Entering a Post-Antibiotic Era? What Can Be Done?

Scanning electron micrograph image of
methicillin resistant Staphylococcus aureus (MRSA)

Here is an excellent perspective piece on the problem of antibiotic resistance, as well as possible strategies to combat this issue, that was just published in the New England Journal of Medicine. 

Before discussing the article, here is some background information on antibiotic resistance. The discovery of antibiotics revolutionized medical care; not only were once life-threatening conditions treatable, but the use of antibiotics has been essential to the success of many complicated surgical procedures, for surviving many cancer therapies, et cetera. It has been approximately 84 years since antibiotics were first discovered in the 1920s. Although we initially saw a boom in the production of "new" antibiotic compounds, the creation of new compounds has dropped off dramatically and has not kept pace with the emergence of drug resistance. We are potentially entering a "post-antibiotic era," as bacteria are now routinely encountered that are nearly-and sometimes totally-resistant to all known antibiotics. Someone developing an infection with a multi-drug resistant organism is more likely to die from the infection, and if they survive, more likely to have significant long-term complications from the episode. 

In the aforementioned New England Journal of Medicine article the authors (Spellberg, Bartlett and Gilbert) outline the nature of the antibiotic resistance problem, including the issue of there being a paucity of "new" compounds in the antibiotic production pipeline, especially for resistant bacteria. Our antibiotic arsenal has largely been adapted from nature, where bacteria have been combatting each other with these compounds for millennia. 

The unfortunate reality is that bacteria have already developed counter-measures to the antibiotics we have adopted from nature (resistance to antibiotics). When we use a "new" antibiotic in humans or animals, it does not take long to see the emergence of resistance (as bacteria already possess the means to combat these compounds). 

The authors note several areas where antibiotic resistance can be combatted. They argue for more robust infection control strategies (thereby preventing the development of infections in the first place), making it easier and more lucrative for companies to invest in creating antimicrobials, employing good antibiotic stewardship strategies (preserving the antibiotics we still have) and developing new anti-infective strategies that do not drive antibiotic resistance as much as current therapies. 

It has been less than a century since antibiotics were first discovered and they have only been in widespread use for the last 75 years or so. Given their nature-that they were adapted from nature and resistance to these compounds (and other "new" compounds yet to be discovered) already exists in nature-we have to employ any and all strategies we can to prevent the development of infections, to preserve our existing antibiotic arsenal and to promote the development of new antibiotics and novel strategies to combat infections. We must act now, and collaboratively, if we want to avoid entering the dreaded "post-antibiotic era." 

Some good information on the problem of antibiotic resistance can be found at the CDC. 

Neglected Tropical Diseases: An Update From the WHO

Distribution of soil-transmitted helminths (STHs) and proportion
of children requiring preventive chemotherapy; where we practice
in Honduras STHs are a major problem (www.who.int)

The World Health Organization (WHO) just released its second report on Neglected Tropical Diseases (NTDs); this is a 152 page document outlining the global response to combatting NTDs. The WHO also released a one page summary of this report's findings which can be found here.

As I have previously noted, NTDs include a group of seventeen tropical infections, mostly worms, that are associated with high morbidity (things such as poor growth and mental development in children, pregnancy complications) but low mortality. Despite their major negative effects on health they do not receive much "press" (as opposed to better known diseases such as malaria, HIV and tuberculosis). It is estimated that 1 in 6 people in the world currently suffer from an NTD. 

Global improvements in access to STH therapy have occurred over
the past few years (www.who.int)

In our work in Honduras we focus on decreasing the burden of NTDs, specifically, soil-transmitted helminths (intestinal worms). We estimate that somewhere between 30-70% of the patients we see are infected with one or more of these worms. We provide anti-helminthic therapy according to WHO guidelines, with the hopes of decreasing the overall burden of these infections in the population at large. According to the WHO, "deworming school-aged children is probably the most economically efficient public health activity that can be implemented in any low-income country."

Overall the WHO document is positive, noting recent improvements in combatting NTDs globally. Two diseases have been targeted for elimination, including guinea worm disease in 2015 and yaws in 2020. Global coverage for many other NTDs has improved in recent years, as well. Although there have been significant advances over the past few years, there is still a great deal of work to be done. 

The report also highlights the global dengue problem; the incidence of this disease has increased 30-fold in the past 50 years, and sustainable preventive measures need to be adopted globally to prevent continued spread of this mosquito-borne illness. 

VCU GH2DP Honduras Trip: Final Update

Scouting out potential clinic sites
in Lomitas 

Good morning from Olanchito! Here are some additional thoughts from yesterday's activities.

