Changing attitudes towards antibiotics in Pakistan: The stewardship challenge

Antibiotic stewardship is a crucial concept in the field of healthcare, with the overuse and misuse of antibiotics leading to the development of antibiotic-resistant bacteria, a global public health threat. During my exploration of this issue, I have gained valuable insights from various professionals, particularly from Dr. Shazaween, Research Coordinator at Agha Khan University. Based on her suggestions, I have decided to write a detailed article on the state of antibiotic stewardship in Pakistan, where the misuse of antibiotics is a pressing issue.

In addition to my discussions with healthcare professionals like Dr. Shazaween, I have also conducted concrete research and gathered overviews from pharmacists who are on the front lines of dispensing antibiotics in Pakistan. By incorporating their perspectives and experiences, I hope to provide a comprehensive analysis of the state of antibiotic stewardship in Pakistan, and the challenges and opportunities for improvement. Through this collaborative effort, I aim to provide insights and recommendations that can inform policies and practices to ensure the responsible use of antibiotics in Pakistan and beyond.

Antibiotic stewardship is a critical approach that focuses on the appropriate and responsible use of antibiotics. It is aimed at reducing the emergence of antibiotic resistance, which is a major public health concern globally. In Pakistan, the issue of antibiotic resistance has become a significant challenge due to the misuse and overuse of antibiotics. The lack of awareness about antibiotic resistance among healthcare professionals and the general public has contributed to this problem.

Dr. Shazaween, Research Coordinator at Agha Khan University, suggests that one of the major factors contributing to the lack of awareness about antibiotic resistance in Pakistan is the inadequate training of healthcare professionals. She points out that most healthcare professionals in Pakistan do not receive adequate training on antibiotic prescribing practices and antibiotic stewardship. As a result, they tend to prescribe antibiotics indiscriminately, leading to the emergence of antibiotic resistance.

To gain insight into the situation on the ground, I reached out to working pharmacists to collect their reviews on antibiotic stewardship in Pakistan. The pharmacists revealed that the misuse and overuse of antibiotics is a prevalent practice in the country. They also noted that patients often demand antibiotics even for conditions that do not require antibiotics, such as the common cold. The pharmacists indicated that this behavior is fueled by the lack of awareness about the consequences of antibiotic resistance.

Specifically Pharmacist Rafay Mujtaba shared his findings from his undergraduate research project, which focused on the perceptions and practices of community pharmacists towards antimicrobial resistance and stewardship in Lahore, Pakistan. He found that in most community pharmacies, there were no pharmacists available, and among the available pharmacists, only half were aware of antimicrobial resistance, and very few knew about stewardship programs. One significant reason for the emergence of antibiotic resistance was the lack of standard operating procedures for culture testing. He also encountered prescriptions from consultant doctors who prescribed multiple antibiotics when there was no clear need. Another contributing factor was the prescription of antibiotic brands that had not been established to be efficacious. For example, over 170 companies in Pakistan are involved in the sales and marketing of cefixime, but only 3 to 4 have functional cephalosporin plants in Pakistan. These are a few of the many factors contributing to antimicrobial resistance in Pakistan, according to Mr. Mujtaba’s observations.

To further back up my research, I delved into the available evidence on Antimicrobial resistance in Pakistan.

