Antimicrobial resistance (AMR) in bacteria is emerging and spreading rapidly worldwide. This phenomenon is nowadays affecting public and animal health dramatically on a global level. In 2014 the UK began the push for a global approach to AMR and HCAIs with the launch of the O’Neil review. To limit this alarming threat on human health, the World Health Organization launched the Global Action Plan on Antimicrobial Resistance. This plan was signed off by most of member states, including Saudi Arabia during the World Health Assembly in 2015. The plan consists of 5 pillars; to improve awareness, stringing knowledge through surveillance, reduce the incidence of infection, optimise the use of antimicrobial agents, and develop the economic case for sustainable investment to support the need in all countries in regards to new medicines, diagnostic tools, vaccines, and other interventions. To have tailored strategies, different countries initiated their own national AMR action plans, and the most notable similarity between all action plans is the willingness to tackle the antimicrobial misuse in both human and animal/agricultural sectors.
The Former UK Prime Minister, David Cameron, said:
“Resistance to antibiotics is now a very real and worrying threat, as bacteria mutate to become immune to their effects.
If we fail to act, we are looking at an almost unthinkable scenario where antibiotics no longer work and we are cast back into the dark ages of medicine where treatable infections and injuries will kill once again.”
Professor Dame Sally Davies, Chief Medical Officer for England, said:
“The soaring number of antibiotic-resistant infections poses such a great threat to society that in 20 years’ time we could be taken back to a 19th century environment where everyday infections kill us as a result of routine operations.
We have reached a critical point and must act now on a global scale to slow down antimicrobial resistance. In Europe, 25,000 people a year already die from infections which are resistant to our drugs of last resort. The biotech and pharmaceutical industry will be central to resolving this crisis which will impact on all areas of modern medicine.”
Dr Hussein A. Gezairy, Regional Director for the Eastern Mediterranean WHO said
“Antimicrobial resistance: no action today, no cure tomorrow”
Many of life-saving interventions, such as cancer chemotherapy and major surgeries depend on effective antimicrobials to succeed. Unfortunately however, the current dependence on antibiotics – whether to treat, prevent, or stimulate food animal growths – have exponentially increased this resistance. Despite this known fact, approximately 10 million tons of antibiotics are globally used every 10 minutes, which mostly are not related to justified medical use. As a result to the global march of AMR, common infections, such as urinary-tract infections are becoming difficult to treat. This is mainly due to bacteria that are resistant to last-line antibiotics, or even pan-drug resistant that are not responding to any commercially available antibiotics. The multidrug-resistant (MDR) pathogens are spreading rapidly in many parts of the world causing severe medical and economic consequences. It is estimated that at least every 10 minutes a patient dies in the USA or Europe because of fatal infections caused by antibiotic resistant bacteria.
A systematic literature review of MDR in Gram-negative bacilli (GNB) showed a substantial increase in the rate of carbapenem-resistant GNB in Saudi Arabia over the last decade in comparison with the rates of the 1990s. It also documented the increasing prevalence of extended spectrum beta-lactamase (ESBL) producing isolates from Saudi Arabia, where some institutes had 29% ESBL rates among Escherichia coli (E. coli) and 65% ESBL rates among Klebsiella pneumoniae (K. pneumoniae). As a result, these increasing rates have been associated with many reported outbreaks and mortality that ranged between 11-40%.
A Saudi national surveillance on Gram-positive cocci demonstrated that 32% of Staphylococcus aureus (S. aureus) are methicillin-resistant (MRSA), and 33% of Streptococcus pneumoniae are resistant penicillin G and 26% are resistant to erythromycin.14 A study from Riyadh15 demonstrated that S. aureus was colonizing the nasal cavity of 40% of the 200 tested healthcare workers. Among those S. aureus, 45% were methicillin-resistant (MRSA), resulting in total prevalence of 18% health workers carrying MRSA. A national survey16 on anti-tuberculosis drug resistance found that only 1.6% of total TB demonstrated MDR phenotype. These figures of high prevalence among different bacterial species in Saudi Arabia are unfortunately likely to be sustained, if not increased to due to several factors.
A hospital in Riyadh has well demonstrated the overuse of antimicrobial agents from 4 adult ICUs in 2010, where the highest use was meropenem (33.2 defined daily doses [DDD] per 100 bed-days), followed by piperacillin-tazobactam (16.0 DDD/100 bed-days). On the other hand, the DDD/100 bed-days in 37 ICUs in the United States was 3.75 for carbapenems and 7.08 for antipseudomonal penicillins. Over-the-counter antibiotics without prescription in Saudi community pharmacies is another issue that is driving the improper use of antibiotics. Only one out of 88 pharmacists in Eastern province refused to sell antibiotics without a prescription, and 77.6% of the pharmacies in Riyadh dispensed antibiotics without a prescription.
Heavy international travel activities due to the large population of expatriates and to pilgrimage the holy cities is a known risk factor for acquiring and transmitting infectious diseases, including those caused by antibiotic resistant bacteria. A recent study showed that returned travellers from Hajj have acquired MDR A. baumannii and NDM producing E. coli during the Hajj event. Previous data from 2 major hospitals in Makkah showed that ceftazidime resistance is evident in 24.6% of E. coli, 34.4% of K. pneumoniae, and 52.7% of P. aeruginosa. Another report showed that septicemia episodes in Makkah are increased by 16.5% during Hajj time due to the influx of international patients.
Another issue that can contribute to the spread of AMR is the challenges related to the adherence of infection control practices. The hand hygiene compliance rate in a hospital in Makkah in 2011 was 50.3%. The effectiveness of hand hygiene compliance was well demonstrated in controlling a nosocomial outbreak caused by carbapenem-resistant K. pneumoniae in Riyadh.