Whenever we go to the doctor and come away with the usual concoction of medicines including antibiotics, we unwittingly become a part of the cycle that gives birth to superbugs.
We may think that we are not in the line of fire but according to a study published in The Lancet, in 2019, superbugs played a role in almost 5 million deaths worldwide, including about 1.2 million that were directly attributable to superbugs.
Two years earlier, in 2017, The World Health Organisation had warned that superbugs were a threat to human health and that new antibiotics to combat these superbugs were not going to be developed in time. The scenario sounds all too familiar and similar to the COVID-19 pandemic where an infection – for which we did not have the medicines to fight – rapidly found its way across the globe.
What really are superbugs?
“Superbug” is a term coined to describe multidrug-resistant bacteria (MDR). “These are bacteria which circumvent the effects of antibiotics and proliferate or multiply uncontrollably in the host,” explains Prof Chin Beek Yoke. Like all supervillains, the superbug is not indestructible, but we have very little in our arsenal of antibiotics that can defeat them.
Although we most commonly hear about Methicillin-resistant Staphylococcus aureus (MRSA), a drug-resistant staphylococcus infection, it’s important to know that superbugs are not just a certain type of bacteria. Any bacteria species can develop a resistance to antibiotics, and become a superbug. Some examples are Salmonella, a common and highly virulent food-borne infection caused by contaminated food and water; and drug-resistant tuberculosis (TB).
“Bacteria are very smart. They will mutate to overcome antibiotics. Once bacteria have the resistance gene in them, they can duplicate vertically (i.e. multiply) or duplicate horizontally where they combine with different species of bacteria. That’s how bacteria propagate their multi-drug resistance in nature,” explains Prof Chin.
Down the drain
How do our actions contribute to the problem?
“A few of the key reasons why superbugs are prevalent are the unnecessary and over-prescription of antibiotics for reasons other than bacterial infections, the use of unapproved or black market antibiotics which are not at full strength, as well as patients not completing the full course of antibiotics,” says Prof Chin. For example, in the case of TB, the drug-resistant strain was exacerbated by patients who either did not complete a full course of TB treatment, was prescribed the wrong treatment (the wrong dose or length of time), were not given the correct medication or took ‘black-market’ medications.
According to the National Antibiotic Resistance Surveillance Report 2020, published by the Institute for Medical Research in Malaysia, most MDR cases were restricted to medical, orthopaedic and surgical wards. There is no concrete evidence to demonstrate MDR in the community yet however, increasing resistance patterns have surfaced for some antibiotics tested on various strains of bacteria. Anecdotal evidence also suggests habits that can become initiators of MDR in the very near future, i.e. antibiotic over-prescription, and patients who insist on antibiotics even when they don’t need them. “These actions will actually pave the way for the development of more superbugs,” says Prof Chin.
On top of this, many do not bother to finish their full course of antibiotics. “At times we think we are better symptomatically however, we don’t have evidence whether the bacteria have been killed off or conversely, whether they continue to replicate,” Prof Chin adds. There are also those who keep leftover antibiotics and self-prescribe when they next feel sickly, not knowing whether they actually have a viral or bacterial infection. Additionally, not having the full course of antibiotics required to stop the growth of the bacteria can allow for MDR to grow, thus allowing bacteria in our bodies to build up resistance to the medication.
The other problem comes with the way we dispose of extra antibiotics. “We pour it down the drain or throw it into the trash. The excess antibiotics then get into our ecosystem, in the soil, or may end up in rivers and water bodies,” says Prof Chin. The correct way to dispose of the extra antibiotics is to bring it to your nearest pharmacy. “All pharmacists are equipped to dispose of extra medicines in the appropriate manner.”
In addition to antibiotic pollution, another source that promotes MDR is the practice of putting antibiotics in domestic animals or fish-feed. When humans consume these products, we are taking in residual antibiotics found in the meat. This unintended consumption of antibiotics may modify the otherwise normal bacterial environment in our bodies and render us susceptible to future bacterial infections.
