SCIENCE JOURNALISM  5 min Antibiotic-Resistant Bacteria: The Forgotten Danger in Aden

You come across reports of international organizations warning against the emergence of antibiotic-resistant strains of bacteria, describing it as one of the biggest risks to international health and development that is dangerously on the rise on international level. You read the warnings and start to panic. You try to recall your limited school knowledge in biology. You know antibiotics are supposed to kill bacteria, so what has happened?

You go on reading to understand why (some) bacteria have become resistant to antibiotics.

Consequences of Misuse

Antibiotics are used to treat bacterial infections by administering a certain dose that mostly succeeds in killing the bacteria or preventing its proliferation. However, overuse of antibiotics lead bacteria to adapt to antibiotics by changing their form, size and genome as a form of self-defense against these medications, a process known as “antibiotic resistance”. The result was the emergence of stronger and more virulent bacterial strains called “antibiotic-resistant bacteria”, which customary medications fail to eliminate. Infections with this kind of bacteria may result in a fast deterioration of the patients’ health, complicate treatment of diseases like tuberculosis and pneumonia to an almost impossible level and make minor infections lethal, thereby increasing mortality rates.

According to reports, 700.000 people die every year from antibiotic-resistant bacteria. Unless urgent action is taken, it is likely that the annual mortalities will reach 10 million by 2050. A study mentioned that 1.27 million deaths by antibiotic-resistant bacteria occurred in 204 countries and regions around the world in 2019, with a daily average of 3500 deaths. Authors warned that the world is facing a health problem potentially more serious than major diseases like HIV and Malaria, as it has already become a leading cause of death in all age groups and economies. However, it poses a bigger threat in low-income countries due to lack of infrastructure, such as clean water and sewage networks, and due to the unavailability of microbiological tests prior to antibiotic administration, as well the lower quality of medications.

An Unattended Danger

When mentioning poor and low-income countries, we cannot forget Yemen, particularly Aden, the city visited by anesthesiologist Götz Gerresheim in 2020 as part of the Doctors-Without-Borders (MSF) staff. He was shocked by the rate of antibiotic-resistant infections among locals that reached 60% of total infections. Ironically, in his hospital in Germany the rate of these infections was only two cases per year, yet this was enough to spread panic there.

The causes behind the spread of such infections in Aden’s hospitals is the lack of technical means and scarcity of laboratories where bacterial strains can be cultured and tested for antibiotic sensitivity, in addition to the unavailability of qualified staff able to interpret culture results.

I wanted to learn about the MSF’s assessment of the status quo in Aden and recent estimations of infection rates. However, the media official of the MSF in Aden did not provide an answer. Upon inquiring about current rates at the health office in Aden, the answer was: “We do not have such statistics”.
The studies tackling antibiotic-resistance in Aden are few and do not match the seriousness of the problem. The latest study conducted in 2020 and including three hospitals, Al-Jomhuriya, Khalifa and Al-Sadaqa, aimed to determine the strains of the antibiotic-resistant bacteria spread in Aden’s hospitals. Samples were acquired via swabs from 120 patients who underwent surgeries, then cultured and tested for resistance against the most widely used antibiotics in the Yemeni market. The results revealed that 56.6% of samples showed a positive bacterial growth. This, as the study mentioned, is an alarming high percentage. The study also identified four strains of bacteria that were most frequently isolated, all of which highly resistant to most tested antibiotics.

Dr. Khalid Saeed Al-Suedy, Dean of Faculty of Pharmacy at the University of Aden, who supervised the study, stated that the problem of antibiotic resistance is one of the most significant health threats developing countries like Yemen. He also confirmed that lack of diagnostic laboratories is an important cause of the widely-spread antibiotic resistance in Yemen. “When a patient is admitted to the hospital, doctors prescribe medication based on initial clinical examination and without resorting to biomedical laboratories to detect pathogenic bacteria and determine the mostly effective antibiotic.” Excessive prescription of antibiotics remains the main problem. “Our problem in Yemen is that doctors rush to prescribe antibiotics of strong generations to obtain a successful treatment.”

As for solutions that may limit the spread of antibiotic-resistant bacteria, Dr. Khaled suggested: “Moderation in using antibiotics. Additionally, it is important to set specific criteria for the disposal of industrial and hospital waste in a way that does not cause environmental pollution, which creates new antibiotic-resistant bacterial strains. It is also necessary to develop alternative drugs to antibiotics”.

Factors Exacerbating the Problem

The problem mentioned by Dr. Khaled about excessive antibiotic prescriptions was proven by a study conducted in 2015 to identify the steps doctors follow in prescribing antibiotics in Aden’s hospitals. The result revealed that out of 400 medical prescriptions 337 were antibiotic prescriptions, an equivalent of 84.2%, which, according to the study, goes beyond the guidelines of the World Health Organization (WHO).

