KATHMANDU– A couple of days ago, a doctor from Nepal named Dr. Sujata Pant posted a picture of a lab report on social media, which went viral. The report on the manual blood culture and sensitivity test revealed the sensitivity of Klebsiella bacteria, where 21 antibiotic-resistant bacteria were seen.
Dr. Pant posted the lab report and wrote, ‘Do not use antibiotics without consulting a doctor’ and in no time, it went viral in social media groups of doctors’. She did not want to reveal the source of the report, but she further added that such reports of antibiotic resistance keep coming at the Kanti Children’s Hospital where she works.
Similarly, on June 24, the same Klebsiella bacteria was also seen in a patient during a urine test. During the antibiotic sensitivity test, 18 antibiotic-resistant bacteria were found to be resistant.
Comparing the mentioned lab report with the research report of the Ministry of Health (CAPTURA Country Report: Nepal), there are many similarities to confirm the truth. According to the report, most of the antibiotics mentioned in the report are resistant. Reportedly, ampicillin 91.9 percent, amoxycillin 77.43 percent, cefepime 72.58, cefuroxime 65.69, and cefixime 62.69 percent resistance have been observed. In that report, 22 antibiotic-resistant cases have been mentioned, and the least resistant of all was seen in Amikacin with 22.15.
Both the lab report and the study reported harm and danger for random use of antibiotics in Nepal. According to the report, high resistance has been seen in Acinetobacter, E-coil, S. aureus, and S. typhi.
Dr. Madan Upadhyay, former focal person of antimicrobial resistance (AMR) under the Ministry of Health, says that for the last three decades, no new medicine (antibiotic) has been discovered to kill bacteria.
The bacteria have built resistance to the old antibiotics, causing the medicine not to work. According to the World Health Organization (WHO), if this trend continues, it is estimated that by 2050, the number of patients who will die due to antibiotics not working will reach 10 million per year. Doctors say that developing countries like Nepal are suspected to be the most affected by it.
Viruses, bacteria, fungi, and other parasites are also microbials despite their appearance and forms, and the term antimicrobial covers them all.
Former VC and ICU Specialist of Patan Institute of Health Sciences Dr. Arjun Karki said that antimicrobial resistance (AMR) is a condition in which bacteria become immune to those drugs that kill them.
“The existence of bacteria is similar to humans, and like us, they also want to survive no matter how hard the situation becomes. They cause diseases and infections, so we want to cure them as soon as possible, but bacteria develop resistance to the medicine, which is called antimicrobial resistance and also antifungal for fungus. Anti-virus is given for viruses,” said Karki.
Susceptibility Testing without Antibiotic Prescription
It is a universal belief that before prescribing antibiotics to patients, healthcare workers should do antibiotic susceptibility testing (AST). According to a study conducted by the Nepal Health Research Council, it has been found that 68 percent of people in Nepal use antibiotics without AST.
According to Dr. Meghnath Dhimal, chief of the research section at the Nepal Health Research Council (NHRC), in the Situational Assessment of Antibiotics Use and its Resistance in Nepal, only 32% of the doctors/health workers have access to laboratory facilities for AST; among them, only 49% recommend antibiotic susceptibility testing before prescribing antibiotics, which is a significant reason for influencing rational prescriptions of antibiotics. Similarly, around 59% of doctors and health workers had heard of national guidelines for antibiotic prescriptions, among which only 54% had access.
Community Pharmacies: The majority of the drug dispensers (43.4%) dispense antibiotics without a doctor’s or health worker’s prescription.
Azithromycin (24.5%), Amoxicillin/Amoxyclav (20.5%), Cefixime (14.8%), Ciprofloxacin (14.1%), and Metronidazole (9%) were the most commonly dispensed antibiotics without prescriptions from doctors and health workers.
Outpatients: The majority of the outpatients (85.4%) consult with doctors or health workers before consuming antibiotics. About one-fourth (22%) of the outpatients did not consume a full course of antibiotics. Similarly, about 10% and 8% of the outpatients consume antibiotics as prophylaxis and consume double-dose antibiotics for fastest recovery, respectively. Around 22% of them save residual antibiotics for treating similar symptoms in the future. Additionally, around 28% of the outpatients mentioned that they buy antibiotics without a doctor’s or health worker’s prescription.
Prescription and consumption of antibiotics: About 85% of health workers/doctors did not prescribe antibiotics by their generic name. Similarly, more than one-third, that is, 37.8%, of prescribed medicines were antibiotics, which is higher than the standard as given by the WHO. The consumption of antibiotics by inpatients based on the AWaRe classification showed a majority of antibiotics consumed was from the Watch group, i.e., 70%, followed by the Access group, i.e., 29.8%, and 0.1% was from the Reserve group. The five most frequently consumed antibiotics were ceftriaxone, metronidazole, ornidazole, piperacillin tazobactam, and azithromycin, respectively.
