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Combating Antimicrobial Resistance in Rural Nepal: An Integrated Approach

Pabitra* is a 17 year-old girl in far west Nepal who came to Bayalpata Hospital for a superficial puncture wound to the left index finger. She was diagnosed with a soft tissue infection. She completed her course of first-line antibiotics, but she missed her follow up appointment, because of the long and expensive travel to the hospital.

When she finally returned, she presented with pain and discoloration, and was diagnosed with an infection in the bone which necessitated amputation of her left index finger. The bacteria in her finger resisted the effects of our first-line antimicrobial treatment.

There are many things we have learned evaluating Pabitra’s case.

Antimicrobial resistance (AMR) is a growing concern in high- and low-income countries alike. It occurs when a microorganism, referred to as “superbugs”, is able to stop antimicrobials, such as antibiotics, from harming them. We have seen these resistance patterns in the influenza virus, HIV, tuberculosis, malaria, E. coli and gonorrhea, just to name a few. As AMR causes standard treatments to be ineffective, easily treated infections persist. As a result, we are forced to use stronger and newer antibiotics, typically reserved for severe cases, which generates new resistance to these back-up medications. This results in lengthier hospital stays, higher healthcare costs, and sometimes, disability and death.

The best practices to combat AMR, promoted by the Centers for Disease Control and Prevention, European Center for Disease Prevention and Control and the World Health Organization, include prioritizing better hygiene in healthcare facilities, regulated prescriptions of antibiotics, public education, and eliminating overprescribing through antibiotic stewardship programs. This includes an integrated healthcare approach, involving inpatient and outpatient monitoring systems in which patient’s antimicrobial prescriptions are reviewed by a trained and coordinated team, both at the facility and community level. 

What we have observed at Bayalpata Hospital mirrors what’s happening nationally. For this reason, there is a push for prohibiting the sale of antibiotics without a prescription, tests that distinguish viral infections from bacterial, centralized databases with antibiotics and their resistance patterns, education on antibiotic use, strict hygiene practices, as well as having antibiotic stewardships in every facility. 

At Bayalpata Hospital, we launched our microorganism culturing and antimicrobial sensitivity test program. Since 2015, Bayalpata Hospital has been able to culture thousands of specimens from urine, blood, pus, and other body fluids. With these data, we are determining which bacteria are prevalent in our community and which of our medications are capable of effectively treating them. 

This information will assist in developing evidence-based protocols, in which antibiotic prescribing is closely monitored by providers trained in the WHO online antibiotic stewardship course.

Bayalpata Hospital is taking steps to stifle this urgent public health issue, and prevent amputations like what Pabitra experienced. Collecting and evaluating data around antimicrobial resistance is one example of Possible’s pragmatic and evidence-based approach to research, with the goal of making interventions that lead to health impacts on the ground and health systems change more broadly. 

By Medical Director Santosh Dhungana & HEAL Fellow Nadra Crawford

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