Why won’t this bacterial infection go away?

Nuru, a woman in her late 20s, has had a battle with a urinary tract infection (UTI), which just will not go away.

“I first had a UTI about 10 years ago,” she says. “I had very frequent urination and after the tests, the doctors told me that I had a bacterial infection. I was put on medication that was injected through my veins. I thought it had ended.

“I never had any problem with urination again, or any noticeable symptoms. But about two years ago, while doing a routine check-up, a urine test revealed that I had a bacterial infection. They gave me more antibiotics and told me to return for more tests. Three weeks later, I returned, more tests were done, but the infection was still there.

The bacteria were not responding to the medication.

“I was given another type of drugs that doctors said was a stronger antibiotic. I was even told not to drink alcohol because the drugs were too strong. I took the drugs and three weeks later, I returned to the hospital. Again, the doctors said there was still an infection.

“This time, they gave me on injections, administered through the veins, that I received for three days. The drugs were indeed very strong. They made me dizzy and nauseated.

“By this time, I felt this medicine should work and I did not go for more tests, immediately after the treatment. I, however, tested again earlier this year, and the infection was still there. I have been given other medications, but it still has not gone,” she says.

The dilemma of bacterial resistance to antibiotics had dawned on her. And she is not alone. Other people, including men, women and children, report infections that manifest with high fevers and headaches, which persist and only subside after trying two or more antibiotics.

Doomsday
Bacterial resistance to drugs is now a common part of the Ugandan health cycle, beyond just cases of multi-drug-resistant tuberculosis. Scientists confirm many a patient’s reports of recurring infections that do not respond to more than one type of antibiotics.

And now, a doomsday scenario, where antibiotics may no longer save us from bacteria, and its fatal effect, is a possibility that scientists are now treating seriously.

Why?
Because the misuse and abuse of antibiotic drugs is persistently lowering their ability to fight bacterial infections.

Drug misuse by patients is only one link in a long chain of causative actions undermining anti-bacterial medication’s efficacy. The rise of resistance to antibiotics has also been driven by; poor quality medical care, where misdiagnoses and wrong prescriptions are issued; pharmaceutical companies, which have either not done new research for stronger medication, or are producing quack medicines; and the evolution process of bacterium, in which a survival for the fittest evolutionary process, keeps the organisms mutating, to beat the medicine.

Bacteria are responsible for such diseases as typhoid, tuberculosis, strep throat, gonorrhoea and many others. The prospect of having no drug protection against these, is a scenario worthy of all foreboding.

“The scale of the problem is significant,” says Samuel Opio, the secretary-general, Pharmaceutical Society of Uganda.

“It is like a time bomb,” says Helen Byomire Ndagije, head of Drug Information Department at National Drug Authority.

“It is something, which should be of everybody’s concern,” adds Rudolf Buga, a microbiologist at the Makerere University School of Public Health.

And it is now a problem of international concern as well; only a month ago, an associate director at America’s national health institute, the Centre for Disease Control and Prevention (CDC), told an American TV station that the age of the antibiotic has ended.

“We’re in the post-antibiotic era…there are patients for whom we have no therapy,” Dr Arjun Srinivasan said.

But even if bacterial resistance to antibiotics is a global concern, there are reasons why the situation in Uganda is a cause for a more acute sense of concern.

A shortage of proper bacteria testing equipment, an influx of low quality drugs, an easy accessibility to antibiotics and a shortage of an antibiotic policy, have allowed this problem to spread, says Mr Buga.

How you are abusing antibiotics
The problem arises from an indiscriminate use of antibiotics, which results into misuse and abuse.

He explains: “There is a lot of misuse because people do not know what antibiotic to use for what type of case.

“Clinicians themselves prescribe antibiotics when it is not necessary. It is not a must that when somebody has a bacterial infection, you are supposed to put them on antibiotics immediately. When an antibiotic is given to somebody, there is supposed to be proof that there is that infection. There has got to be an antibiotic sensitivity pattern done to determine which antibiotic is really capable of combating this organism,” he says.