Veterinarians/Para-veterinarians: About 34% of veterinarians/para-veterinarians have access to laboratory facilities for AST in their working area; among them, only 32% recommend susceptibility testing prior to antibiotic prescriptions. Additionally, it was found that only 18% of veterinarians/para-veterinarians always recommend antibiotic susceptibility tests before prescribing antibiotics.
Veterinary Pharmacists : About 66% of the veterinary pharmacists do not keep an animal’s record for dispensing antibiotics, and the majority of veterinary pharmacists consider the weight of the animal before prescribing antibiotics. Tetracycline, oxytetracycline, enrofloxacin, and gentamicin were identified as the most commonly dispensed antibiotics from the vet pharmacies.
Farmers (Cattle/Poultry) : Around 44% of the farmers responded that they treat their sick animals by themselves. The majority of the farmers treat animals by using local medicines (37.4%), followed by buying drugs (30.5%), and isolating sick animals from others (15.5%) as measures for self-treatment. More than half (55%) of the farmers were found using residual antibiotics for the future.
Random use of antibiotics
A cross-sectional study at Patan Hospital in 2021 found that the total DDD of parenteral antibiotics increased by 23% from 2017 to 2019. An older assessment in 2017 found that 79% of 324 participants (selected from the public) purchased antibiotics over the counter, and 43% of the participants understood that fever could be treated with antibiotics. The same study interviewed 33 private pharmacies, 23% of whom responded that antibiotics could be used to treat viral diseases.
Some hospitals have given strong antibiotics to patients as soon as they enter the hospital. A few years ago, in a study conducted by swasthyakhabar.com, it was seen that B&B Hospital in Kathmandu used antibiotics without AST. In a study conducted on four patients, it was seen in the pharmacy bill of the hospital that antibiotics were used continuously for 37 to 52 days even after resistance.
The lab report of B&B Hospital has shown that the two drugs used in the patient (colistin and Cilanem) have been repeatedly resistant. According to the lab test, only one patient, Arjun Bhandari, was found to have antibiotic resistance to imipenem (Cilanem) five times and colistin four times.
However, the use of antibiotics has continued. They looked for an alternative to B&B Hospital because the infection was not controlled even after long treatment. Dhan Bahadur Khadka made a special report on this topic in the Swasthya Khabar newspaper in April 2016. The case filed by the hospital against the report reached the Supreme Court through the District Court and High Court.
Later, after a long run, the Supreme Court decided in favor of Dhan Bahadur Khadka and Swasthya Khabar newspaper.
Antibiotics in poultry and fish
According to the study published in MDPI titled “Antibiotic Use in Broiler Poultry Farms in Kathmandu Valley of Nepal: Which Antibiotics and Why?”, a cross-sectional questionnaire study was conducted involving field visits to large poultry farms (flock size ≥ 3000) in the Kathmandu, Bhaktapur, and Lalitpur districts. Out of 30 farms (total flock size 104,200; range 3000–6000), the prevalence of antibiotic use was 90% (95% CI: 73–98%). Six farms (22%) used antibiotics as prophylaxis, while 21 farms (78%) used them for therapeutic purposes. A total of seven antibiotics from six classes (including quinolones, macrolides, and polymyxins) were used. The most commonly used antibiotics were tylosin (47%), colistin (47%), and dual therapies with neomycin and doxycycline (33%). In total, 50,000 grams of antibiotics (including both active and inactive ingredients) were used, averaging 0.5 grams per chicken over a 45-day flock life, with eight farms (26%) using more than two antibiotics.
Dr. Samirmani Dixit said that antibiotics are being used in chickens and fish at an alarming rate. “Antibiotics have been mixed with fish meal and poultry feed. Especially chicken chicks should be given a vaccine, but instead of that, the practice of giving antibiotics is increasing,” Dixti added.
According to Dr. Dixit, this is being done because after giving antibiotics, the chickens will become stronger, not get sick, and also give better eggs. Some time ago, in a study conducted by the Department of Food Technology and Quality Control, it was found that the use of antibiotics in broiler chicken (poultry chicken) meat was excessive.
In the study report of the department, it is mentioned that the amount of tetracycline, macrolides, aminoglycides, sulfonamide, and penicillin, among others, was found in chicken meat. The department collected 75 samples and conducted a study titled ‘Antibiotic Residue in Chicken Meat: A Potential Threat to Food Safety’.
Due to the weak monitoring system in Nepal, the rate of consumption of antibiotics in the veterinary sector has increased recently, Dixit further said. “The bacteria that digested the antibiotics in the chicken’s body have been released very harmfully after moving into the human body.”
He says that the danger caused by the bacteria entering the human body due to eating undercooked chicken meat can be lethal. In addition, he pointed out that the use of antibiotics is increasing in pigs, vegetables, and cattle to produce more milk as well.
It has affected people. Within animal health, a 2020 publication examined poultry rectal swabs and urine from patients visiting Kantipur Hospital in Kathmandu and found multidrug resistance in 80% of E. coli from poultry and 79% from clinical specimens.
