More public awareness, stronger infection prevention control, better control of antibiotic use, and access to microbiology are important measures to address AMR

For the last two weeks, Said Dawood has been stuck alone in an isolation room in the Médecins Sans Frontières (MSF) Kunduz Trauma Centre, still trying to recover from an injury sustained eight months ago.

Working as a skilled labourer in the northern Afghan province of Kunduz, Dawood fell from the fourth floor of a building and suffered open fractures to both of his legs. He was discharged from the trauma centre in March, but twice now has had to be readmitted due to infection.

Recent results from the microbiology laboratory confirmed the suspicions of his doctors – the bacteria that caused the infection is resistant to commonly used antibiotics and requires targeted treatment.

The news shocked Dawood, who didn’t know anything about antimicrobial resistance (AMR). But it comes as no surprise for Dr Letizia Ottino, an MSF infectious disease specialist, who has spent the last year working on AMR in Afghanistan.

“We are dealing with antibiotic resistance every day,” she says.

“It has a serious impact on the healthcare system. Multidrug-resistant infections require more resources to be treated, they require longer hospitalisation, expensive antibiotics and specialised doctors,” Ottino explains.

These very serious infections increase the risk of death, particularly for vulnerable people such as newborns, pregnant women, children with severe acute malnutrition, and those with trauma-related injuries.

New mothers at MSF’s Khost Maternity Hospital face that fear every day as they pull on medical gowns to visit their pre-term babies lying in neonatal intensive care beds.

At the first sign of infection, MSF staff send a blood sample to the newly installed mini-lab – an easily transportable small-scale standalone bacteriology lab that MSF has rolled out in low-resource settings – so they can identify the infection-causing bacteria and tailor antibiotic treatment.

Within MSF projects across Afghanistan, we are implementing a package of services to address AMR, including strengthened infection prevention control measures and the creation of antimicrobial stewardship committees, with staff responsible for ensuring the appropriate choice and correct use of antibiotics for patients.

MSF has also opened two bacteriology labs, in Kunduz and Khost, to help identify bacteria and select the right antibiotic to treat the infection.

Patient and prescriber practices key to addressing AMR

These activities are a good start to addressing AMR in MSF projects, but far more is needed to address the public health problem, Ottino says.

While there is limited data about antibiotic resistance in Afghanistan, Ottino says the available scientific literature shows high levels of AMR in the country.

A new MSF report on AMR in humanitarian contexts points to broad structural challenges – like poor access to quality healthcare, water, sanitation and hygiene services, infection prevention control measures, vaccines, and medical and laboratory supply chains – as drivers of AMR in low-resource settings like Afghanistan.

But patient and prescriber practices also play a significant role, says Dr Zabihullah Fazalzoi, a paediatrician in the MSF-supported paediatric department of the Herat Regional Hospital.

“Over-prescription, overuse, misuse and widespread over-the counter availability of antibiotics all contribute to the growing problem of AMR,” he says.

This has been a long-standing issue, according to an MSF mixed-methods study that looked at perceptions of antibiotics and their use among patients, prescribers and pharmacists in a district hospital in Kabul in 2015.

The study found that patients often had limited knowledge about antibiotics, they frequently overused and misused them, including for a wide range of conditions like common colds, infertility and general body pain, and that antibiotics were widely available for over-the-counter purchase in private pharmacies.

Raising awareness about AMR

Health promoters in MSF projects are trying to increase public education about AMR and encourage better practices in the community.

Haji Abdul Rehman Niamatullah gathers a group of patients in the MSF-supported Boost Provincial Hospital in Lashkar Gah, Helmand. With a flipchart in hand, he explains that antibiotics fight infections caused by bacteria, but they have no effect on common viruses that cause coughs, colds or the flu.

Antibiotic resistance occurs when bacteria, after being exposed to antibiotics, no longer respond to these medications over time. This natural process begins and is accelerated every time we use antibiotics in the wrong way, such as skipping doses or not completing the entire course of treatment. Since the antibiotic cannot kill the bacteria, it becomes more difficult to treat the disease, Niamatullah adds.

Back in the Kunduz Trauma Centre, Dawood has learned first-hand how difficult it can be to treat infections caused by a multidrug-resistant organism. His infection was caused by a highly resistant organism that is called methicillin-resistant Staphylococcus aureus.

After more than two weeks in the trauma centre’s isolation ward, Dawood says he can tell his infection is starting to heal. While he’s grateful for the treatment from MSF staff, Dawood says he’s looking forward to going home soon.