The most common question I get from interviewers and the public when discussing the public health crisis around increasing rates of bacterial resistance to antibiotics, is: What can people do to protect themselves?. There are two parts to the answer; the first is what you can do for yourself, the second is what healthcare professionals (HCPs) and employers should be doing for you.

Why should you care about antibiotic resistance?

The past two years have made us painfully aware of the health and social consequences of a pandemic. Covid-19’s onset was abrupt, its spread rapid, and its toll overwhelming. With all eyes focused on preventing a future, similar catastrophe, we are ignoring the slower development of a pandemic of bacteria resistant to antibiotics that is happening in the here and now, undermining the ability to treat you for common infections and meet medical needs that you take for granted. If you haven’t heard about antibiotic resistance in bacteria, it’s time you did, and it’s time to take notice.

This is not someone else’s problem. It affects you, whether or not you are the one taking antibiotics. Here’s why: if I prescribe you medicine for high blood pressure, diabetes or headaches, that medicine affects you alone. With antibiotics, it’s different. If you take an antibiotic, bacteria that live in and on your body that are able by chance to resist the action of that antibiotic, will survive and replicate, and can become dominant, resulting in infection with that resistant bacterium in the future (reducing your chance of successful treatment) and/or transfer to other people, through your touch. Equally, you may be the recipient of a bacterium resistant to antibiotics through contact with others who have had an antibiotic. To reiterate, this problem affects us all.

A total of 1.27 million people died in 2019 because of a bacterial infection resistant to antibiotics but that figure is unlikely to move you, since quoting large numbers such as this tends to leave people detached and disenfranchised. But what should catch your attention is that the pandemic of bacterial resistance to antibiotics is threatening your chance of being treated for everyday medical and surgical problems. And it’s not something that you can just throw money at to solve.

To illustrate the problem, let’s look at surgical operations. Chances are, you’ll have had one or need one in your lifetime. Each year, an estimated 234 million major surgical procedures are performed worldwide and the vast majority of these will require an antibiotic to be given before the surgeon makes the cut, to prevent a wound infection. If the bacteria capable of causing such an infection are resistant to the antibiotic you are given, then you’ll get a wound infection affecting your skin and/or deeper structures with that antibiotic-resistant bacterium.

One publication estimates that without a useable antibiotic to prevent wound infections during total hip replacement, 40% to 50% of people would develop an infection and without an antibiotic to treat that infection, 30% would die. If that’s where we’re at when you need your hip replacement, would you take those odds? Unlikely, meaning that you will live with chronic mobility problems.

If you think this is pie in the sky, then know that in my hospital in Cape Town alone, over the past two years, we have performed multiple amputations above the knees of patients who had developed bacterial infections of their previous knee replacements, with bacteria resistant to all antibiotics. To save life, amputation was the only choice for control of the infection. And believe me, our stats are no different to other hospitals in South Africa and abroad that see high rates of bacterial resistance to antibiotics.

Read in Daily Maverick: “Access, not excess, is key to reducing antibiotic resistance in SA – experts”

Another example is if you are unfortunate enough to develop cancer, chances are you’ll need chemotherapy and/or radiotherapy – which suppresses your immune system and makes it more likely for you to get a bacterial infection. If there are no antibiotics left to treat bacterial infections or indeed prevent them from happening in the first place, then cancer treatment is automatically threatened. The list goes on… and we haven’t even got to the most common use for antibiotics – everyday, common bacterial infections such as urinary tract infections (cystitis, pyelonephritis), bacterial pneumonia, bacterial skin and soft tissue infections like cellulitis and impetigo, and bacterial meningitis.

Simply put, the more antibiotics the world uses, the more bacterial resistance to antibiotics increases, and the countries that misuse and overuse antibiotics the most see the greatest amount of bacterial resistance. Sadly, a 2015 report showed that the BRICS nations – Brazil, Russia, India, China and South Africa – had the highest use of antibiotics worldwide. South Africa led the pack. But antibiotics are not just used for humans. Animals produced for food in South Africa continue to receive antibiotics to promote growth and get them to market rapidly, despite attempts to phase this out completely. Moreover, food producers can continue to buy animal feed with added antibiotics over the counter without a veterinarian prescription. What happens in humans, happens in animals – give chickens, cattle, sheep or pigs antibiotics and the bacteria in their guts such as salmonella, campylobacter and shigella, resistant to those antibiotics, will increase. During slaughter, those resistant bacteria can contaminate the meat that you end up handling on your chopping board, which you can transfer to others or some may cause an antibiotic-resistant bacterial infection in you.

What can you do, and what should you expect from your healthcare professionals?