In the fiscal year 2017-2018, an assessment of 150 commercial poultry farmers gave insight into farmers’ knowledge, attitudes, and practices. Notably, antimicrobial use for growth promotion was employed by 13% of producers, among whom 35% were using colistin. (The Swasthya Khabar newspaper has written about this in detail in January 2017).
Nepal at high risk
Various studies have shown that antimicrobial resistance is increasing in Nepal. Nepali medical experts and doctors say that Nepal is one of the countries where antibiotics are becoming more ineffective. In charge of the ICU of the TU Teaching Hospital, Dr. Subash Acharya, up to 70 percent of the bacteria (superbugs) that have digested the strongest antibiotics are found in hospitals in Nepal. Whereas in America it is only 10 to 20 percent.
Doctors say that a patient who came to the hospital with some other disease died of pneumonia. According to Dr. Acharya, this death is due to the failure of antibiotics, and pneumonia can happen when the medicine doesn’t work.
Antimicrobial resistance contributes approximately 700,000 deaths annually, and by 2030 it is estimated of global economic loss of more than $ 1.0 trillion annually. It is estimated that by 2030, AMR could force up to 24 million people into extreme poverty and could jeopardize the achievements of the Sustainable Development Goals 2030 for ending poverty, ending hunger, ensuring healthy living, reducing inequality, and revitalizing global development partnerships.
The World Health Organization (WHO) has declared AMR among the top 10 global health threats; it can no longer be addressed by single, isolated interventions with limited impact.
Pneumonia is also caused by hospital-acquired infections because hospital walls, gowns worn by health workers, and equipment also contain bacteria that have digested antibiotics. Acharya said that it will be difficult to protect the patient if they are infected. These bacteria called’superbugs’ are becoming a new challenge in the world. The hospitals should be needed to control it. He said that even though the drugstore, hospital management, and doctors were aware of this, they did not pay proper attention.
Attention of policymakers
Only recently have the stakeholders started talking about AMR. At the 79th United Nations General Assembly (UNGA) Antimicrobial Resistance (AMR) high-level meeting, world political leaders have expressed commitment to a clear set of targets and action plan to reduce human deaths associated with AMR, including reducing the estimated 4.95 million human deaths associated with bacterial antimicrobials.
The declaration also calls for sustainable national financing and US$100 million in catalytic funding, to help achieve a target of at least 60% of countries having funded national action plans on AMR by 2030. This goal is to be reached through, for example, diversifying funding sources and securing more contributors to the Antimicrobial Resistance Multi-Partner Trust Fund.
Head of the ICU department, Dr. Acharya, says that there is a growing fear if the world leaders don’t take this matter seriously because now the biggest fear for humans is from bacteria. So, special attention has also been started because bacteria are the cause of various infections.
“The world has felt the challenge from bacteria after the medicine given against bacteria (antibiotics) started to be ineffective,” Acharya said.
Dr. Roshan Pokharel, secretary of the ministry, says that the study on AMR has been increased, and policies like the National Action Plan for Antimicrobial Resistance (AMR) in Nepal have been made. At the South Asia Regional Media Workshop to Prevent Antimicrobial Resistance (AMR) held in Kathmandu some time ago, he said, they have made a policy. Now is the time to unite for implementation.
According to Dr. Pokharel, in May 2015, the 68th World Health Assembly endorsed the Global Action Plan (GAP) on Antimicrobial Resistance (GAP-AMR) to tackle AMR and urged the member countries to make their own National Action Plan on AMR in alignment with GAP-AMR by May 2017. Commitment by global leaders to combat AMR was further strengthened at the High-Level Meeting on AMR at the United Nations General Assembly on 21 September 2016. He added, ‘The Government of Nepal has undertaken several measures to address the commitment made to contain the challenges of AMR in Nepal. The National Health Policy of Nepal, 2076 BS, has prioritized AMR as an important public health issue and has highlighted the need to develop a national action plan (NAP) to reduce AMR and effectively regulate and control antibiotic use through multisectoral collaborative action. With the growing burden of AMR in the country and commitment made, Nepal requires a National Action Plan (NAP) to tackle the issue of AMR through a ‘One Health’ Approach.’
Dr. Upadhyay says that if humans are not to be defeated in the battle with bacteria, they should be stopped from allowing the bacteria to digest the existing medicine until a new medicine is discovered. He further says, there has been no new antibiotic as a reserve for the past 30 years. “There is a need to work on it as soon as possible,” said Upadhyay.
“The only way to prevent this is stewardship. ‘Every hospital should implement a stewardship program. The government should make a rule that the stewardship program should be implemented compulsorily when renewing or renewing the license of hospitals with more than 100 beds,” said Acharya. “Considering hospital pharmacy as the backbone to support the hospital is the biggest weakness,” he added.
(Khadka is the Executive Editor at NepaliLiveToday.com’s sister organization, the health-related news magazine Swasthyakhabar Patrika)
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