NAVEED, a 25-year-old Pakistani civil servant, lies in a hospital recovering from major surgery after an accident on a building site. In the same ward, 47-year-old Malik, who cut his foot crossing the road, is now coming to terms with an emergency amputation.

Ahamba, a nine-day-old baby in Nigeria, has been fighting an infection since she was born. And in the United States, Tamara, 39, lives in fear of the recurrent infections that have made her life a misery.

Separated by both circumstance and thousands of miles, these four people are more connected than they know. All have fallen victim to infections that no longer respond to medications in the way they used to. Infections that resist the “usual” treatments, which have contributed to the death of an estimated five million people in 2019 alone.

While it’s the world’s most vulnerable people — the ill, young and elderly; those in poorer settings — who are in most immediate danger, the threat of drug-resistant infection puts everyone at risk. Deaths from antimicrobial resistance are predicted to reach over 10 million a year by 2050. And a global threat requires global solutions.

This month, the United Nations will assemble world leaders to address antimicrobial resistance. The aim of the meeting is to negotiate a political declaration for member states to curb the impact the issue is going to have on health, environment and development.

Anything but routine

Speaking from his bed in an intensive care unit, Naveed is barely able to get a sentence out. The 25-year-old had to have his windpipe removed after he was injured on a building site. But that wasn’t the end of his ordeal: after surgery, he developed a drug-resistant infection that could be fatal without the right antibiotic.

Doctors testing Naveed found that the antibiotic needed to save his life was colistin, a treatment meant to be used as a last resort because of its toxicity and side effects. But in Naveed’s case, no other antibiotic could kill the strong bacteria causing his infection.

Operations leave us open to infection because bacteria can enter the bloodstream through surgical wounds, so patients are often given antibiotics before and during surgery. But if the antibiotics don’t work, bacteria are still able to infect us. This is what happened to Naveed. His infection consigned him to intensive care for several more days while the colistin fought back against his infection.

Meanwhile, Malik cut his foot after his sandal came off when he was crossing the road in Rawalpindi. It seemed innocuous enough at the time: partly because of a previous foot injury, he hardly felt anything. But after several days, the wound began to ooze with pus. It was infected and wasn’t healing.

The 47-year-old tailor has diabetes, and his blood sugar levels weren’t well managed. It put him at an increased risk of complications from foot injuries, including problems healing.

When doctors in his hometown weren’t able to get his inf­e­ction under control, Malik was rushed to hospital in Pesh­awar. It was there he discovered his infection was drug resistant.

Bacteria are able to adapt quickly to defend themselves against the drugs designed to kill them. The more that bacteria are exposed to antibiotics, the more chance they have to develop resistance to them. Some bacteria can defend themselves against multiple drugs.

This was the case for the bacteria that had infected Malik’s foot. By the time he reached the hospital, the infection had destroyed the tissue in his toes. Two of them needed to be amputated. To stop further spread of the infection, Malik was prescribed four antibiotics.

Global health threat

Globally, the consumption of antibiotics increased by almost half between 2000 and 2018. The rate of increase has been steepest in South Asia, where the proportion of people receiving antibiotics each day has more than doubled in the last 25 years.

The increase reflects the fact that antibiotics aren’t always used in the right way. Some­times they are used unnecessarily — for example, for a viral infection like a cold or flu, on which antibiotics will have no effect. Other times they are misused: someone takes the wrong type, dose or course of drug. These inappropriate uses of antibiotics are huge contributors to the emergence of drug-resistant bacteria.

“Drug-resistant infections are a global health threat. But more importantly, they’re a preventable burden of disease that is a consequence of a misuse of resources,” says Dr Yvan Hutin, the director of surveillance, prevention and control at the World Health Organisation.

Sometimes patients can’t afford to be ill. Being sick can be expensive — and a quick course of antibiotics might look like a cheap solution, especially in countries where regulations are either lacking or unenforced.

In some countries, including Pakistan, Kenya and Nigeria, antibiotics are sold over the counter by untrained staff.

They can also promise a quick fix for the doctors themselves. Overburdened healthcare workers often lack the means or time to perform diagnostic tests, and that means prescribing antibiotics without knowing what type of infection they are treating. When doctors mis-prescribe antibiotics, giving patients broad-spectrum drugs when others will do, they present bacteria with the chance to build resistance.

“We have inappropriate use, we have misuse, we have mis-prescriptions,” says Hutin. “We want the appropriate healthcare services given to the right people. We need the data to understand all of this. When we miss the information, the system cannot improve.

“We face a heavy burden of disease from drug-resistant infections that comes from all this misuse and weak health systems”

Challenging circumstances

Like many babies in Nigeria, Ahamba was born outside a hospital, with the help of a traditional birth attendant. She was three months premature, and her underdeveloped immune system was unprepared for the battle she was about to face.

Just five hours after she was born, Ahamba developed a fever and started to bleed from a section of umbilical cord still attached to her navel. She was quickly taken to a hospital in Lagos State where she was given antibiotics.

Days passed and the antibiotic given to Ahamba wasn’t working. Her tiny body meant that she was unable to handle the toll of too many antibiotics. Having already tried two different types, doctors skipped straight to meropenem — a broad-spectrum drug that aims to kill a wider range of bacteria. Like the colistin given to Naveed, it’s supposed to be reserved for only the most severe infections.

The misery of chronic infections

While antibiotics use has risen most steeply in lower- and middle-income countries, it’s in rich nations where their overall use has always been — and remains — at its highest. Much of this is down to drugs being given to patients who don’t need them.

In the US, for example, a third of the antibiotics prescribed are done so unnecessarily.

Tamara’s life began to go downhill just as Covid hit. In March 2020, her husband lost his job; the next month, she lost hers. She believes it was stress that started the chronic series of urinary tract infections (UTIs) that have dogged her for more than four years.

Despite having seen multiple doctors up and down the country, Tamara couldn’t find anyone able to cure the infections. In her desperation, she tried various other treatments, including surgical procedures, herbal supplements and medicine she self-administered through a catheter.

This report has been published in collaboration with The Bureau of Investigative Journalism. A detailed version of this article can be accessed on Dawn.com

Published in Dawn, September 4th, 2024