I asked one of the authors of the previous study, Dr. Mohammed Babakry, Professor of Urology at the Faculty of Medicine and Health Sciences of the University of Aden, whether there were more recent studies assessing the same issue. His answer was: “There are no recent studies, but it is noticeable that things are getting worse due to the lack of health policies obliging health practitioners to abide by it”. Additionally, Dr. Babakry believed that patients also carry part of the blame for antibiotic misuse.

"Patients often use antibiotics without doctors’ consultations, when they suffer from mild symptoms, such as in the case of upper respiratory inflammation like common cold and sinusitis. These infections are viral, not bacterial, and thereby, do not require antibiotics. However, if the patient happens to use antibiotics, the result can only be a catastrophe.”

According to the WHO, another factor behind the spread of antibiotic-resistant bacteria is their administration in animal husbandry. Dr. Salem Nasser, Vice Dean of Nasser Faculty of Agricultural Sciences for Higher Education and Research, confirmed such administrations in Yemen. “Antibiotics are used in treating animals from infection and for killing bacteria. They are also added to poultry feed and drinking water to stimulate growth with unknown percentages. However, even small percentages can be harmful on the long run.”

Consequently, there is a tendency to use natural plant-based alternatives to industrial feed. Dr. Salem continued: “We are currently experimenting on producing natural forage from beeswax and black seed that may stimulate poultry growth instead of antibiotic-packed feed.” Dr. Salem is currently working on publishing a study on this matter soon, he said.

Moreover, smuggled and adulterated medications are considered as among the factors contributing in the spread of resistant bacteria. The most recent statistic, though dating a few years back, concluded that around 80% of drugs available in Yemen were smuggled into the country, 40% were adulterated or contained inactive ingredients. According to Dr. Marwan Al-Sharjaby, Deputy Director of Medical Supervision at the Health Office in Aden, the situation has not changed: “The amount of smuggled drugs is no less than 70% and the increased exchange rate of the US-Dollar contributed in promoting contraband.”

Surgeons’ Nightmare

Dr. Rami Rashad, Consultant of General and Thoracic Surgery at the Al-Joumhoryia state hospital in Aden, described the problem of antibiotic resistance as a nightmare: “The infection of antibiotic-resistant bacteria is one of the biggest challenges we are facing. In addition, it is the main cause of death in the surgical field. This is a real nightmare for surgeons. We do not have a medical policy to fight back. Also, we suffer from lack of knowledge in this respect, but the concerned authorities do not encourage academic and medical research despite the danger of the problem. Everyone is at risk with no exception, even newborns”.

Prevention remains the best solution: “it is possible to limit the spread of antibiotic-resistant infections by applying necessary sanitization during surgeries, taking extra caution when dealing with internal organs like the intestines and sanitizing the tools used in surgeries according to the guidelines of the WHO”.
As for infection estimations, Dr. Rami confirmed that it records 70-80% of the total bacterial infection. He believed that among the causes of its spread in Aden’s hospitals is the lack of technical means: “We suffer from the unavailability of biomedical laboratories that culture bacteria to determine the mostly suited antibiotic, and the unavailability of technicians qualified to interpret the cultures’ results, in addition to the misuse of antibiotics by doctors. Some physicians lacking work ethics have become agents of pharmaceutical companies. They test new antibiotics on patients in order to get privileges from pharmaceutical companies.”

Dr. Rami continued: “Fourth-generation antibiotics were introduced in Yemen without supervision. They are expensive, with a single injection costing more than 6.000 Yemeni Rial (around 24 US-Dollar) [EA6] and the patient may need up to 14 injections. Also, they are very strong drugs and their side effects can damage vital organs, such as the kidneys and the liver. In short, a loss on all scales.”

Indeed, the high rate of antibiotic-resistant infection in a country like Yemen is a real catastrophe. An infected person needs to stay longer in the hospital to recover, which puts an extra burden on hospitals and medical care expenditures, all in the light of a collapsing health sector and a deteriorating economic situation. Moreover, such infections increase the death toll in a country with more than enough causes of mortality.

A lot can be done to address this impending threat. First of all, authorities should realize the magnitude of the problem. This can be done by organizing awareness-raising campaigns in hospitals to limit infectious factors, supervising health practitioners, controlling the dispensing of antibiotics without medical prescriptions and tightening regulations to put an end to smuggled drugs. However, the reality is that while the world is panic-stricken by antibiotic resistance and prepares to face it, Yemen does not seem to share that attitude. It is as though it is not concerned with the threat, despite it having everything it takes for antibiotic-resistance to become a real disaster.
 

January 2023