The emergence of the Covid-19 pandemic has arguably accelerated the looming threat of antimicrobial resistance with widespread reports of cocktail of antibiotics being inappropriately used in Bangladesh to treat this primarily viral respiratory illness.
This is in the context of longstanding systematic misuse of antibiotics worldwide with no meaningful improvement in antibiotic prescribing practices since the World Health Organization announced its global action plan to tackle this rapidly evolving public health crisis in 2015.
While a global challenge, nonjudicial use of antibiotics is particularly rampant in Bangladesh and other low- and middle-income countries due to systemic factors such as overwhelming patient volumes restrictive thorough clinical assessment, limited access to investigations, and inaccurate attitudes of both patients and clinicians of the role of antibiotics and over the counter availability of antibiotics.
There is no doubt that antibiotics, when used appropriately, are potentially lifesaving. However, excessive antibiotic use is a key contributor to antimicrobial resistance such that bacterial conditions that are easily treatable today may no longer be treatable in the future due to bacteria becoming resistant to its therapy -- this is particularly menacing as the last novel class of antibiotics were discovered in 1987.
On an individual patient level, inappropriate antibiotic use increases the risk of short-term adverse reactions such as anaphylaxis and antibiotic-resistant severe diarrhoea, as well as long-term consequences such as disrupted healthy gut bacteria. Unnecessary antibiotics also place a significant financial cost on already stretched health systems as well as individuals as many require out of pocket expenditure.
In Bangladesh, one of the most vulnerable groups exposed to inappropriate antibiotic use are children under five years of age. Using data from the Bangladesh Demographic and Health Survey, a population-based analysis of 18,000 households, we found widespread use of antibiotics in under-five children with symptoms of acute respiratory infections (cough, runny nose or fever) despite such infections being predominantly of viral aetiology, that is, antibiotics are usually unnecessary.
Our study, published in BMJ Global Health, found that antibiotic misuse was prevalent across all socioeconomic groups in Bangladesh irrespective of household wealth or education level. However, children in rural Bangladesh were found to be 60% more likely to be exposed to antibiotics compared to those in urban regions such as Dhaka.
This was partly attributed to the inequitable distribution of primary health-care providers with limited access to trained health care professionals in rural Bangladesh resulting in an overreliance on unlicensed village practitioners and drug store clerks who tend to more frequently prescribe antibiotics.
Given the clear dangers of excessive antibiotic use, significant gains can be made through coordinated policies to improve antibiotic stewardship in Bangladesh.
Firstly, educational programs and awareness campaigns that aim to modify the antibiotic prescribing patterns of trained and untrained healthcare practitioners, such as drug store clerks, have been shown to be cost effective and sustainable over the longer term in both urban and rural settings.
This may be implemented in various forms including onsite training for clinicians, brief online modules, or physical pamphlets that are supplied along with antibiotics to drug store venders. Importantly, clinicians should be empowered with communication skills for succinct conversations during consultation with parents or caregivers when antibiotics are not indicated, given many health care providers feel pressured to prescribe antibiotics due to carers’ demand.
Secondly, given the significant knowledge gap that exists amongst health care providers on evidence based antibiotic prescribing, that is, whether to prescribe antibiotics for a particular confirmed or presumed diagnosis, the availability of nationally-developed clinical practice guidelines at point of care services may serve as an important reference point. This should ideally be used in conjunction with educational training to familiarize practitioners with the guidelines first.
Finally, we need to recognize the reality that drug store venders are often the first point of contact for millions of Bangladeshis seeking health care advice, particularly in rural areas. Consequently, over-the-counter use of antibiotics is a significant contributor to antibiotic misuse and thus requires policies and stricter enforcement of guidelines to limit inappropriate antibiotic dispensing.
However, the implementation of this is complicated by the fact that a large proportion of the population do not have access to a primary health care physician for a prescription. Therefore, having a blanket restriction on all antibiotics may not be appropriate as it would obstruct patients receiving potentially lifesaving treatment.
An alternative strategy here may be to classify antibiotics into different categories, with some available over the counter under limited and clear circumstances by the drug store vendor (such as a checklist).
Tackling inappropriate antibiotic use in Bangladesh is an issue worth prioritizing. While our findings provide a baseline for antibiotic use in under-five children with acute respiratory symptoms, it would be important to analyze post-pandemic data over the coming years to investigate the trend of antibiotic consumption during the height of the pandemic and monitor the effectiveness of any interventions implemented.
Dr Riashad Monjur is a Junior Medical Officer at St. George Hospital, Sydney. Dr Md Zakiul Hassan is an Infectious Disease Researcher at icddr,b. Md Jubayer Biswas is an Infectious Disease Researcher at icddr,b. Dr Nusrat Homaira, MBBS, MPH, PhD is a respiratory epidemiologist and senior lecturer with the University of New South Wales, Sydney, Australia.