December 2, 2022

South Africa: The widespread abuse of antibiotics in humans, animals and the environment must end

I know of many cases where employers won’t allow sick leave without employees having antibiotics to prove

In the first two articles in this series on the antibiotic resistance pandemic, we established the scale of the problem, with new data showing that 4.5 million people died in 2019 from antibiotic-resistant bacterial infection, including nearly 1.3 million as a direct result of this infection. . Moreover, the use of antibiotics during childhood is associated with various diseases later in life.

We also explained how bacteria become resistant to antibiotics and that the more antibiotics we use, the more resistance increases. This results in the need to use antibiotics of last resort for everyday infections such as cystitis, pneumonia, gonorrhea and meningitis, some of which are now incurable. In addition, we have also explained how this process occurs in animals, whether it is your pets or animals produced for food.

This is the third in a series on antibiotic resistance.

Read part one: There’s another pandemic we should be focusing on: antibiotic-resistant infections

Read Part 2: Why “War” Against Bacteria Is the Wrong Strategy

In this article, we will examine how the use of antibiotics has been abused and misused in human health, food production and pets, and how we are polluting our environment with antibiotics to the detriment of human and animal health. .

About one-third to one-half of all antibiotics used in humans are useless. The majority of abuse occurs in primary care, where people are given antibiotics for viral infections like colds, “flu”, bronchitis and diarrhea or any number of aches and pains.

Antibiotics only work against bacterial infections, not viruses or non-specific symptoms – you can’t insert a square peg into a round hole. All they do when used incorrectly is increase resistance and cause unwanted side effects.

Hospital prescribers are also at fault, using antibiotics when not needed, often continuing antibiotics too long, choosing the wrong antibiotic, and not sending or acting on test results.

The choice of antibiotic is also important. Doctors often use “broad-spectrum” antibiotics which do more damage to your bacterial ecosystem and can cause resistance in a wider range of bacteria than narrow-spectrum antibiotics like the good old – but much less “sexy” – penicillin. Not submitting the correct tests before starting an antibiotic or not interpreting them correctly increases exposure to these broad-spectrum antibiotics.

What’s behind this useless prescription? The answer is complex. First of all, many prescribers do a great job and understand the problem we are facing. Others have different priorities and continue to misprescribe.

Reasons for unnecessary antibiotics include a desire to cover all bases regardless of the likelihood of bacterial infection, lack of understanding of the correct use of antibiotics and the harm they cause, a desire to please to the patient so that they return in the future (a particular problem in private health care), difficulty in accessing care so that the prescriber may feel like they have “one bite to eat” cherry” (more common in the public sector) and sometimes due to social pressure, when patients insist on being given an antibiotic. In some countries like China (not South Africa), doctors’ compensation has been directly tied to the number of prescriptions they have written, a major perverse incentive.

Another social pressure is evident in South Africa; a prescription for antibiotics is often taken as proof of illness, and I know of many cases where employers won’t believe an employee is sick or allow sick leave without them having antibiotics to prove .

South Africa faces a second problem in that it suffers from a heavy burden of infectious diseases due to lack of access to clean water and safe sanitation, incomplete vaccination coverage and poverty, which increases the transmission of pathogens due to overcrowding.

Additionally, we have a large population with immunosuppression – HIV, malnutrition, tuberculosis and other chronic diseases – which means there is a huge burden of people presenting for medical care with non-bacterial illnesses. The more sick people attend clinics for whatever reason, the more likely they are to end up on unnecessary antibiotics.

The O’Neill report estimated that simply improving access to safe drinking water and sanitation facilities could reduce the number of cases of associated diarrhea treated with antibiotics by 60%. Maximizing vaccination coverage to prevent pneumonia would also significantly reduce antibiotic use.

Thus, reducing the societal problems that cause infections is an important part of the solution to combating antibiotic resistance. But that’s easier said than done in cash-strapped low- and middle-income countries like South Africa.

