa, the private sector hospitals are doing this predominantly through antibiotic stewardship and infection control programmes, although a number of public hospitals have also started this work, according to Gary Kantor from the Best Care Always (BCA) campaign which promotes safer evidence-based practices in hospitals.

Simple infection control measures like washing hands or isolating patients infected with resistant organisms aren’t being routinely done, according to Mendelson. 

BCA has educated and supported hospitals to strengthen infection control measures like these. Over 200 private hospitals have signed on to the campaign and according to Kantor improvements are already being seen. 

“Simple infection control measures, we believe, have resulted in the reduced infection rates we are seeing in private hospitals over the past two to three years,” he said. 

Antibiotic stewardship

Stewardship programmes, which monitor and guide the use of antibiotics in hospitals, have also been proven to work. 

“Stewardship encourages prescribers to only give an antibiotic when it is needed – don’t give these drugs for flu or viral infections. If it is needed you’ve got to prescribe appropriately: it’s got to be the right drug at the right time for the right duration,” Mendelson said. 

“Broad spectrum antibiotics target many different types of bacteria and are also often unnecessarily prescribed.” 

An antibiotic designed to target the specific bacteria responsible for the infection, narrower spectrum antibiotics, should rather be prescribed. 

In a 2012 pilot study Mendelson conducted at Groote Schuur Hospital in the Western Cape, he found stewardship programmes greatly reduced the amount of antibiotics prescribed as well as significant savings in costs.

“We chose two medical wards in the hospital and introduced a prescription chart to function as a guide to prescribers. We did weekly ward rounds with experts from various disciplines who looked at each individual patient and made sure drugs were stopped when unnecessary or changed the drug to one more appropriate for the particular infection.” 

After a year the team compared antibiotic use to that of the previous year when no stewardship programme existed.  

“There was almost a 20% reduction in the amount of antibiotics used resulting in savings of about a quarter of a million rand just for those two wards,” said Mendelson.  

National plan on the way

According to Precious Matsoso Director General at the health department work has begun on developing a national plan to combat the trend in South Africa. 

It will include infection control and antimicrobial stewardship guidelines as well as a plan to “strengthen the surveillance systems so we know which microbial agents show resistance and where”, she said. 

But, according to Brink, there also needs to be a public awareness campaign to change the South African mind-set.  

Matsoso agreed: “Unfortunately we have doctors who feel there is a pill for every ill. They prescribe antibiotics for every patient with a sneeze, cough or runny nose who walks into their facility. There are also patients who think that a doctor who doesn’t prescribe them an antibiotic is not a good doctor,” she said.  

“We need to address this: we cannot be complacent on such a serious issue – we need to wake up,” she added.

Dirt comes out in the wash

About three years ago, a Gauteng hospital experienced an outbreak of a highly resistant strain of klebsiella pneumonia in its paediatric ward, according to the director general of the national health department, Precious Matsoso.

“I sent inspectors to investigate and they came back with a report which said that a common problem was there was no hand washing at this facility.”

It was a basic infection control measure that could prevent the spread of resistant bacteria between patients, said Matsoso.

Global research has revealed that doctors wash their hands less than 50% of the time they are supposed to.

“We, as clinicians, are lousy at washing our hands,” said Marc Mendelson from the University of Cape Town. He said it was a “major issue” that needed to be addressed in South African hospitals by educating healthcare providers.

“Hand hygiene is so important. It doesn’t cost us extra to wash our hands and do it routinely,” Matsoso said. “We will need to launch a big campaign about that.” 

Antimicrobials fed to livestock presents enormous challenges

Antimicrobial resistance – the lowering of the ability of drugs to treat infections – “is not just about human health, it’s also about animals”, the director general of the health department, Precious Matsoso, said.

Eighty percent of all antimicrobials are used outside human health, predominantly to treat or prevent infection and to promote growth in animals, according to Marc Mendelson from the University of Cape Town.

Moritz van Vuuren, from the University of Pretoria’s infectious diseases department, said: “Farmers need a prescription from a veterinarian to use antibiotics to treat or prevent infection in animals.