The more antibiotics you and others use, the more likely you and others are to fall victim to a bacterial infection resistant to antibiotics. So, first, here’s what you can do:

• Educate yourself about when you would need an antibiotic. In 2015, a WHO survey of South Africans showed that people thought antibiotics could be used to treat the common cold, measles, HIV (all of which are viral infections), headaches, body pains, constipation, and many other problems that are not caused by bacteria;

• Antibiotics have no effect on viruses, only against bacteria, yet the number-one reason for people taking an antibiotic unnecessarily is for the common cold and other respiratory viral infections. Taking an antibiotic for these reasons is only going to increase your pool of bacteria that are resistant to antibiotics, put yourself at risk of antibiotic side-effects, and increase risk for others if you transfer resistant bacteria to them, without doing you any good whatsoever. Sadly, Covid-19 caused by the virus SARS-CoV-2 has been yet another example, on a truly grand scale, of how a respiratory viral infection can drive increased unnecessary antibiotic prescribing resulting in increasing levels of antibiotic resistance in bacteria.

The next time you have a cold, diarrhoea (without blood), or non-specific symptoms like body aches and headache, either take painkillers such as paracetamol, cough decongestants or other symptomatic relief, or if necessary, see your local pharmacist rather than going to a doctor first.

Prevention is better than resistance – vaccination is a primary way of preventing infections and hence the need to use antibiotics in the first place. Therefore, make sure that you and your children are up to date with immunisations. If you have chronic illness, are pregnant, or are immune-suppressed with HIV, cancer or other causes, get an annual influenza vaccine and ensure you are up to date with your Covid-19 vaccine boosters

An added bonus for reducing antibiotic use through vaccination – be it against bacterial infections like diphtheria, pneumococcus (most common cause of pneumonia), tetanus or typhoid, or against viral infections such as measles, rubella, mumps, polio, influenza, rotavirus, or Covid-19 – is that all vaccines will reduce the likelihood of inappropriate antibiotic prescriptions being made, just by the mere fact that you are less likely to need to see a doctor or nurse in the first place. Indeed, studies show that increasing influenza vaccination coverage reduces antibiotic prescribing in that community. The pneumococcal vaccine (PCV-13) roll-out in South Africa has been shown to significantly reduce pneumococcal pneumonia, but in addition, to reduce the amount of a particular strain of pneumococcus, which carries the most antibiotic resistance mechanisms. Hence increasing pneumococcal vaccine coverage also reduces the amount of antibiotic-resistant pneumococcal infections in the community.

• Perhaps the most-common question I get relates to whether you should finish a course of antibiotics if you feel well before the end. There are actually two answers to the question. The first is, that if you didn’t need an antibiotic in the first place (as per the multiple instances explained above), then the shorter the time you are on an antibiotic, the better (ideally, not at all). In this scenario, not finishing the course of antibiotics would be in your best interests. However, if you do have a bacterial infection that needs treating, then I suggest you follow the advice of the doctor in terms of duration of treatment, and critically, the instructions that are on label in terms of how often to take the antibiotic and any advice relating to timing/food/etc.

For many antibiotics, the number of doses each day is important. You don’t need to sit watching a clock to pop it in your mouth at the exact time, but try not to miss a dose. Ask your doctor what the evidence is for the shortest duration for the antibiotic s/he is giving you. There have been more and more studies now showing that shorter courses are as good as longer ones. The doctor should know, or be able to look it up here.

• Never share antibiotics with others. That is likely to treat people who don’t need an antibiotic at all, or if they do, then more likely to be the wrong antibiotic and for the wrong duration – each antibiotic is different, and different infections need different choices;

• Never try to buy antibiotics over the counter at pharmacies or informal sellers. They are not allowed to give them to you in South Africa, yet unfortunately we know that this does sometimes happen. Antibiotics should only be given out when prescribed by a doctor or nurse prescriber. Unfortunately, antibiotics are among the commonest drugs to be falsified and produced by unscrupulous people to substandard levels, especially if you buy them off the street;

• Perform and encourage people around you to perform basic measures to prevent transmission of bacteria and viruses. These include regular hand hygiene (especially if you are sick or caring for someone who is sick), good cough and sneeze etiquette (into the crook of your elbow) and for goodness sake, leave your nose alone! If you go to the doctor or are admitted to hospital, don’t allow anybody to touch you unless they perform hand hygiene in front of you. Any healthcare professional who objects isn’t worth a dime. I often advise patients in hospital that if any healthcare professional tries to touch them without performing hand hygiene, then scream;

• Practise good food preparation techniques, particularly when handling food, be it meat, vegetables or fruit. Lobby your local shops to source antibiotic-free produce, or at least brands who have good antibiotic use policies. As consumers you have a voice. It’s time to use it more.

These simple measures will ensure that you protect yourself as best you can. But you are only half of the equation. What should you demand from your doctor, HCPs, and your employers?

