Resist AMR

A lecturer of pharmacology and the heartache of drug resistance

Owolabi’s wife of 19 years died after a brain tumour was successfully removed. He tries not to blame the hospital where she contracted the infection that killed her. He understands sterile conditions are difficult to maintain in even the best of Nigerian facilities. And he believes his wife was treated in one of the country’s best hospitals.

She had been sick for months with vague symptoms wrongly diagnosed as a premenopausal state. She was hospitalized at one point and discharged. When her symptoms worsened, an emergency MRI revealed the tumour.

Although it was a complex, nine-hour procedure, it was common for the surgeon. The anaesthetist ordered potent antibiotics, including ceftriaxone (Rocephin) for infection prophylaxis. “After surgery, I was there until about 9 p.m.,” Owolabi remembers. “She was fully conscious. I saw her smiling to me, and I waved back. I wasn’t allowed to get close to her at the ICU. I didn’t want to stress her.”

Owolabi went home where their three children waited anxiously. The ringing phone jerked him awake at 2 a.m.

He was needed in the hospital immediately, without explanation. He would learn hours later that his wife was overcome with fever. “The doctor asked where I lived. I told him, and he said it is too dangerous to drive in the night.” He was worried about the crime in some areas of their Nigerian city. They thought his wife’s condition stable enough to wait till morning.

Owolabi rushed to the ICU at 6 the next morning. His wife’s consciousness had deteriorated. There was suspicion of raised intracranial pressure. The plan was a second surgery to check for bleeding. Owolabi signed the consent form. “I was ready to give anything to save her life,” he says.

There was no bleeding but severe swelling of the brain. They tried to decompress the brain so it could breathe.

Forty-eight hours after the second surgery, her temperature and pulse rate spiked. It became evident that although the tumour was gone, an infection had snuck into her system, most likely where that first incision had been made. And the infection had not been hindered by the strong antibiotic prophylaxis.

A blood culture and markers of sepsis were ordered, among other investigations. The doctors increased the antibiotic arsenal by adding Meropenem. It being Nigeria where malaria is endemic, they added antimalarials.

All possible methods were used to bring down the high fever, including tepid sponging. They yielded little or no result. In short time, she fell into shock, with her blood pressure plummeting to 60/40 mm Hg. Her consciousness further deteriorated. She was placed on life support with inotropes to support her blood pressure.

The blood culture results revealed growth of coliforms resistant to all antibiotics tested. The doctors decided to try colistin, an antibiotic of last resort, that is scarce, expensive and toxic. But the drug had to be flown from the United Kingdom by a pharmacist relative of Owolabi after his “agonizing and exhaustive search for it in Nigeria was not fruitful”.

Despite the colistin, Owolabi’s wife remained unresponsive in the hospital for seven weeks, calm and quiet. At about week six, the fever switched to hypothermia, with her temperature dropping as low as 36.2˚ C.

Owolabi had been on leave from his university where he taught pharmacology and rarely left her side. His eldest daughter was studying for university exams while his eldest son was preparing for his final college and university entrance exams. He was torn and confused over how to handle the children. It was their mother in hospital as well as his wife. They deserved to know what was going on, he thought. He brought his daughter one day.

Owolabi saw his wife in a dream one night. “She came to give me a hug.” Then she said goodbye. She died two days later.

Towards the end, the doctors agreed it was septicaemia caused by antimicrobial resistance – a global public health crisis that kills around 700 000 people annually. They would never know the source. Possibly the operating theatre. Possibly the intensive care unit.

Owolabi may not blame the hospital, but there is anger for the way of life in his country – for the financial hardships and the ease of buying medications without prescriptions that allows millions of people to self-medicate, many times incorrectly. “The uncontrolled distribution of these drugs is the problem,” he says. And which is how the microbes that sneak into humans and animals can mutate as they evolve to resist the medicines designed to wipe them out.

He has returned to teaching and turned up the volume on his lectures on antibiotics and other anti-infection medicines and the responsible use of them. “My experience has had an impact on my life and my teaching of pharmacology,” he says solemnly. He tells his colleagues and his students, many who will go into medicine and others into pharmacology, about the enormity of the problem. “You need to be more responsible with prescriptions and the management of infection,” he commands.

He does not often mention his wife to his students. “But she has an influence on what I teach about antibiotics.”

Owolabi asked to remain anonymous.

 

Wow wow wow: A club way to teach young people about drug resistance.

Glorious Erhuanga is rarely ill, she says. Which is a good thing because she does not care much for medical drugs. And because, by her own admission, she is an abuser of drugs. “I do abuse drugs in the sense that I don’t completely do the course. If you feel strong enough, you stop. But your illness is not gone completely, they [pathogens] hide in your body,” she explains.

She also admits that even though she knows about prescription drugs because her mother is a nurse, she never understood how they work or how dangerous abusing them and even self-medicating can be until she joined the Health and Hygiene Club at her school two years ago, where she met “Aunty Biola”, the person in charge of the club.

