Walking into the out-patients’ department of Patan Hospital in Nepal recently, I saw the mother of a child enrolled into an enteric fever clinical trial a few years ago. She was back with her second child, who also had enteric fever. She had initially given her second child the same antibiotic that helped treat her first child, but her second child did not recover. She wondered why, with the same disease, the medicine did not work.
This is sadly not unusual. The ability of bacteria to develop resistance to antibiotics is a natural phenomenon, and the misuse of antibiotics in both human and veterinary medicine can accelerate this ability. The misuse of antibiotics has made antimicrobial resistance (AMR) a serious threat to global public health, threatening the effective prevention and treatment of an ever increasing range of infections.
There are significant variations in global patterns of AMR, and these trends are continuously evolving. In a 23-year retrospective analysis done within our hospital in Nepal, we found that resistance to several commonly used antibiotics is increasing, including fluoroquinolones and cephalosporins. Healthcare teams worldwide have had to evolve and adapt to respond to such changing burdens.
One area where improvements need to be made is at the pharmacy level. For the implementation of an effective antimicrobial stewardship, the role of pharmacists is key, especially given that the health systems in low-income countries are cash strapped and overloaded. Going to the hospital costs patients more money and time compared with going to a pharmacy, thus pharmacies are a popular choice.
In Nepal, as in many developing countries, urban cities such as Kathmandu are dotted with private local pharmacies. Most of these are staffed by inadequately trained pharmacists, or paramedical personnel with no pharmacy training. According to the law, pharmacies are required to dispense antibiotics strictly on prescriptions only, while recording details of users and prescribing physicians. However, inspections by the Department of Drug Administration have shown that antibiotics are widely sold through pharmacies on an ad hoc basis without any prescriptions. An ongoing surveillance of pharmacy sales within the Kathmandu Valley has shown that the most widely sold antibiotic is azithromycin, followed by cefixime and amoxicillin, with almost 86% of these being sold without a prescription.
As part of this surveillance, over the past three years, we have been conducting public engagement programs with private local pharmacies and their customers. These interactions have shown many misunderstandings about antibiotic use, especially regarding antibiotics’ efficacy against viruses, prescription compliance, and the need for prescriptions before antibiotic dispensation. These clearly demonstrate the need for more public education on correct antibiotic use.
Continuing education for pharmacists is also needed, especially on the rational use of antibiotics. Training should encourage resisting patient pressure, and asking for evidence of laboratory diagnosis in order to identify the pathogen and resistance patterns. A common concern for the pharmacies has been “Pharmacy is a business, if we do not sell, we do not eat”. For pharmacies to deliver antimicrobial stewardship effectively, concerns about business will have to be addressed.
Continued widespread sale and inappropriate use of antibiotics will lead to a future where there will be no more effective antibiotics left, causing increased death and disability from what are currently simple infections. As long as there is no health system in place addressing cost and timely care issues, people will tend to go to pharmacies for treatment. Therefore, pharmacies must be supported to do more to prevent the inappropriate use of antibiotics.