Rise in antibiotic resistance has health officials worried

Patients in the emergency unit at Kamuli General Hospital. Health experts in Uganda have warned that the country is registering worrying increases in death and cost of healthcare because of drug-resistant infections.

What you need to know:

  • Health experts blame the issue on patients who do not complete the dose prescribed to them.

Health experts in Uganda have warned that the country is registering worrying increases in death and cost of healthcare because of drug-resistant infections.

This follows a new study conducted in Uganda and 203 other countries, which indicates that infections with drug resistant-bacteria caused about 1.2 million deaths in 2019— more deaths than HIV/Aids (690,000) or malaria (409,000) combined.

Drug resistance typically occurs when changes in the infectious agent cause drugs to become less effective. Experts say excessive and inappropriate use of antibiotics—combined with the challenge of insufficient access to the medicines—are responsible for the emergence of drug-resistant bacteria.

“Antimicrobial resistance or AMR is basically having organisms not being able to be killed by drugs. And this has been evolving over time majorly because of misuse of drugs, especially antibiotics,” Prof Samuel Majalija, a microbiologist at Makerere University, told Sunday Monitor.

Dr Andrew Kambugu, the director of Infectious Disease Institute (IDI) of Makerere University, said it is now estimated that AMR is “now killing more people than non-communicable diseases.”

He added: “Resource-limited environments like Uganda and Africa are places where AMR can thrive because…control of aspects like prescription is not good.”

The Ministry of Health is working with IDI, the American Centres for Disease Control (CDC), and other partners to sketch a better portrait of AMR in Uganda.

The next pandemic?
The government stated in their AMR work plan for 2018-2023 that “resistance to the most commonly used antimicrobials such as penicillins, tetracyclines, cotrimoxazole, was in some cases above 80 percent.”

Most worrying is the increasing resistance to last-line treatment for bacterial infections carbapenems, which ranges from four to 30 percent. The prevalence of bacteria—which is resistant to another commonly used penicillin derivative called methicillin—ranges from four to 50 percent.

The government also revealed that the prevalence of extended-spectrum beta-lactamase (ESBL), a group of bacteria that cannot be killed by penicillin and other common antimicrobials like cephalosphorins, was higher—between 10 to 75 percent among samples analysed. 

The Health Minister, Dr Jane Ruth Aceng, acknowledges that while AMR “is not yet a very big problem” in Uganda, its gradual growth is down to “misuse of antibiotics that are bought off the counter.” 

It is a verdict that Prof Nelson Ssewankambo—the President of Uganda National Academy of Sciences (UNAS)—concurs with.  

UNAS is a body that has been central in helping the government develop the work plan for fighting AMR.

“Misuse of antibiotics and overusing them are the main causes of antimicrobial resistance. People just walk into pharmacies and buy antibiotics whether they need them or not,” Prof Ssewankambo said, adding: “They think that because they are coughing they need antibiotics… Pharmacies just give the medicines out. Why would someone give out antibiotics to somebody without a prescription [from a doctor]?”

Dr Rosemary Byanyima, the acting director of Mulago National Referral Hospital, said sometimes medical workers and pharmacists overprescribe certain drugs because they want to sell or promote certain medicines. Indeed, pharmaceutical companies or their dealers have been known to penetrate and dominate health systems by “luring” and persuading medical practitioners to generously prescribe medicine.

Dr Grace Najjuka, the head of National Microbiology Reference Laboratory (NMRL), reckons the laboratory plays a crucial role “for patient care” and that “antibiotics are used irrationally” once laboratories are side-stepped.

Higher death risks
Prof Majalija of Makerere University said the problem of AMR cuts across both humans and animals, thus the need for a one-health approach to combat.

“When a drug is misused in the animals, for example, if you give to chicken, cattle and dog, the same bacteria which live in the chicken and cattle they jump and go to human beings, carrying the same drug resistance,” he said, adding that all attempts have to be made to ensure that drug-resistant infectious agents don’t reach the human being.

Dr Byanyima said patients grappling with AMR often spend more time in hospital and they require more expensive medicines because cheaper drugs are not effective on them.
“We have a unit where we have a microbiologist. So we do culture and sensitivity [tests to determine the effective medicine for the disease]…we want to again study and see [the burden of drug resistance],” she said.

According to Mr Robin Obura, a laboratory expert—who does culture and sensitivity tests in Lira— they charge anywhere between Shs60,000 to Shs80,000 per test.  

Common diseases that may not respond to drugs include pneumonia from an infectious agent called Klebsiella pneumoniae.  

The Health sector performance report for 2020/2021 indicates that it is the second leading cause of hospital admission deaths, accounting for 2,944 mortalities. Malaria, a disease which Dr Betty Balikagala—in 2019—found evidence of resistance to the commonly used artemisinin drug, was the leading cause of hospital admissions and deaths in 2020/2021 at 5,017 mortalities. 

At least 45,042 people died in hospitals in 2019/2020 while in 2020/2021, the number increased to 45,990.
The Uganda Aids Commission has also reported issues of resistance of the HIV to antiretroviral treatment. 
Dr Najjuka said drug resistance is also very high in Staphylococcus aurous, another common infectious agent, which causes abscesses or swellings and is often found in small wounds on the body. 

She revealed that another type of infectious agent, pseudomonas, which is normally found in patients that are critically ill has also shown significant levels of drug resistance.

No new antibiotics
Prof Majalija believes people should tread carefully because the rate at which antibiotics are being developed has declined.

“Over the last 20 years, there has not been any new antibiotic because of the expense and the small global market,” he revealed.

Prof Majalija said due to AMR some drugs like penicillin have become so weak and they have been phased out. Amoxicillin, a drug for treating cough and bacterial infection, has also become “very weak.” 

To address the AMR problem, Dr Lisa Nelson—the CDC country director—advises that Uganda “invest[s] in critical capacity…to understand where these threats are going.” 

She is nonetheless heartened to observe that Uganda is heading “in the right direction by having a College of American Pathologists accredited facility [National Microbiology Reference Laboratory], which can produce internationally recognisable antimicrobial resistance results.”

To that end, Dr Byanyima says Mulago hospital has “of recent…tried to be strict on prescription habits.” 
The Health ministry has also put in place an antimicrobial committee that responds to empirical data.

“We want to caution our people to take very seriously the issue of prescriptive medicines and stick to taking prescribed medicines of the right doses and the right number of days,” Dr Aceng concluded.

Can herbal medicine come to the rescue?
Dr Daniel Lule, a doctor at Aloesha Organic—a herbal [alternative] medicine facility in Kampala—told Sunday Monitor that they receive many patients who are swapping synthetic drugs for herbal medicines. 

He, however, warned that herbal medicine will not be a soft landing forever because either branch of medicine uses the same ingredients. For now, though, he is happy that “people who are coming [for herbal medicine] after the [synthetic] drugs have failed to heal them, are getting healed.”

He adds: “This could be because the molecules in our herbs are different from those in the drugs they were taking.”



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