“She told us about our health and also about some things we take unserious, which can actually damage our health, like self-medication,” recalls Glorious.

Aunty Biola was talking about the rampant practice among students that people from her organization could not help but observe when they first introduced the Health and Hygiene Club in four schools in Nigeria’s Lagos state. They had started the club concept to promote good water, sanitation and hygiene habits, like handwashing, as a way to prevent the spread of infections common to the country.

It was an alternative to the one-off events and campaigns typically staged once a year, a model that the Dr. Ameyo Stella Adadevoh (DRASA) Health Trust, an organization working to strengthen Nigeria’s health security, believed was not working.

The club concept embedded emphasis on “harnessing peer pressure for good” with students leading the way to changing behaviours among their peers. As “health ambassadors”, the club members learned the facts on a variety of topics in each weekly club session then passed on that knowledge to their peers in various ways, including during a morning assembly in the school yard and through any format they chose: dance, dramas, debates, competitions, writing essays, music, even rap songs.

 

Stumbling onto the AMR problem

Week after week in the four experimental club programmes in 2016–2017, the DRASA staff noticed the alarming way the students shared what should be prescription-only drugs. Students were taking antibiotics for headaches and antimalarial drugs for fever. Yet, few of them ever went to see a doctor.

The reality of malaria and little household resources for health clinic visits in Nigeria often leads students and their parents to street-side vendors peddling real and possibly fake medications for the asking and for bargain prices. It is a dangerous level of over-the-counter self-medicating that prompted DRASA to expand its focus.

“We decided to empower young people to make decisions about their health from a point of knowledge and not from a point of ignorance,” says DRASA Managing Director Niniola Williams. “We’re giving them facts and getting them to understand why what they are currently doing is harmful. We are not telling them what to do.”

DRASA partnered with the World Health Organization (WHO) to focus the education on antimicrobial resistance, or AMR, and expand into six more schools. AMR is a problem that is rampant across the African continent, and globally leads to some 700 000 deaths annually, according to WHO data.

AMR featured prominently when Glorious, now 17, listened to the Health and Hygiene Club introduction. And she was hooked.

“What struck me about the club?” she pauses. “They told us about Dr Ameyo Stella Adedevoh and how she helped protect Nigeria from Ebola. I thought wow wow wow, these people really have lots to offer us, and we’ll get to know what we don’t know concerning our health matter. I told my friends we have to join these people – let’s not follow the crowd. No knowledge is wasted.”

The evaluation data for the first year of the club programme’s partnership with WHO indicated the AMR club model had been influential: Among the 320 health ambassadors, awareness that antibiotics should only be used for bacterial infections went from 34% at the start of the school year to 82% at the end. And awareness that the full dose of antibiotic must be consumed went from 39% to 74%.

“I remember we had another student whose mother was a nurse,” says Williams, “and they had a shelf of medication at home. The mother taught the children which drugs to take for various symptoms, without a test. As a result of our programme, the student was able to change that practice at home.”

 

Why schools?

Omotayo Hamzat, WHO National Programme Officer for Health Technology and Innovation in Nigeria, says the Organization was looking for innovative ways to tackle the AMR problem. They found the DRASA clubs already in a few schools, where infections pass more easily than study notes. “We concluded we could use youth as champions or ambassadors for change to drive good hygiene and antibiotic practices,” he explains.

“I am forever a DRASA ambassador,” says Glorious of the club’s impact on her. “It changed my thinking. I don’t just assume sickness should be treated my special way, I need to seek the advice of a doctor. With what I have learned, I don’t think I’ll be able to forget it.”

DRASA is confident this approach can work with all students like Glorious. “I hope it catches on all around the world. The students come up with things we could never dream of,” says Williams.

The Government agrees. Although the COVID-19 pandemic put the expansion plans on hold, DRASA and WHO are currently working on scaling the club model to ensure students around the country have access to this type of learning.

In addition to the many crises the pandemic has wrought, it is now is threatening to exacerbate the level of AMR.

Many people in Nigeria presume they have malaria or typhoid whenever they feel feverish and treat it without testing or seeking professional advice, William explains.

This is especially concerning with the COVID-19 outbreak and the seemingly low numbers across the country. The poor health-seeking behaviours are adding to the problem due to the heavy level of self-medicating with antimalarial drugs or paracetamol for what could be the coronavirus or other serious infections.

“That’s why now, more than ever,” she stresses, “we need to empower our youth all over the country to understand the extent of the AMR challenge and be our ambassadors for behaviour change in their schools, homes and communities.”

 

 

 

 

 

 

 

 

 

Turning the unknown into common knowledge in the race to limit antimicrobial resistance

Vanessa Carter nearly lost her face to antibiotic resistance.

She likely acquired a bacterial infection while in hospital during one of many complicated facial surgeries. None of the many doctors she had in the first six years of those surgeries ever mentioned antibiotic resistance to her. Because she was oblivious to the dangers of stopping an antibiotic drug or even an antibiotic ointment after a couple of days when it appeared to not be working, she sees herself as part of the complication – back then.

