COMBATING AGAINST ANTIBIOTICS RESISTANCE AT NATIONAL LEVEL IN PAKISTAN: REASONS AND RECOMMENDATIONS

By:MR.NAEEM ULLAH KHAN

(Punjab University Law College , Lahore)Assisted By:

SYED KASHIF NAWAZ(Department of Microbiology and Molecular Genetics, University of the Punjab Lahore

Pakistan)

PROF. DR. SHAHIDA HASNAIN(Department of Microbiology and Molecular Genetics, University of the Punjab Lahore

Pakistan)

Abstract: The clinical application of antibiotics has resulted in a significant reduction in the morbidity and mortality rate associated with infectious diseases. Due to excessive use of antibiotics both in animals and human beings, a new problem has originated i-e antibiotics resistant infections. This problem has distorted the graceful image of antibiotics usage. Getting rid of antibiotics is not the solution of the problem. The only best way to resolve the issue is to develop strategies controlling the misusage of antibiotics. In this article, different suggestions have been given which should be implicated in Pakistan for avoiding the possible danger of antibiotics resistant infections in Pakistan.

Introduction:

An antibiotic is chemical produced by microorganisms or derivative of such chemicals which killls susceptible microorganisms or inhibit their growth (Prescott et al., 2005). The clinical application of antibiotics has resulted in a significant reduction in the morbidity and mortality rate colligated with infectious diseases. Their use has been widened to veterinary medicine, where they are utilized as therapeutic agents, prophylactics and animal growth promoters, and to agriculture for the control of plant diseases (Wegener, 2003; Goldman, 2004; Levy and Marshall, 2004).

It is estimated that some 1–10 million tons of antibiotics have been released into the biosphere over the last 60 years (European Commission, 2005). This has exerted a very strong selective pressure for the appearance of resistant strains. Resistance rates vary from country to country (Gales et al, 2001). Overall, isolates from Latin American countries show the lowest susceptibility rates to all antimicrobial agents followed by Asian-Pacific isolates and European strains. Strains from Canada exhibit the best global susceptibility testing results. (Gales et al, 2001).

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Antibiotic resistant strains have made a lot of infectious diseases difficult to treat (CDC. 2007). Moreover, side effects of antibiotics like allergic reactions, excess adverse effects, and increase in medical costs enhances the sufferings of patients. Imprudent antibiotic prescription not only masks correct diagnosis but also result in delay of proper treatment (Liu et al. 2001). Although the problem has been recognized for many years, injudicious use of antibiotics continues to be a major public health problem (Nash et al., 2002). Centers for Disease Control and Prevention (CDC) U.S.A have launched the national campaign to reduce the spread of resistance to antibiotics, judicious antibiotic use remains a challenge (CDC., 2007; Gonzales et al, 2001).A lot of research work has been done for finding out the major reasons of antibiotics resistance which show that antibiotic prescriptions are irrelevant leading to no change in the course of the disease. This inappropriate use of antibiotics and the increased volume of antibiotic use have magnified bacterial resistance to a major public health concern (Gonzales et al, 2001; Liu et al., 2001; Neu, 1994; Wang et al., 1999). There is a need of constant monitoring at national, regional level as these surveillance efforts are imperative to provide clinicians with information for choosing empirical treatment regimens. (Aziz et al, 2006).

Possible causes of Antibiotic Resistance in Pakistan: Antibiotics resistance threat in Pakistan has been explored on research grounds for a long time. Major reasons found are following:

1- Lack of awareness about antibiotic resistance bacteria in Public2- Self medication of antibiotics by patients3- Cross infection.4- Inappropriate prescription by doctors. 5- Misuse of Antibiotics in Live stock.6- Lack of stringent control of the concerned authorities over antibiotics sale.

1- Lack of awareness:Majority of people in Pakistan is not aware of antibiotic resistance. In case of infection, they do not wait for activity of natural immunity to combat problem but try to start using antibiotics for rapid relief. They don’t think that their impatience attitude not only imparts metabolic load on their kidney or liver (depending on the type of antibiotics) but also destroy normal microbial flora resulting in weakness. This careless attitude is the one of the factors responsible for antibiotic resistance in Pakistan.

2- Self medication of antibiotics by patients:Rational use of drug is one of the cornerstones of good medical practice and is a concern around the world including the developed countries (Simon et al, 2005). One of the most worrisome issues concerning medication abuse is the easy over-the-counter availability of medicines in general (Davidoff, 2005; Werler , 2005; Charlton, 2005 ; Coombes, 2005; Qidwai et al, 2005) and antibiotics (Al-Bakri et al, 2005).In community-based emergency departments of USA, seventeen percent of patients are reported to take “left-over” antibiotics without

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consulting their physicians, most commonly for cough (11%) or sore throat (42%). Surprisingly, patients with a higher level of education were more prone to misuse antibiotics (Richman et al, 2001). Survey report by Sturm et al (1997) in Karachi shows that at least 9% of public uses antibiotics without prescription. If the government does not concentrate on the antibiotics sale monitoring, antibiotic misuse can increase.

