Doctors in Jordan are warning of a looming public health crisis posed by antibiotic-resistant bacteria.
By Elizabeth Whitman
The recent horrifying Ebola outbreak has distracted us from what is potentially a much larger threat to global public health: antibiotic-resistant bacteria. The World Health Organization estimates that multi-drug resistant tuberculosis alone kills 150,000 people each year. In a report released earlier this year, WHO said doctors over-prescribing antibiotics and their misuse played a major role in the alarming rise of so-called superbugs. “Without urgent, coordinated action, the world is heading towards a post-antibiotic era, in which common infection and minor injuries, which have been treatable for decades, can once again kill,” the report warned. So Jordan, with its fast-growing medical sector and laxly-observed drug dispensing guidelines, had better sit up and take notice.
In September, global medical NGO Medecins Sans Frontieres (MSF) held a conference in Amman specifically to discuss antibiotic resistance. They chose the Jordanian capital, said Richard Murphy, an infectious-disease specialist with MSF, because it’s where “we’ve been able to show how large an impact [resistant bacteria] have on our patients.” MSF runs a surgical reconstruction project in Ashrafiyyeh, where patients from all over the Arab world seek treatment for complicated medical cases, from bone infections to burn wounds.
Since the project began in 2006, MSF’s doctors there have encountered such high rates of resistance that MSF is frequently forced to use a costly ($2,600 to $3,000 for a full course) intravenous antibiotic, imipenem, which is used in Europe as a last resort. Over half of MSF’s maxillofacial and orthopedic patients arrive with antibiotic resistant infections, which require surgery in addition to the six weeks of antibiotics.
At the University of Jordan Hospital’s infectious diseases department, Dr. Faris Bakri, said: “We are observing increased resistance” in potentially dangerous bacteria like acinetobacter, staph aureus, VRE, E. coli, and S. pneumonia—to name just a few. “These data should be looked into further,” he stated.
Still, the implications are fairly clear. “A urinary tract infection used to be a very mild disease,” Bakri explained, but because the bacteria that usually cause it, E. coli, have developed resistance, patients now have to be admitted to the hospital for medical investigation. “We do ultrasound. We do blood tests. These are expensive,” he said. When oral antibiotics fail, patients are put on expensive intravenous ones, which can “have side effects. Sometimes the patients face complications.”
While Bakri has studied rates of resistance among different bacteria, the hospital has yet to measure the added costs from these cases of resistance. Still, he said, “they’re making a lot of cost for the hospital. I’m sure of it.”
When an infection has resistant bacteria, the costs of treatment skyrocket. Patients have to be isolated in separate rooms, need trained staff to attend to them, and require more expensive medicine. Spending more time in hospital can also increase the likelihood of acquiring another infection.
Marc Schakal, head of mission for Iraq and Jordan for MSF, noted that foreign patients, especially from war-torn countries who have flocked to Jordan over recent years in their thousands, can develop resistance because of unclean environments. “In Syria and in Iraq, it’s hard to get optimal initial therapy,” Murphy elaborated.
Patients living in conflict zones where medical care is weak or non-existent end up with injuries that “are susceptible to becoming infected,” Murphy said. By the time they arrive in Amman, they have late-stage infections and injuries that are far more costly, complicated, and difficult to treat.
As violence permeates many of the countries around Jordan, Schakal was concerned because “conflict is a factor of increasing [antibiotic] resistance.” Bacteria have unique identities tied to their environments, he explained, and when their environment changes—such as when patients travel to other countries for refuge or treatment—“it helps them spread and change the way they grow.”
But war-injured patients are not solely to blame for resistance, Schakal pointed out. “Anyone who consumes antibiotics is part of the problem, even if they’re not refugees.”
“Awareness is very low,” said Dr. Dana Darwish, an assistant professor in clinical pharmacy at the University of Petra who lectures to increase public awareness about antibiotic resistance. Despite how pervasive the problem is, “there isn’t research in Jordan estimating the levels of resistance, its extent, prevalence, and types,” because “everyone works independently and autonomously,” Darwish said.
Najwa Jarour, head of the infectious diseases department at Jordan’s Ministry of Health couldn’t say by how much, but she was certain antibiotic resistance “will increase the cost of treatment.”As Darwish pointed out, in cases of antibiotic resistance where the government is footing the bill, “this is extra cost on a government that needs every penny.”
Both Jarour and Darwish agreed on another cost as well: human life. “It will increase deaths,” Jarour said. While Darwish noted: “If the case is complex, it will end with the patient’s death. It’s happened before and it will continue to happen.”
Like most organisms, if bacteria are bombarded with material that tries to destroy them, then they will evolve to develop mechanisms that fight back. “It’s a normal phenomenon,” said Dr. Alireza Mafi, a medical officer with the Eastern Mediterranean regional office of WHO. Accelerating the process, however, is humans’ improper use of antibiotics. “We didn’t develop the culture of responsible use of antibiotics,” and now, humans are paying a hefty price. “We are at the edge of modern medicine,” Mafi warned. “We are going back to a time when there were no antibiotics.”
In Jordan and the surrounding region, the improper use of antibiotics is widespread. As a 2014 study by Petra University researchers, including Darwish, detailed, people avoid seeing doctors for diagnoses and drug prescriptions and instead go directly to pharmacies, obtain drugs from relatives, or even use leftovers. They may be saving money in the short-term, but they’re not necessarily taking the proper medication or dosages for what ails them. According to experts, antibiotics are supposed to treat bacterial infections, not viruses or other non-bacterial ailments. “Unfortunately, we see some patients with antibiotics, even if they don’t have any kind of bacteria,” Schakal said.
Outside the realm of medicine, antibiotics are frequently used—properly or not—in agriculture and livestock. Sometimes it’s to treat actual infections in sick animals, explained Mafi, but sometimes antibiotics are used to make them gain weight, a dangerous practice that fosters resistance in bacteria.
Meanwhile, as resistance grows, new antibiotics are diminishing. Pharmaceutical companies are not investing in the research and development of antibiotics, because other medicines are more profitable. In the past three decades, just two new classes of antibiotics have been developed.
Schakal tried to maintain a positive perspective. He said MSF’s Amman clinic’s development of best practices for managing antibiotics has gleaned some very good results, and the model could be duplicated in other hospitals. MSF has paid close attention to the issue of resistance since 2006, learning to carefully manage cases by testing bacteria for resistance before selecting and administering antibiotics. It also isolates patients with resistant bacteria.
Although the Ministry of Health has observed antibiotic resistance for the past two years, according to UJ Hospital’s Bakri there hasn’t been a sufficient collaboration between the UJ Hospital and the ministry. He said the future will bring greater collaboration, but “it’s something that needs a lot of time and effort. This will not happen overnight.”
Darwish was more openly critical. Asked whether the ministry was being proactive in addressing antibiotic resistance, she stated unequivocally: “No,” elaborating that even though the current law does not allow antibiotics to be dispensed without a prescription, “the law is not enforced, despite all the reports of self-medication and misuse.”
Meanwhile, Murphy suggested that the government take simple steps to counter antibiotic abuse, such as restricting over-the-counter dispensation, developing a surveillance system, and improving professional training. Making sure every hospital has an infection control officer and committee as well as a stewardship program would also help.
“Jordan has a lot of good policies but they’re not enforced,” Mafi elaborated. The country has no guidelines for standard treatments—a claim based on WHO’s own communications with the health care sector in Jordan—so every player in the health sector needs to sit down and “coordinate among themselves,” Mafi urged. Until then, the very real threat posed by superbugs will remain.