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Resistance to antibiotic is a worldwide problem which has almost become a health emergency. It is more appropriately termed as Antimicrobial Resistance – AMR. It is estimated that AMR became the cause of death of 1.29 million patients last year, and by 2050, 10 million patients are expected to lose life because the treatment with antibiotics would not work due to resistance.
There are multiple reasons for antimicrobial resistance, the most important of which is inappropriate use of antibacterial drugs/ antibiotics. The resistance development does not remain localized in the country where it develops; it is transmitted across many countries quickly due to global travels.
Pakistan is a fertile ground for development of antimicrobial resistance. We are familiar with these scenarios.
Scenario I – A patient with cough and fever goes to the family doctor near his home who diagnoses respiratory infection. The GP has no way to know which microbe might have caused it, and therefore cannot choose a specific antibiotic. He is also under pressure to ensure early relief otherwise he would lose the patient and his practice. So, the GP will give the most powerful antibiotic in his arsenal or give even two antibiotics to make doubly sure. The microbe is unnecessarily exposed to antibiotics. The patient feels better the next day, does not return to doctor, and stops the treatment. The antibiotic course duration is not completed, the infection is not fully controlled and the microbe which was down with the first two doses becomes active again. The patient may recover due to his/her immunity, but the microbe got insufficient exposure which can lead to develop of resistance. This is an everyday scenario and that is why antimicrobial resistance is quite high in Pakistan. In a vicious cycle, more powerful drugs are used more inappropriately, and the cycle goes on increasing the AMR.
Scenario II – A patient had been suffering from some undiagnosed infection for several weeks and lands in a consultant clinic. The history shows that he had taken multiple antibiotics already. The consultant diagnoses the infection, but he is in a quandary to select antibiotic. He also fears that the patient has AMR already. He is therefore compelled to give 2-3 antibiotics to give full coverage. He also advises to continue treatment for ten days. The patient gets much better in five days and stops taking medicine. By giving insufficient exposure, he is contributing to the likelihood of AMR.
Scenario III – A patient is admitted in hospital in serious condition. He has high grade fever and looks visibly toxic. The diagnosis is that his infection is spread in the blood, and he is suffering from septicemia. The consultant orders culture and sensitivity test. The blood sample is drawn and sent to laboratory. The lab first cultures the blood to grow the microbes present in it. If these are successfully grown, these are identified. In the next step, various antibiotic discs are applied to the grown microbes. If the microbe shows sensitivity to the antibiotic, a clear zone – zone of inhibition develops around the antibiotic disc. This is measured with a vernier caliper, bigger the zone, greater the sensitivity. The microbiologist develops an antibiogram and recommends which antibiotic should be used in that patient. This is important because error in selection of antibiotic may be too costly and may even cost life in this patient.
Now take this scenario to a remote place, may be a field hospital set up for battling army, or refugees. Many patients are serious, and treatment is urgent. Basic lab is available, but qualified microbiologist is not there. The lab technician can do up to culture and applying antibiotic discs but cannot interpret antibiogram to make a correct recommendation.
This is a classic dilemma in all remote hospitals where some facilities are available but qualified staff is not there. Médecins Sans Frontières – MSF has worked on it and developed an Application which is being tested in their own labs. After completion of testing, the App shall become available for free download and use.
This is how it will work.
For patients where AMR is suspected and the patient is serious, the blood sample shall be sent to the lab for culture and sensitivity. The lab technician shall do the culture and upon getting the growth, shall apply available antibiotic discs. It will be incubated overnight. By next morning, zones of inhibition will appear in the petri dish. There is no qualified microbiologist, and the role of App comes here.
The lab technician shall take a picture of the petri dish with his mobile and the App shall do the rest. It will calculate the size of zones, shall develop antibiogram, and recommend the most suitable antibiotic. The App works on the basis of enormous data that is fed into it.
When available for free download and use, the app shall be a big support to doctors working outside the settled hospitals. The patients shall get the right antibiotic and the treatment outcome shall be better.
Unfortunately, this App shall not be able to help in curbing the emergence of antimicrobial resistance. The development of resistance starts in the outpatient treatment and evolves into inpatients.
Pakistan is among the highest antibiotic consuming countries. We are also among the top in promoting drug resistance through inappropriate use of antibiotics, overuse, self-medication, and free availability of all kinds of drugs. The problem is in basic administration of healthcare system, and it is suffering like so much else.
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