Pills that make medicine ill

The sale of prescription drugs over the counter threatens to wipe out the power of antibiotics. Unregulated high doses have built up resistance in bacteria, and experts now fear a world in which common infections once again kill.

The admission that pharmacies are breaking the law by selling prescription-only drugs over the counter is much more than just a law-enforcement issue.

In one particular area it poses a serious threat to public health.

Last month the World Health Organisation (WHO) described global antimicrobial resistance levels – predominantly caused by the incorrect and repeated use of antibiotics – as a major threat to public health, one so serious that it threatened to wipe out the achievements of modern medicine.

“A post-antibiotic era in which common infections and minor injuries can kill, far from being an apocalyptic fantasy, is instead a very real possibility for the 21st century,” warned Dr Keiji Fukuda, assistant director general of WHO, in the foreword of the Antimicrobial Resistance Global Report on Surveillance.

The document is the most comprehensive source of data on drug resistance to date, collating statistics from 114 countries and examining resistant forms of bacteria that cause a range of illnesses including diarrhoea, gonorrhoea, bronchitis, meningitis, pneumonia, skin infections and wound infections.

Traditionally, antibiotic resistance refers only to the resistance to antibiotics that occurs in common bacteria that cause infections. Antimicrobial resistance goes beyond this and takes into consideration resistance to drugs used to treat infections caused by other microbes such as parasites, viruses and fungi, said WHO staff.

When microorganisms are exposed to an antimicrobial, or antibiotic, the more susceptible organisms perish. But some resistant organisms survive to pass on this resistance to subsequent generations.

“Without urgent action we are heading for a post-antibiotic era, in which common infections and minor injuries can once again kill,” the organisation said.

It warned that common infections in neonatal and intensive- care units were becoming extremely difficult, and sometimes impossible, to treat, while antibacterial drugs to prevent post-surgery site infections were now less effective or totally ineffective.

Penicillin, the world’s first antibiotic, was discovered in 1928 by Sir Alexander Fleming, who in a 1945 Nobel Lecture warned that bacteria could come become resistant to the drugs. When they were first used in the 1940s, medical care was transformed and infectious diseases were no longer necessarily deadly.

But over several decades, almost every type of bacteria became less responsive to treatment because of the use and misuse of antimicrobials in treating humans and animals. The term “superbug” is often used to describe microorganisms that are multi-drug resistant, the most well known being Methicillin-resistant Staphylococcus aureus, or MRSA, commonly found in health-care settings.

Stronger microorganisms and a “virtually empty” pipeline for the development of the new antibacterial drugs, said WHO staff, meant commonly acquired infections such as pneumonia might not respond to recommended drugs, putting the lives of patients at risk. It is worth noting that no new antibiotic has been developed since 1987.

The UAE was one of only a few countries in the Middle East that provided data for more than five of the requested bacteria types for the report. The data listed, however, originated only from Abu Dhabi. There was no data available for Dubai and the Northern Emirates, which are governed by the Dubai Health Authority and the Ministry of Health respectively.

The Health Authority-Abu Dhabi (Haad) has been more transparent about its findings.

In 2012 a high-ranking member of the authority, Dr Jens Thomsen, now section head of occupational and environmental health at Haad, revealed the findings from the first year of a mandatory Antimicrobial Resistance Surveillance programme in the emirate.

He said the levels of resistance of the 14 most relevant human pathogens had already reached a “concerning high level” compared to other countries.

More recent Haad figures in the WHO report showed that a quarter of Eschericihia coli, or E.coli, cultures isolated for study were resistant to third-generation cephalosporins, meaning treatment of severe infections would have to rely on carbapenems, an antibiotic of last resort.

“These antibacterials are more expensive, may not be available in recourse-constrained settings and are also likely to further accelerate development of resistance,” WHO said.

The resistance of the Klebsiella pneumoniae bacteria, which causes pneumonia, urinary tract infections and bloodstream infections, to third-generation cephalosporins was at 17.4 per cent as per national data, and 42 per cent as per a 2005 study of 45 isolates in a hospital setting. In Oman, it was 22 per cent, and in Switzerland, the UK and Bahrain, it was 6.8 per cent, 5.3 per cent and 50 per cent respectively. Again, this scenario requires more reliance on the last-resort carbapenems. Haad also discovered, however, that 1.5 per cent of the bacteria were also resistant to these carbapenems.

“Of great concern is the fact that K.pneumoniae [bacterium] resistant also to carbapenems has been identified in most of the countries that provided data,” the report said. “The large gaps in knowledge of the situation in many parts of the world further add to this concern.”

Resistance in the UAE of Staphylococcus aureus, causing wound infections and bloodstream infections, was at 27.5 per cent, or one in four instances. Resistance of Non-typhoidal salmonella, causing diarrhoea, was at 13.2 per cent, and one in 10 Shigella species, responsible for dysentery and diarrhoea, were resistant to fluoroquinolones, a group of synthetic antibiotics.

Globally, resistance to the drug of last resort for gonorrhoea, caused by the bacterium Neisseria gonorrhoea, has already been reported in several countries, with half of the WHO regions reporting resistance of 25 per cent or more. If left untreated, it can cause infertility, neonatal blindness and adverse pregnancy outcomes.

According to WHO, the effect of resistant gonorrhoea will have a major effect on disease-control efforts because of the increased serious complication and “separate gonococcal entities such as neonatal infections and disseminated gonococcal infections will become much more common”.

On releasing the data, the WHO called for urgent and drastic action to try to slow down the rise in levels of resistance to antibiotics.

According to the group, 50 per cent of all medicines were prescribed, dispensed or sold incorrectly, and half of patients failed to take them properly. Furthermore, half of all countries did not implement basic policies that promoted the rational use of medicines.

This is particularly pertinent in the UAE, where the illegal sale of prescription-only medicines, including antibiotics, over the counter is “endemic”, according to some sources.

A recent study in the British Journal of Applied Science and Technology by David Yeboah and Tracey Yeboah, of Abu Dhabi University, that was reported in The National, said it had become acceptable to pharmacies and customers in the capital to “indulge in the practice with impunity, and with no due regard for the law and basic ethics”.

It is, in fact, illegal to sell any prescription drugs, including antibiotics, without a proper prescription. The onus is on the seller, not the buyer.

Article 11 of the 1983 Federal Law Concerning Pharmaceutical Profession and Establishments states: “A licensed pharmacist may not dispense any Medicine of Pharmaceutical Preparation except on a medical prescription stating in clear handwriting the name of the physician who has issued the prescription, his seal, signature and issue date, provided that the physician is licensed to practise human or veterinary medicine in the state.”

The reality, in Abu Dhabi at least, is very different.

The Yeboah study stated that all of the 73 pharmacies observed admitted to selling medicines without the necessary prescription, the majority because “everybody is doing it” and “the next pharmacy will sell if I don’t”.

Of 131 patients who were asked if they regularly bought prescription medicines over the counter, 126 said they did, and all of them said the would do so again.

A Ministry of Health policy document from 2008 also acknowledged that 70 per cent of pharmacists sold antibiotics illegally.

WHO is urging countries to adopt an easy three-prong approach to taking antibiotics. First and most importantly, people should only use them when they are prescribed by a doctor, and authorities should do everything they can to make sure this happens.

Second, a patient should always complete the full course, and third, no one should ever share antibiotics with other people or use leftover prescriptions.

The pressure is also on the policymakers. WHO has called on them to: strengthen resistance tracking; strengthen infection control and prevention; regulate the proper use of medicines and promote cooperation and sharing among all stakeholders.

munderwood@thenational.ae

Published: May 26, 2014 04:00 AM

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