Animals

Antibiotics are also misused and abused in animal health. Think pets, like your adorable pooch or Miss Tiddles. Unnecessary use of antibiotics in pets can lead to antibiotic resistant bacterial infections in the same way as in humans, as animals also exist in symbiosis with bacteria.

Additionally, humans and their pets can exchange bacteria through touch and petting. It is therefore in your interest that Fifi Trixibelle only receives an antibiotic when she needs it!

Another major cause for concern is the production of animal protein. Drivers of antibiotic abuse in chickens, cattle, sheep, pigs, etc. are quite different. Like doctors, many responsible farmers and veterinarians work together to limit the use of antibiotics.

But, the animal protein industry is often all about thin margins, and so getting animals to market as soon as possible, at a decent size and healthy, is a constant challenge.

For decades, antibiotics have been added to food and/or water to optimize and accelerate growth, i.e. as animal growth promoters. Access to antibiotics in feed has historically been governed by a different law in South Africa, which means farmers can buy feed containing antibiotics without a prescription and without a prescription from a veterinarian.

Antibiotics are also regularly used to prevent infections in herds or herds. Think about it; if you have 30,000 chickens in a shed and a few start coughing, you’re not going to go from chicken to chicken with a stethoscope and treat only those that show signs of infection. Therefore, antibiotics are also given to animals in bulk in their feed and water to prevent infections.

And we’re really talking about vast amounts. In some countries, up to 80% of all antibiotics purchased will go to animals, mostly in food production.

How does the use of antibiotics in food animals affect humans? Once again, exposure to antibiotics will cause antibiotic resistance in their gut bacteria; the sensitive having been largely killed.

During slaughter, the spillage of intestinal contents onto the carcass can transfer these antibiotic resistant bacteria, and if proper food hygiene is not employed from farm to fork, these antibiotic resistant bacteria can potentially end up in you. and on you. This is why good kitchen hygiene is so important when handling animal protein, and indeed all types of food, including vegetables and fruits, as we will soon see.

Vaccination of food producing animals is a major means of reducing infections and is widely used in food production systems. The Norwegian salmon industry, for example, has reduced antibiotic use in aquaculture to almost zero by vaccinating each anesthetized farmed salmon individually. Click here to see how it’s done.

Improving other infection prevention measures on farms, such as increasing the space animals are housed in, dietary changes, etc., have also been successful in reducing the need for antibiotics. The problem is that it requires a financial commitment, whereas antibiotics in food are cheap as mud in comparison. In low- and middle-income countries, this is a major obstacle to stopping their overconsumption.

Even vegetables are affected

For all of you who enjoy a plant-based diet, I’m afraid you’re not exempt from similar issues.

Antibiotic manufacturers have been polluting the environment for decades, as has our improper disposal of antibiotics, and when we and animals excrete antibiotics or their breakdown products in wastewater, they enter the soil and waterways. water.

Environmental bacteria are exposed to greater amounts of antibiotics, and the exposure-benefit-exposure cycle continues, increasing antibiotic-resistant bacteria in the environment. They can in turn enter the food chain via animals or directly into humans.

There have been numerous reports of fruits and vegetables carrying antibiotic resistant bacteria at the point of sale, including tomatoes, spinach, lettuce, cucumber, green beans, and sprouts to name a few- ones, and from all parts of the world, including here in South Africa. .

It should be clear by now that the pandemic of antibiotic-resistant bacterial infections is a multi-faceted problem, which provides one of the best examples of what we call a ‘One Health’ problem – a problem that affects human health. , animal and environmental.

If we are to reduce the impact of this pandemic, the solutions lie in interventions to address the misuse and overuse of antibiotics across all three sectors. The next article in this series will look at what you as an individual can do to break the cycle, protect yourself and protect public health.

Marc Mendelson is Professor of Infectious Diseases and Head of the Division of Infectious Diseases and HIV Medicine at Groote Schuur Hospital, University of Cape Town.