• Truth is, there are many excellent doctors and nurses out there who prescribe antibiotics well and are dedicated to reducing bacterial resistance to antibiotics. But one cannot escape the fact that if (as we know from studies) more than half of all antibiotics we take are unnecessary, then many doctors must be doing something wrong. This goes for antibiotics prescribed in clinics and hospitals, and spans the public and private health systems. None is exempt.

Knowledge is power, so by understanding more about when an antibiotic is necessary is going to prevent you going to the doctor in the first place. But if you do, it’s time to stop treating doctors like gods, and have an adult conversation about why s/he is giving you an antibiotic and what the alternatives might be.

Read in Daily Maverick: “Newborns face increasing risk as antibiotics fail in the face of infection”

Part of the myth that antibiotics work for everything is that we tend to go to see our doctor, not on day one of feeling unwell, but usually around day three or four, when symptoms peak. Using the common cold as an example, the natural history of the infection (in this case, what happens if no antibiotics are given), is that symptoms will begin to get better on their own around day four. So, if the doctor gives you an antibiotic and hey presto, the next day you feel better, it’s thanks to the antibiotic, right? No. Most of the time, it’s due to the natural history of the infection. But! I hear you cry, “the doctor says I might have a bacterial infection as well!” In almost all instances, that is not the case, and if the doctor thinks that may be the case, there are guidelines and simple tests that can be done. So, chat to her/him about what those are. In some countries, like the UK, doctors use “delayed prescriptions”, where they will give you a prescription but advise you only to collect the antibiotics if the symptoms worsen or new ones develop, as per their instructions. That is another option for your piece of mind. But that only works when circumstances allow and would not be practical in many rural settings in South Africa.

Should doctors and nurses who misuse antibiotics be penalised? Yes. Will they be? Probably not. Accountability is lacking and all that can practically be done is to offer continuing professional development with education about proper antibiotic prescribing. South Africa does have practical guidelines for antibiotic prescribing both through its Essential Medicines List and Structured Treatment Guidelines (both of which are in app form), and the WHO has just published an excellent set of guidelines for optimal use of antibiotics as an app.

• If you really want to weep, stand in any ward in one of South Africa’s public sector hospitals, and watch how many healthcare professionals wash their hands (either with alcohol-based hand rub or soap and water) before and after touching a patient (in fact there are five moments for hand hygiene prescribed by the WHO, but these two are arguably the most important). Clearly there are exceptions, but most of the time, only about 40% of HCPs will perform hand hygiene. Hospitals are the major area where you will find bacteria that are resistant to multiple antibiotics, some that are now resistant to everything. Hand hygiene performed by HCPs forms the most effective way of reducing the chance that you will become infected and forms a central component of infection prevention and control – the series of measures that protect patients from acquiring infections in hospital.

Generally, infections you acquire in hospital occur because patients who are admitted need at least one of four things – a plastic cannula to be inserted into a major vein (central line) or into a vein in the arm (peripheral line) to receive fluids or intravenous medicines; a catheter to be placed in their bladder to help them urinate; have an operation requiring the skin to be cut; or a very small percentage may need help with their breathing that requires sedation, a tube into the windpipe and a ventilator to take over the mechanical action of your lungs. All these procedures involve bypassing your important immune barriers such as your skin, as well as giving bacteria direct access to your urinary system and airways. If HCPs don’t wash their hands properly when handling these areas of entry and the hardware itself, then infection happens.

What can you do about this? Patients and carers need to become more involved as valued team members along with HCPs in reducing the chance of acquiring such an infection, thus ensuring patient safety in hospital. HCPs need to encourage patients and carers to participate. People worry about HCPs taking offence and having your care compromised if you speak up. Don’t be! You’ll be surprised how appreciative HCPs will be. Hospital managers too need to be more pro-active – a culture of unaccountability and lack of professionalism around patient safety has been allowed to grow. It’s one thing to talk about the ideal of “patient-centred care” but if you can’t even ensure that your own staff aren’t causing harm, then that ideal carries no substance.

• Antibiotics hold a bewildering status in society. I have been involved in, and heard of, countless other cases, where patients report employers dismissing the fact that they are sick if antibiotics are not given by their doctors. For all the reasons explained above, most of the time, not giving antibiotics is a good thing, but does not equate to whether someone is fit for work or not. That is a different issue and employers need to de-link the idea that antibiotics are a confirmation of illness. There are also patients who pay for their visit to a doctor, who may feel short-changed if they leave without a prescription. Rather pay your doctor to give you the correct treatment and advice for the illness you have, than give you harmful medicine if you don’t need it.

The time for treating antibiotics like candy is long gone. Antibiotic resistance is a universal public health crisis, threatens the modern medicine you take for granted, and affects you as much as the next person, whether you are the one taking the antibiotic or not. Educate yourselves and others, prevent infection through vaccination and good hygiene practices, and have adult conversations with your healthcare providers. DM/MC

Marc Mendelson, Professor of Infectious Diseases, Groote Schuur Hospital, University of Cape Town.