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Dubai: The case of the six-year-old girl who developed antibiotic resistance is not an isolated one in the world of antibiotics.

As these super drugs are routinely prescribed, controversies on their abuse and overuse are beginning to throw a big question-mark on whether antibiotics have outgrown their effectiveness.

The question doing the rounds in many medical corridors is: Is the golden age of antibiotics over?

“No, this is not true,” said Dr Sandeep Pargi, consultant pulmonologist at Aster Mankhool Hospital, Dubai.

“Antibiotics still have a great scope as new ones are being discovered. There are some old-generation antibiotics that are being phased out due to resistance [issues] but many are being discovered as we speak.”

 Antibiotics still have a great scope as new ones are being discovered. There are some old-generation antibiotics being phased out because of resistance [issues] but many are being discovered.”

 - Dr Sandeep Pargi | Consultant pulmonologist


Dr Atul Aundhekar, a Dubai-based general practitioner who has done considerable research on antibiotics, said: “Antibiotics are the greatest weapon in the hands of the physician, provided he uses them judiciously.”

Dr Aundhekar cites the 4Rs of antibiotic usage: right antibiotic; right dose: right duration and right frequency.

“This is important to avoid any kind of resistant strains developing. Microorganisms mutate and develop drug resistance if the antibiotic used does not adhere to the above principle,” said Dr Aundhekar.

 Once the doctor is sure of the nature and kind of microorganism, he will be able to prescribe the right potency and dosage of antibiotics. For viral infections, one can have palliative therapies.”

 - Dr Atul Aundhekar | General practitioner


Adding fuel to this fire, a recent report in the British Medical Journal declared that there is absolutely no evidence for the arbitrary lengths of time people are told to take antibiotics, which can range from two to 10 days or even longer, and that it might be better for them to stop as soon as they feel better, to reduce the global growth of antibiotic resistance in bacteria.

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Professor Colin Garner, senior pharmacologist and chief executive of Antibiotic Research UK network of commercial and university scientists, said: “At the moment, we are using antibiotics indiscriminately and hoping they might work. We can’t even tell if someone has a bacterial infection or a viral one that antibiotics won’t work on anyway.”

Dr Pargi believes doctors need to rely a lot on old-fashioned diagnosis before rushing in to prescribe antibiotics. “Antibiotics work against bacterial infections. Very often, doctors prescribe antibiotics for viral fever and infections which would anyway subside within a week.”

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Dr Aundhekar added: “There is a process of evidence-based deductions that a doctor goes through while assessing his patient. There are direct indicators of bacterial infections such as a purulent (pus) discharge, plus surrogate indicators that are ascertained through blood tests.

“Once the doctor is sure of the nature and kind of microorganism, he will be able to prescribe the right potency and dosage of antibiotics. For viral infections, one can have palliative therapies which give relief, mitigate symptoms, as once the viral infection subdues, symptoms go away.”

‘My daughter’s infection has turned chronic’

Dana Mohammad (name changed), a Jordanian expatriate living in Abu Dhabi, is at her wit’s end. For the last two years, her six- year-old daughter has been in and out of hospitals having undergone five different courses of antibiotics for an E. coli urine infection that has now developed resistance.

“My daughter’s infection has turned chronic. From the age of four, my daughter’s urine began to smell strongly and I requested her paediatrician to carry out urine tests as she was falling ill frequently. The doctor failed to conduct a proper germ culture despite my insistence and the routine test did not show the E. coli infection,” said the harassed mother. It was only when her little one developed pneumonia and required hospitalisation that the infection was detected.
The report showed her positive for E. coli. However, the antibiotic dosage for the pneumonia cleared up that disease but the type of antibiotic given for the urine infection was too weak which the family came to know only after seeking yet another opinion.

“Taking my daughter for a second opinion, I was told the antibiotic for her urine infection was in the wrong dose and would not work. As a result, she developed a resistant strain,” recounted the mother.