Prof Chin is not a stranger to superbugs having encountered it twice in her life. The first time occurred when she had a cyst behind her ear removed in the operating theatre. The procedure was simple and painless, but over the next few days, the stitched up incision started growing bullae, which are sacs of clear yellow fluid filled with pus.
She went back to the surgeon to get topical and oral antibiotics. These did not work and the wound got worse and started to ‘weep’ or generate a copious amount of dripping pus, in which she had to dress it like a wound. “Over the next two weeks, I was given three to four different classes of antibiotics. Unfortunately, none of them could control the bacterial growth, and at times, I had to change the gauze dressing every few hours,” she recalls.
She finally consulted a tropical medicine specialist (she was in the US at the time). “The doctor took a swab of the wound, cultured it and typed the bacteria. It was MRSA,” she says. (According to Prof Chin, a clinical swab should have been done when the wound first started showing signs of non-responsiveness to antibiotics.)
Prof Chin was given a powerful last resort antibiotic and the wound dried up within a day. “But we can only use that particular antibiotic as a last resort medication because if it is used as a first resort drug, and if the bacteria turn out to be resistant to it, there may be nothing else that can be done to control the MDR,” she says.
Get me to the doc on time
Prof Chin counts herself lucky to have managed to get the right medication on time. Many don’t. “There have been cases where individuals get exposed to a superbug in their leg, and if they don’t get the proper antibiotics in a timely manner, as a last resort, it is more often than not amputated,” she warns. In some cases, if the superbug gets into the blood, it becomes systemic and may be fatal.
“With my second experience, I had cut myself with a piece of broken glass and the next day I saw some blisters resembling bullae appearing. Because of my earlier experience, I consulted the doctor within 24 hours and explained my history of MRSA.
“For people who don’t have that experience, you will have to gauge for yourselves. Look at the wound or cut, and if it doesn’t appear normal to you, take a picture of it, and another 24 hours later. Notice if it has gotten better with topical antiseptic or antibiotic cream. If within a day or two it remains the same or has grown larger, do consult a doctor. If the bullae look suspicious, the doctor will probably take a culture and type it so that they can treat it accordingly,” she advises. Providing the doctor with the complete history of your cut or laceration, or where you think you had picked up the superbug will go a long way to assist them in providing you with the best treatment option and care.
The bug stops here
Multidrug-resistant bacteria are everywhere. But one of the benefits of the Covid pandemic is that it helped escalate an appreciation of hygiene among us. “Making sure we wipe surfaces, and clean items that come into our household are good habits to have. Wash all fruits and vegetables after purchase, before storage and cooking. This will prevent the bacteria from propagating,” says Prof Chin. One of the things she warns against is the common habit of trying fruit from stalls or at supermarkets. “If you really want to, wipe them first with a wet wipe.”
She also says that we should wear shoes and socks when travelling in areas where contaminated soil or water is prevalent. “Avoid walking in areas where soil and water appear unsanitary as MDRs can remain on the skin and enter our bodies anywhere there are cuts or lacerations.”
However, while caution is good, there is no cause for panic. “If you have an MDR, let’s say on your skin, it’s not going to harm you because your skin is a very good protective organ. Bacteria or pathogens can only enter when there is a cut. So if you don’t have a cut or laceration, you will be fine. Just make sure to wash your hands and feet or any exposed areas.”
The same goes for the times when you ingest bacteria. “You will usually have enough stomach acid to kill it and most of the time we have enough innate immune cells in our bodies to fight them off,” she explains. However, those who are immunocompromised or have a weak immune system must be wary of contracting bacterial infections as your immune system may not be able to keep up with the rapidly growing bacteria.
One of the most important ways to fight superbugs, Prof Chin emphasises, is education and awareness. People need to understand why MDRs exist. “If they don’t know, then there is fear and misinformation,” says Prof Chin
“It is very simple, a majority of the MDR superbugs are ‘created’ by humans, i.e. through ‘Antibiotic Pollution’,” says Prof Chin. And just as it is manmade, it is up to us to fight off this supervillain in our midst.