Now, she is a force for common knowledge.

“What should be common knowledge?” the self-described patient advocate begins to explain. What smoking is to cancer, the abuse of antibiotics should be to drug resistance, she continues.

“Taking two doses of an antibiotic in the morning because you might forget at lunch time could aggravate resistance. That should be common knowledge. Double-dosing your child could aggravate resistance. That should be common knowledge.”

Patients need more information, Carter says. “It could have made a massive difference to my face and to my life at that time.”

“Don’t dumb it down,” stresses Carter, who also works feverishly for behaviour change at all levels, from patients to medical practitioners to researchers and private sector marketers. “Teach people so they can empower themselves so they can participate in the management of infections in and out of hospital. I’ve never seen antibiotic packaging that warns a person about resistance. When I go to a pharmacy, I ask for inserts about various antibiotics, and I don’t see it. That would be one avenue to improve communication.”

Carter required an extensive facial reconstruction after a car accident in 2004 in Johannesburg, South Africa, that severely injured her abdomen and face, including a broken nose, a smashed cheekbone and eye socket, loss of her right eye, a broken jaw and massive facial lacerations. She also sustained neck and back injuries as well as a fractured pelvic bone.

She acquired two antibiotic-resistant infections during the decade it took to reconstruct her face. The first occurred in 2010 when bacteria formed on the alloplastic prosthetic inserted under her right eye socket. The infection did not respond to the antibiotics prescribed, and it wasn’t until nearly a year later that it was diagnosed as methicillin-resistant Staphylococcus aureus.

There was no medical team communication about her situation. She heard differing advice from each of her super specialists. Some of them insisted the prosthetic should remain because the infection was elsewhere. Her plastic surgeon went against them and removed it, which likely saved her life.

The infection returned in 2012, along with an allergy, after yet another surgery. The infection could have come from the hospital or resurfaced from the previously infected area but was resistant to the antibiotic. The allergy was potentially from the antibiotic ointment.

“In your mind you think antibiotic ointment will help heal the wound faster. But we don’t get the explanation that this is an antibiotic. And with medicines as well as ointments, we don’t hear take at “equal” intervals, which is important,” Carter explains. People are accustomed to hearing “take three times a day”, but the advice does not emphasize why it must be at set times, which Carter points out is critical to keeping the bacteria (in the case of antibiotics) from building up their strength.

Taking antimicrobials, including antibiotics, any time of day can lead to either overexposing or underexposing the microbes, again, boosting their resistance, she explains.

What is resistance and what are solutions?

 The improper use of antimicrobial medicines, including antibiotics, enables bacteria, viruses, fungi and parasites to mutate into superbugs that are resistant to the drugs designed to kill them.

“Many patients don’t understand that antibiotics are used to treat the dangerous bacteria in their body and not the human body,” says Carter. They think the body becomes resistant to the antibiotic, but it is the bacteria that becomes resistant.

Carter believes pharmaceutical packaging with a warning that misuse of antibiotics can cause bacterial resistance would help counter that confusion.

More conversations about responsible antimicrobial use between patients and all health care workers, including doctors, is a necessity, she stresses.

“Policy is also significant,” she adds. “Why is it so easy to get antibiotics in some countries? And so easy to use them in farming?”

 

On being a patient advocate

As a patient advocate, Carter spends a great deal of time with academic researchers and advisory groups in South Africa and internationally with ASPIRES, a research collaborative involving Imperial College London, the University of Cape Town and others. With them, the marketing specialist and founder of Healthcare Communications and Social Media South Africa discusses her personal story and views around what could have improved her experience during her many surgeries.

She also works as a “civil society champion” with the African Centres for Disease Control and Prevention, promotes the Antibiotic Guardian pledge campaign in South Africa and has coordinated Twitter chats among leading specialists in the region to amplify awareness on what should be common knowledge about the use of medical drugs, from antibiotics to antimalarials.

Seven years ago, when Carter committed to being a patient advocate, antimicrobial resistance was barely discussed. Conversations have expanded since then, but she sees it as too-slow a pace in what is becoming a race to stymie the increasing resistance of microbes to the drugs available to fight them.

Globally, some 700 000 people die annually because of microbial resistance, according to World Health Organization data. The Review on Antimicrobial Resistance estimates that 4.1 million people in Africa may die of it by 2050 if what should be common practice by patients and medical personnel remains unchanged.

“We live in countries where health care is difficult to access,” she says of the reality that many people in Africa cannot afford to seek out a doctor and sometimes self-medicate with antibiotics or other antimicrobial medicines from unlicensed vendors. “I don’t know if anyone has the answer for how to approach that because, understandably, when you are ill, you do whatever you can to get medication. If it’s difficult to obtain it in the health system, where else do you turn?”

“While I know common knowledge isn’t the silver magic to changing this type of behaviour,” she adds, I believe it is a good place to start.”