Since the diagnosis, the little girl has been in and out of hospitals, including two stays at a hospital in Jordan, losing out on school days and has been subjected to bitter medicines, some intravenously, so much so that it has impacted her happy nature.

“I cannot believe a doctor’s short-sightedness could have wreaked such havoc on my six-year-old’s body, destroying her immune system,” said the mother, who is also consulting a trusted homeopath from the UK to provide some relief to her daughter.

Prescription protocol: How long is too long?

With antibiotics prescription time lengths stretching from three days to over 10 days, the debate acquires more potency. Should the prescription period be reduced to combat the threat of antibiotic resistance?

Dr Sandeep Pargi, consultant pulmonologist at Aster Mankhool Hospital, Dubai and Dr Atul Aundhekar, general practitioner, agree that medical evidence suggests it is important to complete a course.

“If the antibiotics have been prescribed in morning and evening dosage for five days, one must follow the course. Stopping it midway might subdue the microorganism but absence of the right dose might give it time to mutate to develop a resistance to that drug,” said Dr Aundhekar.

“There is a reason why antibiotics are prescribed in particular dosages in particular potencies with an exact duration of three, five or seven days. Double blind trials conducted with these medicines have been used to determine their efficacy for various kinds of bacterial infections. The medicine must be had in the dosage and duration prescribed to avoid possibility of re-infection or secondary infection and resistance.”

Dr Pargi said, “An antibiotic course is either three, five, seven or nine days. None of the antibiotics go beyond 14-day prescriptions except those administered in case of tuberculosis.

“If the course is three days, then that is what one needs to follow. If the course is 14 days, follow that. The danger arises when people self-medicate, get over-the-counter antibiotics and switch from one to another on their own. They might take two or three antibiotics for a longer period and develop resistance.”

Germ Culture: Why is this required?

Germ culture is an important requisite in antibiotic regimen. In case of persistent infections in the urinary tract or throat, doctors do a germ culture to ascertain what antibiotic really works.

“The swab taken from the patient is placed in a Petri dish and colonised. The technician is able to ascertain what specific antibiotic it is sensitive to. This culture is effective in prescribing the accurate dose and type of medicine required,” explained Dr Aundhekar.

The reason why when a doctor prescribes an antibiotic, he needs to take into account the extent of an infection (minor or major) in terms of degree, its involvement (how many systems in the body has it compromised such as circulatory, excretory, digestive and respiratory) and the constitution of the patient.

Dr Nas Al Jaffri (right), based in Abu Dhabi, disclosed the case of an adult male patient who developed a drug resistant E. coli urine infection. “The patient came to me with advanced case of ESBL (Extended Spectrum Beta-Lactamases) E. coli strain and I had to start him on an aggressive drug regime of ciprolaxin. When that failed, I put him on another regime. However, his infection would not subside and he was running fever. Ideally, I would have had to admit him to hospital for intravenous antibiotic dose. However, I managed to keep him out of hospital but still administered a broad spectrum IV dose which was effective and he finally was able to get disease free.”

Overuse, misuse and abuse

Overuse can occur only when there is trial and error with different types of antibiotics which usually occurs when people self-medicate, said doctors.

Patients can be prescribed antibiotics as many times as they need through the year, provided the protocol and guidelines are followed. Every hospital around the world follows a set antibiotic policy. In Scandinavian countries especially, doctors are judicious in prescribing antibiotics. When this strategy is followed, which should be the case in the rest of the world, there is little danger of resistance, said Dr Pargi.

One of the challenges in preventing the abuse of antibiotics is the emergence of drug-resistant strains of microorganisms. This is particularly true in the case of tuberculosis which has seen the microorganism mutate so quickly, especially in developing countries, that the new strains are multi-drug resistant (MDR).