“However, they can purchase the drugs for use in growth promotion without a script.”

Antibiotics, specifically, are widely used in the feed and water of South African livestock to promote growth as a “kind of performance enhancer”, Mendelson said.

But some of them were very similar to the ones used for humans and posed a risk to people.

The most intensive use of antibiotics for this purpose occurred in commercial pig and poultry farming in South Africa, according to Van Vuuren.

Generally, it wasn’t happening in the farming of sheep and cattle.

But cattle farmed in feedlots, when they are put in a pen shortly after weaning and fed for about four months before they are slaughtered, could be exposed to antibiotics used to promote their growth.

European ban
Using antibiotics for growth promotion in livestock was banned in the European Union in 2006, although it was widely opposed by farmers, Van Vuuren said.

Although he believes South Africa “needs to do the same”, “it will not happen soon”.

“It took 10 years for this to happen in a First-World scenario and to achieve this in a country such as ours will be very difficult.”

He said there would be a similarly strong “backlash” from South African farmers if such a ban was introduced.

Farmers would argue that they would not be able to farm profitably without antibiotics as an aid.

“The farming community is not going to take this lying down,” he said.

But there were less aggressive ways to approach the problem, such as banning only the antibiotics that would pose a risk to human health.

“If you can’t ban it entirely, you can control it.”

For example, he said, you could first look at the “four most critically important ones that pose the biggest risk” and ban them in an initial phase.

“Once you have succeeded, you can go on to the next phase and tackle the next four that are not as risky but are still important.

“In this way you can stagger the process and diminish the pain to the recipients of such a move.”

Surveillance is lacking
Another important problem, according to Van Vuuren, “is actually knowing what is used and where”.

He was involved in a national veterinary surveillance programme that was looking specifically at ­antimicrobial use, but that was ended in 2007 because international funding was drying up.

“We approached the department of agriculture, forestry and fisheries to request they take over funding of the project but we were unsuccessful,” he said.

According to Steve Galane, the acting spokesperson for the ­department, it could not ­support the programme owing to the “un­availability of funds”.

But he added that the department was “participating in the development of a national strategy to address antimicrobial resistance with the hope that a solution can be found, striking a balance between animal production needs and resistance challenges”. 

What can the ordinary person do?

Ensure your children are fully immunised because this will reduce the need for antibiotics in the first place. Adult vaccinations are also important, particularly for influenza, which can cause secondary bacterial infections that may require antibiotic treatment.

Wash your hands
Studies in Pakistan have shown a 50% reduction in childhood deaths from diarrhoea and pneumonia in households who regularly washed their hands.

Make sure doctors wash their hands
Make sure that any contact with a healthcare provider, is preceded by the professional performing hand hygiene. This will reduce the likelihood of spreading bacteria to you. Use alcohol-based solutions or soap and water for hand hygiene.

You do not need antibiotics for a cold
Viral infections such as the ­common cold do not respond to antibiotics and their use is more likely to damage than give benefit. A very large number of different viruses can cause the symptoms of the common cold. None of them responds to antibiotics.

Ask your doctor
Talk openly with your healthcare provider to establish if an anti­biotic is really needed. It’s okay to have this kind of conversation with your doctor.

Get tested
If your doctor believes an antibiotic is needed, discuss with him or her about whether a suitable specimen should be sent to the laboratory for confirmation and for antibiotic sensitivity ­testing. Although ideal, it is not always necessary and will depend on your particular case, the type of infection and whether it was acquired in the community or hospital setting. These tests can also be expensive.

Follow the rules
If an antibiotic is prescribed for a bacterial infection, complete the course as directed by the doctor, nurse or pharmacist, even if you feel better after just one day. Try not to miss doses. This will result in antibiotic concentrations not being high enough to kill the bacteria and more likelihood of causing resistance. There are very few infections that require prolonged antibiotics. The vast majority of bacterial infections can be treated in just three to five days.

Source: Professor Marc Mendelson, infectious disease department, University of Cape Town

Amy Green was a health reporter at Bhekisisa from 2013 until 2016.