3- Cross infection:Lack of guidelines for hospital infection control and prevention is pushing Pakistani population towards cross infection (Badaruddin, 2006). If unchecked, these preventable and avoidable infections can increase the morbidity and mortality associated with antibiotic resistant bacterial spread and can contribute to rising costs of health care(Hussein and Khalid, 2007). Little literature is available on hospital acquired infections in Pakistan and related issues such as frequent occurrence of multi-resistant-bacteria, and the economic loss and suffering of individuals, who bear the high health care costs.

4- Inappropriate prescription by doctors: Inappropriate prescription of antibiotics by General Practitoners (GPs) is serious issue causing elevated chances of antibiotic resistant strains. Insistent patient demand is reported to be associated with such antibiotic prescriptions (Alevizos et al, 2007). In Pakistan, most of General Practitioners prescribe antibiotics without Microbial Diagnostic tests (Minimal Inhibitory Concentration of Antibiotics and Antibiotics Sensitivity tests) (Khurshid et al, 2002).

5- Misuse of Antibiotics in Live stock:Intensive animal production involves giving livestock animals’ large quantities of antibiotics to promote growth and prevent infection. These uses promote the selection of antibiotic resistance in bacterial populations. The resistant bacteria from agricultural environments may be transmitted to humans, in whom they cause disease that cannot be treated by conventional antibiotics. Major routs of antibiotics resistance in Pakistan are dairy (Farzana, 2004) and Poultry industry (Naeem K. 1998).

6-Lack of legislation related to antibiotics:The most important reason for antibiotic resistance emergence is the lack of legislation. In Pakistan, no law is present for controlling and observing antibiotic sale.

Recommendations:1- Public awareness programmes should be initiated at grass root level. For that purpose, print and electronic media should be used as much as possible. NGOs should play their concrete role to prevent the misuse of antibiotics.Seminars and conferences should be conducted by both private and public sectors for highlighting the problem.

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2- Antibiotics sale should be conditional to the prescription by qualified doctors or microbiologists. Through this practice, Self medication can be discouraged. For this strategy , laws should be developed and implicated sincerely.

3- Fool proof strategies should be developed for eliminating the chances of nosocomial infections. Entry of limited healthy persons should be allowed for a patient for minimizing exposure of healthy population. Infecting materials should also be treated and dumped carefully. Public sector should monitor the sanitary conditions and ways of dumping infecting materials.

4- Inappropriate prescriptions can be avoided by developing strong legislation. General practitioners and veterinary doctors should be trained for the wise use of antibiotics. It is sorrowful that the patients put their life in risks by taking antibiotics at the advice of unqualified and untrained medicine sellers. It is most probably due to lack of awareness and knowledge about the potential serious hazardous effects of use of antibiotics. In the proposed law we strongly recommend that provision should be included to prevent this type of medical activity in the developing world particularly in Pakistan.

5- Live stock should be treated with antibiotics only on the prescription of qualified veterinary doctors and microbiolgists. In this regard, legislation is very important.

(Remaining part which has not been published uptill now)

6- Critical analysis depicts that there is a no law regarding to the use of antibiotics in the world particularly in developing countries. Suggesting the antibiotics to the patients and animals etc without applying antibiotic sensitivity test causes a serious damage to the health of animals and particularly humans beings which is the violation of human rights in a civic society and it is the responsibility of state that some stringent and concrete steps must be taken in this context. We propose that the government should make a strong legislative enactment to prevent the misuse of antibiotics without the recommendation of authorized medical practitioner. We are proposing a legislative draft which must contain the following provisions for the elimination of shortsighted use of antibiotics. a): That there should be legal definition of antibiotic.b): That no antibiotic medication should be suggested without applying sensitivity tests (Minimal Inhibitory Concentration and Kirby Baur Test).

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c): That in a case of violation of the above mentioned provision, a physical punishment and fine should be awarded by the court to the guilty party.d): That antibiotics sale should be conditional with the subscription of authorized medical practitioner or microbiologist.e): That there may be an expert review board composed of microbiologists, molecular biologists, Biochemists and doctors (MBBS, DVM) who examine the patient whether the proposed antibiotic medicine is scientifically appropriate for the patient.f): That there should be an independent medical dispute resolution court particularly for antibiotic misuse.g): That the court should be presided by a chief medical officer or microbiologists.h): That the court should has the same power as provided in the code of criminal procedure (Cr.Pc) for the criminal court of first class magistrate.i): That the case should has to be decided within a prescribed time frame.j): That there should be “medical council“at tehsil, district and divisional level composed of microbiologists, molecular biologists, Biochemists and doctors. The main function of the council must be to create the awareness in the public at grass root level. Similarly, at the national level there should be a chief medical council. The chief medical council should publish annual report in the official gazette.

7- Alternative medication should be preferred for minor infections.

8-There should be exclusive research institution concentrating on reemerging infections in Pakistan at least at National level.

Conclusion:This analytical approach demonstrates that rational use of antibiotics is one of corner stones of good medical practice and is a relevant around the developing world including Pakistan. Simple guidelines for safe use of limited number of antibiotics medication should be developed through education of private antibiotics medicines on common diseases in the country. We strongly recommend that there should be a stringent control on the misuse of antibiotics medication in the form of concrete legislation in this field so that irrational use of medicines (antimicrobial agents) should be eliminated from medical practice in Pakistan. Last but not least patient education is another imperative factor in the overall promotion of rational use of antibiotic medicine in Pakistan.

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