An alarming number of physicians prescribe antibiotics for only suspected infections, which is contributing to the growing antibiotic resistance in Bangladesh, according to a local study. This is the second instalment of a three-part series
Rajib Hossain, a third-year honours student of Government Titumir College, succumbed to his injuries at Dhaka Medical College Hospital (DMCH) on April 2018, two weeks after losing his hand during a race between two buses at Karwan Bazar.
A physician of the hospital ICU, seeking anonymity, said his injuries, including brain haemorrhage, occurred during the road accident, led him to death.
Another accident took place around two and a half weeks later in Banani area where 13-year-old housemaid Rozina Akhter lost her leg after being run over by a state-run bus. She also succumbed to her injuries later at the ICU of the same hospital.
Physicians at DMCH said they have found that many antibiotics were not working on both of the victims, which made their treatment more difficult. Subsequently, both of the victims died.
However, several physicians in the city suspected that the two accident victims died or were incurable as their bodies might have become antibiotic-resistant.
Senior Scientist Munirul Alam, lead of Enteric Infections at the International Centre for Diarrheal Disease Research, Bangladesh (icddr,b), said it would not be surprising if they had died due to antimicrobial resistance (AMR). Although there was a high possibility, it could not be ascertained as they were not tested.
Lack of mass awareness
Lack of awareness and relaxation in the habit of taking antibiotics has been contributing highly to the constant growth of resistance among the general people, Munirul Alam said.
Dr Sayedur Rahman, professor ofpharmacology at Bangabandhu Sheikh Mujib Medical University (BSMMU), identified several reasons for AMR growth throughout the country.
He said from a study conducted years ago, they have found that the reasons behind the increase in resistance are diagnostic uncertainty (73.8%), emergence of resistant microbes (72%), treatment by quacks (52.3%), lack of information about sensitivity pattern (49.1%), concern about cost of sensitivity testing (48.1%), patient request, expectation or satisfaction (34.6%), time constraints (30.4%), promotion of newer antimicrobials (21.5%), concern about cost of return visit (20.1%), and finally, possibility of losing a patient (16.4%).
Years after the study, the situation has merely changed, he added.
Prof Sayedur Rahman said irrational or inappropriate use of antibiotics has a larger impact on human health than any other medicines.
"Improper use of other medicines can only make the person concerned resistant to the drugs only," he said adding: "But antibiotics could never be limited to individual resistance only. It would have an impact on other people directly or indirectly.
"Our patients are always in a hurry and very casual about taking antibiotics. They have very little knowledge about the antibiotics 'curse' and very few feel that it could be deadly as well. The patients, whether in urban or rural area, most often go to a pharmacy whenever they think they need a quick relief and the medicine seller appears very generous and gives them antibiotics, pushing the patients towards a death trap."
The professor said patients often find clever ways to obtain more antibiotics. "Once they find the medicine works after taking an incomplete dose, they demand the same antibiotics again from the same or a nearby pharmacy, or take antibiotics left from previous illnesses," he added.
Antibiotic given without culture and sensitivity tests
A research team, led by SM Raquibul Hasan, titled "Pattern of antibiotics use at the primary health care level of Bangladesh: Survey Report 1," of the department of pharmacy at Stamford University Bangladesh, in April 2009 found that cold, fever and acute respiratory infection (ARI) were prevalent (39.78%) causes that brought patients to physicians. About 55.57% of physicians prescribed antibiotics for suspected infections, while only 33.46% of them prescribed antibiotics in confirmed cases.
Moreover, 37.31% of doctors prescribed antibiotics for appeasing the patients, whereas 62.44% denied them. It also said the doctors seldom received feedback on the completion of antibiotic courses from the patients. On the other hand, a patient survey said 34.76% of them were buying full courses of antibiotics, whereas 56.14% of them did not buy the amount prescribed and 53.46% of stopped taking the medicine when symptoms disappeared.
The situation did not change over time in the country. A study done in 2015 by a research team led by Associate Professor Mohammed Abu Sayeed of International Islamic University Chittagong – Survey on Antibiotic Practices in Chittagong City of Bangladesh – found that antibiotics were seen at 69.49% of total prescriptions.
Highest percentage of azithromycin (30.49%) and lowest percentage of cefradin (12.20%) were prescribed.
Improper monitoring by pharmacists, physicians
As reasons of antibiotic abuse, the report identified improper monitoring by pharmacists, less time for consultation that prevents doctors from counselling their patients properly on completing doses and the dangerous consequences of interrupting treatment, and patients' unwillingness to revisit the doctor after getting well due to high consultation fees.
On the other hand, they also identified unethical promotion by some pharmaceutical companies that encourage pharmacy owners to sell antibiotics, as well as various facilities offered to physicians to prescribe antibiotics, resulting in the drugs being prescribed more frequently, even when it is not required.
They also found no involvement of grade-A pharmacists associated with the healthcare system. Thus, if a doctor makes any mistake with a prescription, then there is no chance of correction due to lack of cross-checking.
The study also found patients claiming that they were not informed by the physicians properly about the dangers of AMR.
Seheli Sejuti Bithi and Minhazur Rahman Khan of the Department of Pharmacy at Jahangirnagar University, and Ahsan Ullah Khan of the Department of Pharmacy at University of Asia Pacific, in their research, titled "Drug utilization study in orthopaedic units: Antibiotics prescribed in hospital out-patients in Dhaka, Bangladesh", collected 498 prescriptions and found that a total of 2,489 drugs were prescribed.
According to their research, 62% (308) of prescriptions contained antibiotics where 52% of patients were treated with monotherapy, followed by 39% receiving a combination of double antibiotics, and 9% a combination of triple antibiotics. Only 10% (31) of the drugs were prescribed by their generic names.
DGDA takes tougher stance
The DGDA distributed placards to drug stores since March, 2018 attempting to raise awareness about the sale of antibiotics without prescriptions.
Pharmacies in Dhanmondi, Mohammadpur, Tejgaon and Mirpur areas said they have displayed the placards and do not sell antibiotics without prescription.
DGDA Director Ruhul Amin said the initiative to distribute the placards was launched after surveillance of pharmacies in 2017 revealed that neither attendants nor buyers were aware of the purpose of prescriptions.
He added that while the focus was on antibiotics, the placards would also help to raise awareness about the necessity of prescriptions for other drugs.