KARACHI, Nov 24: A recent report based on the findings of a commission comprising 26 globally renowned scientists has shown that resistance to antibiotics has spread worldwide and countries are reporting deaths and diseases by antibiotic-resistant bacteria.

Experts have been warning against the repeated and improper use of antibiotics for a long time.

Now, according to the report, Pakistan is among the three countries in the world where over-the-counter sale of carbapenems (a class of antibiotics used for many bacterial infections) have increased. The country is reporting infections caused by a family of germs called carbapenem-resistant enterobacteriaceae (CRE).

(It is important to mention here that theCRE bacteria are found to be resistant to all existing antibiotics and has recently been regarded as the most urgent threat by the US Centres for Disease Control and Prevention).

Representing Pakistan on the commission were Aga Khan University`s Women and Child Health Division faculty members Drs Anita Zaidi, Farah Qamar, Fatima Mir and Zulfiqar Bhutta. The report entitled Antibiotic resistance the need for global solutions was printed online by The Lancet Infectious Diseases, an international medical journal.

`The decreasing effectiveness of antibiotics in treating common infections has quickened in recent years and with the arrival of untreatable strains of bacteria resistant to carbapenem, the world is at thedawn of a post-antibiotic era.

`Within just a few years, we might be faced with dire setbacks, medically, socially and economically, unless real and unprecedented global coordinated actions are immediately taken,` the report warns.

In high-income countries, continued high rates of antibiotic use in hospitals, the community, and agriculture have contributed to selection pressure that has sustained resistant strains, forcing a shift to more expensive and more broad-spectrum antibiotics. In low income and middleincome countries (LMICs), antibiotic use is increasing with rising incomes, high rates of hospitalisation, and high prevalence of hospital infections.

Most antibiotics, the report says, are used unnecessarily in commercial drivenagriculture and by physicians uncertain of a diagnosis or treating largely self-limiting bacterial or viral infections.

According to the report, over-the-counter availability of carbapenems in Egypt, India and Pakistan have increased, although the antibiotic is expensive.

`Most worrying is the emergence of panresistant untreatable carbapenem-resistant Enterobacteriaceae and Acinetobacter spp infections associated with high mortality in neonatal nurseries. In Pakistan, the emergence of this specific type of resistant bacteria is rendering these infections untreatable,` it says.

Studies of newborn sepsis from Bangladesh, Ethiopia, Nepal, Tanzania, Cameroon, Ghana, India, Nigeria, Yemen, Vietnam, Philippines and Egypt supportsimilar trends in pathogens and resistance.

Highlighting resistance to some other drugs, the study says fluoroquinolone (a class of antibiotics) resistance is increasing in India (44pc) and Pakistan (58pc).

The highest burden of deaths caused by infectious diseases, according to the study, is in South Asia and Sub-Saharan Africa.

Countries in these regions also report a high prevalence of multi-drug resistance pathogens with poverty of resources contributing to poor containment of resistant organisms in hospital and community settings. On the other hand, inadequate training of prescribers and laboratory personnel are contributing to rising resistance through inappropriate empirical choices and laboratory diagnostics.

`Poor countries suffer from lack of regulations for pharmaceutical products, leading to availability of counterfeit and low-quality antibiotics.

Use of these ineffective antibiotics amplifies resistance and leads to purchase of more potent and expensive antimicrobials to treat resistant strains,` it says.

Resistance arises as a consequence of mutations in microbes and selection pressure from antibiotic use that provides a competitive advantage for mutated strains. Suboptimum antibiotic doses help stepwise selection of resistance.

Resistance genes are borne on chromosomal, and increasingly, on transmissible extrachromosomal elements.

`The resulting resistant clones-eg, methicillin resistant Staphylococcus aureus (MRSA) USA 300, Escherichia coli ST131, and Klebsiella ST258 are disseminated rapidly worldwide. The spread is facilitated by inter species gene transmission, poor sanitation and hygiene in communities and hospi-tals, and the increasing frequency of global, travel, trade, and disease transmission.

Commenting on the report, Prof Dr Anita Zaidi, chair of the department of paediatrics and child health, AKU, said: `The selection pressure caused by the use of millions of tonnes of antibiotics over the past 75 years since antibiotics were introduced has made almost all disease-causing bacteria resistant to antibiotics commonly used to treat them.

`Simple infections could become deadly in the near future as bacteria evolve to resist the drugs we use to treat them.

`In her opinion, treatment of many infections such as multi-drug resistant tuberculosis and infections acquired in hospitals had become very challenging in Pakistan, and globally.

At the end, the commission recommends focusing on hospital stewardship programmes to use antibiotics responsibly, limiting use in livestock, community education about when to use antibiotics and environmental management.-Faiza Ilyas