• A study conducted by Hussain et al. (2021) found that there is a lack of awareness among healthcare professionals about the appropriate use of antibiotics, leading to the overuse and misuse of antibiotics. The study also revealed that patients in Pakistan have poor knowledge about the consequences of antibiotic resistance.
• Another study conducted by Khan et al. (2020) found that the prescribing practices of healthcare professionals in Pakistan are not consistent with the guidelines for antibiotic stewardship. The study also revealed that there is a lack of monitoring of antibiotic use in hospitals, which contributes to the emergence of antibiotic resistance.
• A study published In the Journal of Infection and Public Health in 2018 reported high levels of resistance to commonly used antibiotics among bacterial isolates from patients in Pakistan. The study found that up to 80% of E. coli and Klebsiella pneumoniae isolates were resistant to commonly used antibiotics, including fluoroquinolones and third-generation cephalosporins. (Reference: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6041842/ )
• A survey conducted by the World Health Organization (WHO) in 2018 found that Pakistan had the highest rate of antibiotic consumption in the world. The survey found that the country had an antibiotic consumption rate of 38 defined daily doses per 1,000 inhabitants per day, which is more than twice the global average. (Reference: https://www.who.int/bulletin/volumes/96/4/18-030418.pdf )
• Another study published in the Journal of Infection and Public Health in 2020 reported a high prevalence of multidrug-resistant (MDR) Acinetobacter baumannii in hospitalized patients in Pakistan. The study found that 92% of the A. baumannii isolates were MDR, with high levels of resistance to commonly used antibiotics such as carbapenems and aminoglycosides. (Reference: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7421542/ )
• A report by the Pakistan Council for Science and Technology in 2017 estimated that AMR could cause up to 10 million deaths globally by 2050, with Pakistan being one of the countries most affected by the problem. The report highlighted the need for urgent action to address AMR in the country, including the development of surveillance systems, the promotion of rational use of antibiotics, and the implementation of infection control measures in healthcare settings. (Reference: https://www.pcst.org.pk/downloads/PCST%20Report%20on%20Antimicrobial%20Resistance%20in%20Pakistan.pdf )

These studies and reports provide strong evidence of the high levels of AMR in Pakistan and the urgent need for action to address the problem. It is essential to promote rational use of antibiotics, strengthen infection control measures in healthcare settings, and invest in research to develop new antibiotics and alternative treatment options.

As a pharmacy student, I believe that addressing the issue of antibiotic resistance requires a coordinated effort from various stakeholders, including healthcare professionals, policymakers, and the general public. Based on my research and analysis, I have identified the following solutions to tackle this issue in Pakistan:

Improve Antibiotic Stewardship: One of the most effective ways to combat antibiotic resistance is to promote the appropriate use of antibiotics. This can be achieved through the implementation of antibiotic stewardship programs, which aim to reduce the emergence of antibiotic-resistant bacteria. In Pakistan, the Drug Regulatory Authority of Pakistan (DRAP) has introduced guidelines for the rational use of antibiotics, which can help to promote antibiotic stewardship.

Enhance Infection Prevention and Control: Effective infection prevention and control measures can reduce the spread of antibiotic-resistant bacteria. These measures include hand hygiene, environmental cleaning, and the appropriate use of personal protective equipment. The Ministry of National Health Services, Regulations and Coordination in Pakistan has issued guidelines for infection prevention and control in healthcare facilities.

Strengthen Regulatory Framework: Regulations on the sale and use of antibiotics can help to reduce the emergence of antibiotic-resistant bacteria. In Pakistan, the DRAP has introduced regulations to restrict the sale of antibiotics without a prescription and promote their appropriate use.

Educate Healthcare Professionals and the Public: Raising awareness about the appropriate use of antibiotics can help to reduce the misuse and overuse of antibiotics. Educational programs for healthcare professionals and the general public can promote the appropriate use of antibiotics. In Pakistan, the Ministry of National Health Services, Regulations and Coordination has launched awareness campaigns to educate the public about the appropriate use of antibiotics.

It is important to note that these solutions have been recommended by official organizations and experts in Pakistan and around the world, and their implementation can have a significant impact on reducing the emergence of antibiotic-resistant bacteria. As a pharmacy student, I believe that the implementation of these solutions, along with continued research and surveillance on antibiotic resistance, can help to ensure the effective treatment of infections and promote public health in Pakistan.

In conclusion, antibiotic stewardship is crucial for the appropriate and responsible use of antibiotics. In Pakistan, there is a lack of awareness about antibiotic resistance among healthcare professionals and the general public. The misuse and overuse of antibiotics is prevalent in the country, contributing to the emergence of antibiotic resistance. To tackle this issue, there is a need for improved training of healthcare professionals on antibiotic stewardship and the appropriate use of antibiotics. Additionally, public awareness campaigns can be launched to educate the general public about the consequences of antibiotic resistance.

About the Author:

Hood Ahmad is a pharmacy student at Iqra University with a passion for promoting responsible antibiotic use. You can connect with Hood on LinkedIn at https://www.dhirubhai.net/in/hood-ahmad-7b059b183