“In tuberculosis, when a person has the disease for the first time, we begin with the first line of multi-drug therapy. Usually, the disease is cured with a course of six months to a year. When a person has TB for the second time, it means the first line of drugs is not likely to be effective so we put him on multi-drug therapy (with a combination of four-seven drugs). When the disease recurs, it means the strain has developed multi-drug resistance (MDR). When this fails, we prescribe XDR or extreme drug resistance therapy,” Dr Pargi said.

The rise of the superbug

Research published in Lancet, the medical journal, indicates that about 50,000 deaths worldwide are caused due to the emergence of the superbug (microorganisms that are resistant to first, second and third line of antibiotics).

One common superbug usually found in hospitals worldwide is methicillin-resistant Staphylococcus aureus (MRSA). This bacterium doesn’t respond to methicillin and related antibiotics. This bacterium can cause skin infections and, in more serious cases, pneumonia or bloodstream infections.

These emerge in hospitals and surgical wards where the chances of infections are very high and the microorganisms thrive and mutate in conditions of poor hygiene and exposure to maximum medication. Dr Pargi said: “Hospitals worldwide need a clear cut and definite antibiotic policy — when to start an antibiotic, the kind of dosage to be administered, set strategy to combat common pathogens, and new research and development into drug-resistant strains.”

Regarding the superbug scare, Dr Pargi refutes the hype. “There is no such thing as a superbug syndrome. In some areas of the world, a lack of hygiene in hospitals gives rise to resistance within the hospital. There is no uniform superbug syndrome. For instance, hospitals in Dubai have no superbugs.” If hospitals do three things, we need not fear superbugs:

1. Follow a definite antibiotic guideline and policy and avoid indiscriminate use;

2. Use them judiciously with ensuring correct protocal of duration, potency and dose is followed; and

3. Maintain hygiene standards in their environment.

What is the right broad spectrum or narrow spectrum antibiotic?

Spectrum is an umbrella term which effectively refers to carpet bombing the microorganisms.

When a bacterial infection develops resistance, there is a possibility of multi strains or secondary infections and the doctor requires a medicine that could cover an entire range of microorganisms. So he uses a broad-spectrum medication which is likely to address several strains of bacteria.

Dr Nas Al Jaffri (right), based in Abu Dhabi, warned against the indiscriminate use of broad spectrum antibiotics. “A majority of antibiotics prescribed to patients are not required at all. Doctors must practise defensive medicine and err on the side of caution.

“It is always advisable to begin with narrow spectrum medication that addresses a particular infection. They can order blood tests to confirm the extent of infection. Only when this does not work should doctors prescribe broad spectrum. Resistant strains can appear if the first line of defence is a broad spectrum antibiotic,” he said.

The pre- and probiotic discipline

While research institutes and medical practitioners continue to debate antibiotic use, at an individual level, we must work on strengthening our immune system that will help minimise the need for antibiotics.

Dr Juliot Vinolia, clinical dietitian and nutritionist, says it is important to consume probiotics. “Our gut has healthy bacteria residing in it. Prebiotics are naturally occurring biotins found in high-fibre foods such as bananas, beans, onions, garlic, apples, turmeric and chicory roots, which help the prexisting healthy flora to thrive and grow.

“When we ingest antibiotics, these not only destroy the harmful gut bacteria but also the healthy bacteria. So if you eat pre- and probiotics, they keep your gut healthy and strong.

“Probiotics are live bacteria found in fermented foods such as yoghurt, kefir, sauerkraut, kimchi, cheese and other dairy products.

“These help the gut to rebuild its destroyed healthy bacterial count after an antibiotic course. It is advisable for people to have both pre- and probiotic foods to help strengthen the immune system.”

Want to avoid antibiotics? Build your immunity

1. Sleep early. Make sure to get eight hours of sleep per night.

2. Keep yourself hydrated. Bacteria are known to thrive and proliferate in a dehydrated gut.

3. Have healthy, balanced and wholesome food, especially fruits, vegetables, dairy and nuts in your diet.

4. Avoid fatty, fried and packed food.

5. Avoid direct sugar.

6. Exercise regularly.

7. Practise good personal hygiene such as wearing clean clothes, having regular baths, hand washing and use of hand sanitisers.

