Antimicrobial resistance in Rural Nepal

Authors: Santosh Dhungana & Nadra Crawford

Antimicrobial resistance (AMR) is a growing concern in high- and low-income countries alike. It occurs when a microorganism such as a bacteria or a virus is able to stop antimicrobials, such as antibiotics, from harming them. Such microorganisms have been referred to as “superbugs” as they are impervious to our standard antimicrobial treatments. 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 our standard treatments to be ineffective, otherwise easily treated infections persist. We are frequently forced to use stronger and newer antibiotics normally reserved for severe cases which generates new resistance to these back-up medications. This all results in lengthier hospital stays, high healthcare costs, disability, and death.

While these consequences of AMR have predominantly been highlighted in high-income countries, there is a growing focus on low- and middle-income countries as major drivers of this global AMR pandemic. What we have learned is that the misuse and the overuse of antimicrobials, in human and animal health alike, allow for the genetic changes needed to fuel resistance. Unfortunately, most low- and middle-income countries are subject to limited affordable health care and casual antimicrobial use policies, which creates challenges for effective medication-use regulations. How can we combat this?

Different organizations and government entities such as the Centers for Disease Control and Prevention, European Center for Disease Prevention and Control and the World Health Organization are promoting best practices to combat AMR. These include prioritizing better hygiene in healthcare facilities, regulated prescriptions of antibiotics, public education, and eliminating overprescribing through antibiotic stewardship programs. An antibiotic stewardship program includes inpatient and outpatient monitoring systems in which patient’s antimicrobial prescriptions are reviewed by a trained team who make recommendations on the best antimicrobial to use and the best way to use it, ultimately improving patient outcome and decreasing resistance.

At Bayalpata Hospital in the remote Far Western region of Nepal, we have taken these best practices to heart as we work to combat AMR in our community. One of the ways we are doing this is by determining which bacteria are prevalent in our community and which of our antibiotics can best treat them. In 2015, we launched our microorganism culturing and antimicrobial sensitivity test program. Since that time, Bayalpata Hospital has been able to culture thousands of specimens from urine, blood, pus, and other body fluids. Body fluids that are found to contain bacteria then undergo antimicrobial sensitivity testing which allows us to see which antibiotics work well against those specific bacteria. With these data, we are able to determine which bacteria are prevalent in our community and which of our medications are capable of effectively treating them. This information will then assist in developing hospital policies and evidence-based protocols for providers to follow.

We all have our part to play to ensure there is effective antimicrobial treatment for the next generation. There is a lot of work to be done to tackle this growing problem. At the community level, Bayalpata Hospital is beginning to implement steps to stifle this extremely urgent public health issue.

Santosh Dhungana, MD

As Provincial Director for Achham – district in far western rural Nepal – Santosh is responsible for patient care and management of staff at Possible managed Bayalpata Hospital. He is passionate about finding ways to make healthcare accessible to the underserved communities and is keen to advance General Practitioners as the pillars for sustainable and affordable healthcare delivery. Santosh attended Medical School at the Institute of Medicine, Kathmandu, and later completed his residency at BP Koirala Institute of Health Sciences, Dharan.

Nadra Crawford, MD

Nadra Crawford was a resident at Contra Costa Regional Medical Center and is a current HEAL Initiative fellow at Possible, Nepal and Lifelong, Oakland. She was born in Los Angeles, CA, received her bachelor’s degree from Colby College in Waterville, ME, and completed medical school at the Escuela Latino Américana de Medicina in Havana, Cuba. Nadra became interested in healing and bridging the gap between healthcare and her community at an early age. When she was 13, she participated in a “medical mission” in the Caribbean where she witnessed commensurate health inequities. These experiences led to her studying medicine abroad, working in the Amazon with the forgotten indigenous people of Peru, and joining the HEAL Initiative.

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