A bacterial culture and sensitivity test, Mr Buga says, isolates a specimen of the specific bacteria causing the infection, and tests it with different types of antibiotics, to see which specific drug will be able to clear the bacteria.

“This is in most cases not done because of a lack of such facilities,” he says. Also, the level of training for lab technicians may vary, and one may fail to interpret the culture and sensitivity results properly.

“So,” he adds, “What people normally end up doing is blind treatment of bacterial infections.”

Ndagije also points out a form of abuse, largely rooted in poverty. It manifests itself in the case of patients who purchase drugs that make up only a fraction of the dose, because they cannot afford the complete dose.

Evolution in action
And it is this, the blind treatment of bacteria and misuse and abuse of drugs, that has allowed bacteria to thrive and outwit the medication we throw at it.

How?
It is a simple theory of survival for the fittest.

“When you take half a dose of medication, you have only put the bacteria to sleep. You have not killed them. And when they wake up, they are stronger than before,” Ms Ndagije says.

Like other organisms, bacteria, does not want to be wiped out. When antibiotics attack them, they devise means of survival.

“The more you use an antibiotic, the more you expose a bacteria to an antibiotic, the greater the likelihood that resistance to that antibiotic is going to develop,” Dr Srinivasan, the associate director at CDC, told PBS TV, last month.

“There are many resistant mechanisms,” says Buga. “Bacteria are made in such a way that they have a system called conjugation, where two bacteria come together and exchange the DNA material between themselves. Or, with this use of erratic use of antibiotics, if one of these bacteria which came into conjugation with another, if it acquired the resistant genes, then it transfers these to the other bacteria, which then spreads and may infect another body.”

“Then, some of the bacteria produce enzymes, which neutralise certain antibiotics. For example, there are organisms, which produce substances/enzymes that neutralise penicillin. So, however much you are given penicillin, it will not help,” he added.

Of the most abused antibiotics in Uganda, Buga mentions Amoxicillin, used indiscriminately in the case of coughs, flus, wounds and other infections. Ciprofloxacin and Co-trimaxazole (Septrin) are other commonly abused antibiotics, Mr Opio adds. The other problem is that even if bacteria have been changing continuously, the medicines used against it have remained the same.

“These drugs that we are using are very old molecules,” Opio says.

One of the most common examples is Penicillin. It was discovered in the early 1920s. That means it is coming to close to 100-years-old,” he adds. Bacteria, it turns out, is many years ahead of our medication.

So, how did it come to this?
“It is not viable,” Mr Opio says.

“There’s not much money to be made in making new antibiotics,” Dr Srinivasan told PBS TV. “We saw a lot of drug companies, who left the field of antibiotic development, because of this combination of factors, that it was getting really hard to discover, to develop new antibiotics, and you don’t make a lot of money in selling these drugs, so the market really wasn’t there.”

“Most of these innovator drugs are coming from the European world,” Mr Opio says. “They look at the viability, the market. What market are they looking for? The European and US market. And what are the diseases there? Obesity. That is where they will put their money. But is obesity a big problem here?” he asks.

The problem of antibiotics resistance has been steadily growing in Uganda, with research by the Alliance for Prudent Use of Antibiotics stating that resistance to Cotrimoxazole (Septrin) rose from 10 per cent in 2001 to 90 per cent in 2007.

The report mentions such common antibiotics as chloramphenicol, ampicillin and cenicillin as among those to whom bacteria has developed resistance in Uganda.

Ugandan scientists interviewed say they are unaware of any research programme, keeping track with the growth of anti-biotic resistance in Uganda, a circumstance that leaves us unaware of just how wide spread the problem may be.

And yet out in the country, Ugandans continue to misuse antibiotics; bacteria continues to mutate and gain resistance; and doomsday continues to grow nearer.

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