Yesterday we traveled from La Hicaca to Lomitas. Lomitas is an even more remote mountainous village that is also accessible by truck.

We met with local community leaders in Lomitas and learned that this area is significantly more accessible to approximately half of the people in this region (than La Hicaca). Based on our prior experiences in this area (we held clinics at Lomitas in 2009-2011), we estimate we may have a 20% increase in patients during our next relief mission if we set up clinics in both La Hicaca and Lomitas.

We were able to scout out potential clinic sites and committed to holding several days of clinic in Lomitas during our May-June trip.

Overall this has been a highly successful trip. We were able to share information with the local Ministry of Health and community leaders, and hear from them how we can better support their efforts to improve the health of people in this area.

One of our future clinic sites, Lomitas

Our goals are to expand our water filter program to cover every home across the 17 villages we serve, to make our clinical services more accessible, and to follow-up on last year's indoor air pollution survey with an educational campaign. Additionally, as Chagas disease was identified as a major health issue in the area we will push forward with a survey project designed to assess people's knowledge about the disease in the region. Lots of work to do before the end of May, but we leave with renewed energy and purpose.

River in Lomitas; our prior research identified that a large
portion of the population here obtains their drinking water
directly from this river, which, although beautiful,  is
contaminated with animal waste

Today we travel back to San Pedro Sula and, tomorrow, back to the US.

You can learn more about the VCU Global Health and Health Disparities Program (GH2DP) and our work in Honduras here.

VCU GH2DP Honduras Trip Update: Days 3-4

Sharing data with the Health Minister, Olanchito

Yesterday morning we got up early and met with the Health Minister in Olanchito. We shared data from the projects we undertook on our June 2012 trip, including our water filter testing project, anemia point prevalence survey and indoor air quality project. We discussed current health issues facing the communities we serve in and around La Hicaca, and discussed ways we can support the Ministry of Health improve the health of the communities we serve.

Dr. Patrick Mason doing an impromptu
clinical consultation 

We then traveled up to La Hicaca where we had a busy day; we visited with local community leaders where we shared the results of the aforementioned projects, and also did a few impromptu clinical visits, inspected the local cistern (a fairly sophisticated structure that pipes in water from two or so hours away, but that has fallen into disrepair) and also inspected several indoor stoves and water filters.

Sharing data with local community
 leaders in La Hicaca

Examining the cistern above La Hicaca

Inspecting water filters

We found out some very interesting things in our conversations with the Health Minister and local community leaders. In our indoor air quality survey we identified that, in general, there was poor understanding about the connection between smoke inhalation and respiratory problems. Our in-country contacts confirmed this, and also helped us identify that indoor smoke is often generated by poorly maintained stove chimneys. This is important as these chimneys can be repaired relatively cheaply and be made to more efficiently ventilate smoke. We were asked to conduct an educational campaign during our next brigade highlighting the relationship between indoor smoke and respiratory health.

School in La Hicaca

We also visited the school where we typically set up our clinic and learned the roof has fallen into disrepair.

Here is an example of a well-connected
chimney entering a stove; we found that
many chimneys were not attached
to the stoves at all, allowing smoke to
freely enter into the home 

We were welcomed into local homes to spend the night and then traveled on to an even more remote village, Lomitas, today. I will blog more on today’s events in a future post. 

You can learn more about the VCU Global Health and Health Disparities Program (GH2DP) and our work in Honduras here. 

VCU GH2DP Honduras Trip Update: Potpourri

Up early in Olanchito, working on our report for the Health Minister and waiting for the day to ramp up.

Here are a few additional (somewhat random) thoughts on some of the things we saw yesterday. 

One of the key pieces of advice I give my travel clinic patients is to be very careful not to ingest municipal water in developing countries (this is a major risk factor for developing diarrheal illness). This includes not eating fresh vegetables (which likely have been washed in bacterial-contaminated municipal water). The caveat to this is that these foods may be okay to eat if you know they were washed with clean water. 

Here is a picture of the lettuce for yesterday's lunch meeting being washed using a water purification system; I went for it, so far so good. 

Lettuce being washed by water purification system

Picture from local pharmacy

Another thing that always surprises me is how many antibiotics one can buy over the counter at pharmacies here; one can find almost anything, including injectables. You only need money to access these medications: they are available without prescription. 

I have never seen local data on antibiotic resistance, but I imagine it is high (at least in the cities) for some of the most common, cheapest antibiotics (such as amoxicillin, which is available here in supermarket checkout lines, like gum and candy are in the US). 

Beyond driving antibiotic resistance, inappropriate antibiotic use can lead to drug toxicity and treatment failure (prescribing the right antibiotic for the right condition for the right amount of time is often tricky for physicians; if the antibiotic is chosen without professional guidance the likelihood its use will be appropriate is low). 

