A growing ‘disease’ antibiotics can’t cure
IN 2016, there was a typhoid outbreak in Harare.
Doctors naturally prescribed an antibiotic called ciprofloxacin, which is recommended by the Ministry of Health and Child Care and the World Health Organisation (WHO) as standard treatment for diarrheal infections.
But it appeared ineffective and they duly investigated.
Stool samples collected from 402 people were studied by scientists from the Africa University Department of Health Sciences, National Microbiology Reference Laboratory and the University of Zimbabwe Department of Medical Laboratory Sciences.
The tests established that the antibiotics were ineffective in dealing with a quarter of the cases.
Usually, when a pathogen fails to respond to medication (antimicrobial agents), especially antibiotics, the outcome is called antimicrobial resistance (AMR).
“A total of 35 S. Typhi isolates were recovered for the period from January to April 2016. When the 35 isolates were characterised, nine (25,7 percent) were resistant to ciprofloxacin. The area with the highest recorded cases of typhoid fever was Budiriro high-density suburb in Harare,” researchers Ndatenda Mutaurwa, Ellen Munemo, Garikai Malunga and Danai Zhou noted in their findings.
The misuse and abuse of antibiotics was blamed for being responsible for this phenomenon.
There are growing allegations that some doctors are in the habit of prescribing
antibiotics for diseases such as colds that can ordinarily be treated by alternative medicines.
It is believed that this creates a situation where pathogens (organisms which carry diseases) become resistant to antibiotics.
And resistance to antibiotics makes treatments more expensive.
In 2018, epidemiologists and other public health experts raised concern that the cholera outbreak experienced then was highly resistant to drugs such as ciprofloxacin and ceftriaxone – antibiotics used to manage cholera patients.
Of the 241 cases tested, 233 were resistant to ciprofloxacin, while 240 out of the same 241 cases were also found to be resistant to ceftriaxone.
Covid-19 also brought a different but dangerous dynamic where doctors and pharmacists began recommending a combination of pills which were sold over-the-counter to asymptomatic cases.
“The initial management of Covid-19 was based on early reports from China and modelled using the historical influenza pandemic, which highlighted the potential for a high number of bacterial coinfections. Some studies also indicated that azithromycin had the potential to disrupt viral replication. Zimbabwe, like other nations, drafted Covid-19 treatment and management protocols based on these reports,” said Drs Itai Chitungo and Grant Murevanhema, including four other researchers, in a paper titled “Inappropriate Antibiotic Use in Zimbabwe in the Covid-19 Era: A Perfect Recipe for Antimicrobial Resistance.”
Dr Joe Chiripanyanga said there is need for a frank conversation among health professionals on the situation.
“We have noticed that there is an increase in drug resistance. It can be attributed to a number of things, including changing patient behaviour. People now go online and search for their symptoms; they approach doctors demanding antibiotics. In some cases, doctors oblige, especially in private institutions,” said Dr Chiripanyanga.
Failure by patients to use antibiotics as prescribed is also blamed for promoting resistance.
“We see that patients are reluctant to finish their courses, they take antibiotics and fail to finish the course; that creates resistance.
“Doctors prescribe antibiotics when it is unnecessary. When a child or an adult comes, doctors are quick to give antibiotics when paracetamol could have worked,” he said.
Over-prescribing
Some pharmacies are also fuelling the trend by dispensing antibiotics without prescription.
However, Mr Geoffrey Guwakuwa, a Harare-based pharmacist, said there are medical practitioners who are “over-prescribing” antibiotics.
“Over-prescribing antibiotics is a growing problem in Zimbabwe. It is mainly due to lack of resources. Ideally, blood cultures and sensitivity tests should be done to ascertain the nature of the causative pathogen. In Zimbabwe, most practitioners do what is called empirical antibiotic prescribing. This is where antibiotics are administered without or before test results of blood cultures and sensitivity tests are received,” said Mr Guwakuwa.
If not addressed, he added, antibiotics will become less effective against bacteria and fungi.
“As pharmacists, our hands are tied as we can only correct dosage errors. What the doctor has written is the law in Zimbabwe, as long as the prescription is valid.
“However, in situations where we have access to the clinical notes of the patient, we can communicate with the doctor and raise concerns over a particular dosage regimen.”
The most commonly prescribed antibiotics are amoxicillin, ciprofloxacin, metronidazole and of late azithromycin, which was part of a concoction given to patients managing Covid-19.
But the Retail Pharmacists Association (RPA) says the deployment of new technologies and platforms through which patients can send prescriptions in advance before collecting their medication could be causing misconceptions that pharmacies are selling antibiotics without prescriptions.
“Due to technology, prescribers can now send prescriptions to the pharmacist through electronic media which also includes social media platforms. This advancement in technology might be construed by the public as ‘laxity’ on the part of the dispenser, as they might not see the script of the patient in front of the line and they assume that the patient had no script, whereas the script would have been sent electronically,” said RPA secretary-general Mr Luckmore Bhunu.
But not all antibiotics are sourced from pharmacies, as
informal traders have set up illegal dispensaries on street corners.
Places like Fife Avenue Shops, pavements along Robert Mugabe Street in the central business district and the area at corner Mbuya Nehanda and Albion Streets in downtown Harare have seen traders push all sorts of drugs believed to have been smuggled from neighbouring countries. New regulations
The Medicines Control Authority of Zimbabwe (MCAZ) is trying to find ways to address increased use of antibiotics and possible AMR.
Dr Zivanai Makoni, a senior medicines assessor with MCAZ, told The Sunday Mail that work is underway to come up with robust laws governing the use of medicines.
“MCAZ ensures that antibiotics are sold from approved sources and through prescriptions by enforcing the enabling statutes; for example, the Medicines and Allied Substance Control Act,” said Dr Makoni.
“The authority is also working on new statues that will tighten laws governing use of antibiotics in animals; for example, Medicated Feeds Regulations, and the Medicines and Allied Substances Control (Veterinary Medicines) Regulations.
“These two regulations will ensure farmers respect withdrawal periods after using antibiotics in animals before they can slaughter, collect milk or eggs for human consumption so that consumers are not exposed to sub-therapeutic quantities of antibiotic residues in these products.”
At a policy level, Zimbabwe has a committee which looks into issues of antimicrobial resistance coordinated by the Ministry of Health and Child Care.
The committee has experts from different sectors in health, regulators and academics.
The committee’s work was mentioned in the World Health Organisation’s newsletter on antimicrobial resistance compiled by Dr Hanan Balkhy, assistant director-general WHO, released on July 1.
Although there has been an increase in the prescription of antibiotics and subsequent cases of antimicrobial resistance, it is not an irreversible challenge.
The design of new antibiotics to replace those that have been abused, increased awareness, regular research and strict monitoring of health professionals can help manage the situation.