8. Those above the age of 60 years are advised to get the pneumococcal vaccine as pneumonia is a common bacterial infection that can be fatal if allowed to advance.
Source: Dr Juliot Vinolia, clinical dietitian and nutritionist

Two sides of the picture

Roxanne Jaffer, businesswoman, British 
Healthy habits have kept her immunity strong
. “I haven’t had antibiotics for the last four years and consciously maintain a healthy lifestyle. I am allergic to sugar and many food products and take care to have organic and healthy foodstuffs rich in pre- and probiotics. 
“I drink turmeric-infused water every morning since the time I suffered multiple foot fractures in the Alps and had to be taken for treatment to London via an air ambulance. The ingestion of turmeric water speeded up my recovery as it is anti-bacterial, and aids quick healing. 
“I also have saffron and cardamom-infused tea which is known to be very therapeutic with anti-cancer and anti-depressant properties. I take long morning walks by the sea, meditate regularly and I think all that has helped in strengthening my immune system.”

 

Latifa Dumalag, 48, Filipina Came out from a life-threatening pneumonia with judicious and effective use of antibiotics.
“I have been suffering from bronchitis and asthma since childhood and have a weak respiratory system. So I did not realise that what seemed to be like a normal cough and cold would rapidly develop into bronchitis and pneumonia. I consulted one clinic first and they gave me medication which was ineffective, and I continued to cough and wheeze. 
“When I contracted fever and could hardly breathe, I was referred to Aster Hospital under Dr Sandeep Pargi who literally brought me back from death. I was put on IV antibiotics and once I recovered after nearly 10 days in hospital, I was given multivitamins and discharged in the first week of October. “I am 95 per cent cured and still have to get constitutionally stronger. But the right dose of antibiotics saved my life.”

 

Kezia Garo Roche, Brazilian
Except for a surgery at 16, she has never taken antibiotics. 
“We all — my brother, sister and I — take after our mother who has a strong constitution and was against antibiotics. I recall as kids, if we fell ill and my mum had to take us to the doctor, she would not want to buy the antibiotics he prescribed. Instead, she would pick a variety of herbs from our family farm and give us decoctions that would make us feel well again.
 “[My] mother’s upbringing with completely natural and herbal remedies have made me so strong that to this day, I have never had a headache in my life. I have no aches or pains.
 I focus on balanced nutrition, good sleep and workouts to keep myself healthy. The only time I had an antibiotic was at the age of 16 when I had to undergo a surgical procedure. 
“My advice is to build on your body’s natural immune system to fight back infections.”

Top 5 antibiotics that are in danger of misuse or abuse

Amoxicillin: A penicillin antibiotic that fights bacteria, Amoxicillin is used to treat several types of infection caused by bacteria. However, doctors mistakenly prescribe it in case of viral throat infections that would have otherwise cleared up with palliative and symptomatic care.

Cephalexin: Used in cases of bacterial infection. Doctors continue to prescribe it erroneously for viral and fungal infections, especially in case of skin infections.

Azithromycin: This antibiotic is used to treat certain bacterial infections, such as bronchitis; pneumonia and infections of the ears, lungs, skin, and reproductive organs. It is an over-the-counter (OTC) antibiotic.

Ciprofloxacin: This is a fluoroquinolone (flor-o-KWIN-o-lone) antibiotic and is often overprescribed when a simpler antibiotic could work.

Sulfonamides antibiotics: These contain sulpha drugs that have an enzyme in them to destroy the cell wall of the bacterial microorganism and inhibits its growth.

In case of prescribing these antibiotics, it is important for the health specialist to recognise the bacterial infection and prescribe the correct potency, dosage and duration as per international guidelines as underuse, overuse or abuse can cause the patient to develop resistance to them.
Source: Dr Atul Aundhekar, general practitioner