Publications

ANTIBIOTIC STEWARDSHIP

It is customary to make New Year resolutions and although I stopped making such several years ago, I will make an exception this year. I would also enjoin all of you to join me in this resolution, which is to ensure proper use of antibiotics. This is important because of the increasing risk of antibiotic resistance. The World Health Organization (WHO) in April 2014 declared the beginning of post antibiotic era and the World Health Assembly in 2015 developed a global action plan on antimicrobial resistance. This is because according to Centre for Diseases Control (CDC) in United States of America (USA) 2 million people developed an infection that is resistant to antibiotics and 23,000 of these people died as a result of the infection. Equally, a British Government report on antimicrobial resistance estimated that 50,000 deaths occur annually in USA and Europe due to antibiotic resistance and worldwide estimates could be as high as 700,000. The situation is likely to be worse in Nigeria because of the indiscriminate use of antibiotics that are often sold over the counter without prescription or medical oversight. Worse still are the street hawkers that sell single digit capsules (usually green and yellow!) with the promise to cure all ills.

As a surgeon, my work is heavily dependent on antibiotics. Most major advances in surgery during the latter part of the Nineteenth century coincided with improvements in sterilization of instruments, anaesthesia and antibiotics. Prior to these more than three quarters of patients died following even the simplest of operations from overwhelming infections. As we advanced in the development of these three adjuncts to surgery, great strides were made in cancer surgery, orthopaedics and transplantation. Sadly with the abuse and overuse of antibiotics worldwide the different groups of bacteria have developed resistance to once effective antibiotics like Methicillin resistant Staphylococcus aureus (MRSA) and Vancomycin resistant Enterococcus (VRE) to name a few. For example, most reports from Nigeria had stated that MRSA was rare but once we started taking swabs particularly from patients transferred from other facilities to Lagoon we discovered a number patients infected with the so called superbug. If the trend continues the risk is that antibiotic resistance would limit our options for treatment in future. Operations would no longer be safe and immune-compromised patients particularly those on chemotherapy will die from life threatening infections resistant to antibiotics. It is also pertinent to note that since the late 1980s no new class of antibiotics has been discovered with little investment in new ones currently.

The Joint Commission International (JCI) has recently published the 6th edition of accreditation standards that would be used for our re-accreditation at the end of this year. One of the pillars of these standards is Medication Management and Use (MMU) 1.1 that requires all institutions to have an effective antibiotic stewardship program. This would require us to have clearly defined indications and proper prescriptions of antibiotics for prophylaxis and treatment of infections. There has to be mandatory oversight and tracking of the effectiveness of measures to improve use of antibiotics. We would need to ensure compliance with stopping prophylactic antibiotics on time and reducing inappropriate use of broad-spectrum antibiotics. As much as possible we must use first line antibiotics, which requires an understanding of the causative bacterium and likely sensitivity. In addition to this the antibiotics must be the appropriate dose taken at the right time with correct time interval and duration of treatment in days.

Antibiotic stewardship would require a culture change for most doctors and pharmacists and an even bigger culture change for the patients. Our biggest challenge would be managing the expectations of patients. This is possible by correctly educating them and being assertive about correct treatment and prescription. There is an old Readers Digest joke that states that if one treats common cold with antibiotics the cold would last for one week and if antibiotics are not used then the cold would last for seven days! Apart from common cold other viral infections that do not require antibiotics include upper respiratory tract infection in children, bronchitis and diarrhoea and vomiting at any age. These are the majority of patients seen in general medical practice.

Once again please let us resolve to have better antibiotic stewardship so we can save the lives of our patients and preserve current antibiotics for the future generations that would include our children and grandchildren.

Dr Jimi Coker
Chief Medical Director


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