Some good information from the WHO on the appropriate use of antibiotics (including in developing countries) can be found here.

You can learn more about the VCU Global Health and Health Disparities Program (GH2DP) and our work in Honduras here. 

VCU GH2DP Honduras Trip Update: Day 2

Honduran countryside

Today we traveled from La Ceiba to Olanchito and met with some of our local community partners.

Our medical and public health work is focused in and around the rural mountain village of La Hicaca. This area includes 17 villages and approximately 2,000 people; as previously noted, these people have very limited access to medical care.

Olanchito, Department of Yoro

Olanchito is the nearest city with a public hospital; this is a good 2 hours away from La Hicaca via truck. This distance is a major barrier to accessing care for people in and around La Hicaca, most of whom do not have access to vehicles.

Today we met with our colleagues from the local Catholic church (which has a major regional presence) as well as a few local volunteers. We discussed the results of last Summer’s water filter project, indoor air quality survey and our anemia point prevalence survey, as well. More importantly, we started to lay down the ground work for this June’s medical and public health trip.

Sharing the results from our June projects with our
community partners (photo credit: Dr. Gonzalo Bearman)

We were able to better identify how many households in the region we serve have water filters; at this point we have 141 water filters 'in the field' that are active (each water filter has to be replaced every 2 years). As there are 248 families in this area we now have provided a source of clean drinking water to approximately 57% of families. Our goal-an ambitious one-is to distribute water filters to the remaining 107 families this Summer. Ultimately we would like to help the local communities in this region develop more sustainable water sources (such as wells), however, local infrastructure (roads, especially) have precluded such projects to date.

We also discussed ways we can provide more people in this region with direct medical services during our June trip. Only 3 of the 17 villages we serve are accessible via truck, and we estimate we only provided care to approximately 20% of all of the people in this region during last year’s trip. By setting up our clinic at multiple villages during this upcoming trip we may be able to provide care to more people. We will drive to Lomitas on Wednesday to see if having a clinic there will be feasible.

Tomorrow we meet with the Minister of Health and then travel up to La Hicaca. I will update the blog when we get back to Olanchito (no WiFi in the mountains).

You can learn more about the VCU Global Health and Health Disparities Program (GH2DP) and our work in Honduras here. 

VCU GH2DP Honduras Trip Update: Day 1

With Jean and Drs. Mason and Bearman at the
airport in San Pedro Sula. 

Today we travelled to the city of La Ceiba in northern Honduras, en route to our meetings with the ministry of health and local community partners in Olanchito, tomorrow. Our flight into San Pedro Sula went smoothly, and once at the airport we were able to pick up our truck and get on the road in good time. 

The sometimes harrowing three hour drive from San Pedro Sula to La Ceiba was a reminder that motor vehicle accidents are a major issue in Honduras.

Road accidents in Central Latin America (including Honduras) are one of the leading causes of years of years of life lost; ‘”years of life lost” (YLL) is another way to look at the affect of deaths on a population (a person who dies from a car accident at 20 accounts for more YLL than someone who dies from a heart attach at age 80, for example).

The graphic appearing below is from an online interactional tool based on data from the recently released Global Burden of Disease study. I have previously blogged about this study: it represents a herculean effort across nearly 500 researchers comparing morbidity and mortality in 2010 to 1990. This graphic depicts the 13 leading causes of YLL in Central Latin America in 1990 versus 2010.

www.healthmetricsandevaluation.org/gbd/visualizations/regional

Note that there have been major health advances in this region across this 20 year period: less children are now dying from diarrheal illness (the number 1 cause of YLL in 1990, down to number 13 in 2010). However, road injury is a major issue (number 3 cause of YLL in 2010) as is interpersonal violence (number 1 cause of YLL in 2010). 

Poster just outside the airport; there are
major issues with interpersonal
violence and drug trafficking in Honduras 

We frequently see people bathing and washing clothes
in rivers and streams; many people also obtain their
drinking water and wash eating utensils in these bodies of
water, as well 

In the roughly 3 hour drive from San Pedro Sula to
Cieba we passed through at least 3 police and
military check points

Getting back to our trip; here are a few brief observations from our drive from San Pedro Sula to La Ceiba: Honduras is a fantastically beautiful country; there were a lot of police and military checkpoints; as we typically observe, people frequently use natural water sources for washing and bathing (we also know many people also obtain their drinking water from these same water sources, a major factor in promoting diarrheal illness).

Tomorrow we trek on to Olanchito, stay tuned.

You can learn more about the VCU Global Health and Health Disparities Program (GH2DP) and our work in Honduras here.