The silent killer: How antibiotic resistance quietly endagers public health

by Janine Cyren Escasura, Rafael Jose Panday, and Josephine Arabella Revereza

Dennis* recalled that besides the mounting medical expenses, he was also extremely afraid of the impact of his illness on his family’s own health. As a husband and father, he said all these weighed heavily on his mental health. 

Dennis, a resident of Los Baños, Laguna was diagnosed with Fournier’s gangrene (FG), a flesh-eating disease that affects your scrotum, penis, or perineum. It is a rare type of infection that requires immediate medical intervention as it can be fatal and deadly if left untreated. In the Philippines, only a total of 131 cases of FG were found over 10 years as reported in a retrospective chart review in the Philippine General Hospital. 

Since he knew nothing of the disease, he shared that he took the risk of trying a number of antibiotics but to his surprise, none of these ended up treating his disease. “Wala rin–hindi rin nakatulong. Ano lang, nayanig lang atay ko doon. Ang dami kong ininom na gamot (It really just challenged my liver. I’ve taken so many medications),” he exclaimed. Looking back, this may have caused him more harm than good. What Dennis did can be classified as antibiotic misuse or overuse which can lead to antibiotic resistance. 

While the COVID-19 pandemic has captured much of the world’s attention, the issue of antimicrobial resistance (AMR) persists in the background, leaving its victims filled with uncertainty and helplessness. 

According to the World Health Organization (WHO), Antimicrobial Resistance (AMR) occurs when ‘’bacteria, viruses, fungi, and parasites change over time and no longer respond to medicines, making infections harder to treat and increasing the risk of disease spread, severe illness, and death’’. In simpler terms, it is when antibiotics may no longer be effective against infectious diseases. 

According to Dr. Ailah S. Jalotjot, an Infectious Disease Specialist at the University Health Service at the University of the Philippines Los Baños, AMR stems from misuse and overuse of antibiotics. “Yung mga patients na nagkaroon na ng multiple and longer antibiotic use and yung mga papalit-palit ng antibiotics, usually sila yung mga may risk of developing antibiotic resistance (patients who had multiple and longer antibiotic use and frequently change antibiotics usually have the risk of developing antibiotic resistance),” she explained.

Dennis had no definite answer about where he got the infection, but he does remember how challenging it was even reaching the point of giving up. ’’Nag desisyon na ako noon, pag ooperahan ako ng pang-apat na straight, ayoko na…Hindi na kakayanin ng katawan ko eh (I had already made a decision back then, that if I were to undergo a fourth consecutive surgery, I would no longer want to proceed… My body simply wouldn’t be able to endure it any longer). 

Dennis battled with FG for almost three years. He was diagnosed back in 2019 during the pandemic and has recovered in 2021 after undergoing a series of tests, strong antibiotics, and operations. He recalled that these said medical treatments totaled to about 1 to 1.2 million pesos. 

Thankfully, after three operations and the right medical care and support, he was given a new lease on life. After a year and three months, he has slowly been easing into his new normal, consisting of check-ups, healthy meals, and walking as an exercise. His grueling battle with the disease is but one of the many rising cases concerning the silent killer, also known as Antimicrobial Resistance (AMR). 

How did the life-saver become a silent killer?

It has been almost a hundred years since the discovery of Penicillin, the first antibiotic medicine by Scottish physician Alexander Flemming, and a little over 80 since it was first used as an antibiotic in 1941.

 During World War II, 2 in every 10 soldiers who had infected wounds died. After soldiers were given Penicillin, the deaths decreased to 1 in every 100. During the early years of the 20th century, the average life expectancy was around 47 years old at a time when diseases such as smallpox, pneumonia, and typhoid fever were death sentences. Nowadays, the average life expectancy is around 73 years old and some of the once deadly diseases can be managed and cured with a few tablets of antibiotics.

However, what came with this medical revolution was a looming threat that continues to this day. A threat which places the sustainability and effectiveness of antibiotics into question.

In a 2017 article from the Yale Journal of Biology and Medicine, Mariya Lobanovska and Pilla Giulia say that four cases of the Penicillin resistant strain of Staphylococcus aureus were reported within just a year after the first antibiotic was used. It was only in the 60’s, when the second generation of antibiotic, Methicillin, was able to halt the spread of the disease. However, just a year later, a methicillin-resistant strain emerged and remains a significant concern to this day.

From there on, a 2014 study by Chih-Jung Chen and Yhu-Chering Huang from the Clinical Microbiology and Infection says that Staphylococcus aureus has long been a healthcare concern in Asia for being one of the major causes of infections that is shown to have an increased rate of resistance to multiple antimicrobial agents.

Staphylococcus aureus (S. aureus) is a group of bacteria commonly found on the skin. Normally, it is harmless and doesn’t cause any problems. However, Leinard Oro, a nurse supervisor at HealthServ Los Baños Medical Center, explained that this bacteria can enter the human body through an open cut or wound which causes different kinds of infections, ranging from mild to severe.

It’s hard to believe that a bacteria commonly found on the skin of the human body could put you at risk of a life-threatening infection. The sad reality is, people with underlying medical conditions who carry the burden of a weakened immune system are the most vulnerable to systemic, life-threatening infections. This is the case of a patient with Chronic Kidney Disease (CKD) handled by Rayda Bumanlag, the head nurse at the hemodialysis unit in Los Baños Doctors Medical Center. 

Nurse Bumanlag shared that her patient was infected by S. aureus and became resistant to antibiotics. Sadly, it has also infected the patient’s heart and developed endocarditis, an inflammation of the inner lining of the heart. “Unfortunately at his age, hindi niya nakayanan . . . nawala rin siya (The patient was not able to cope so he died),” Nurse Bumanlag says.

According to a 2019 report from the World Health Organization (WHO), there are approximately 700,000 annual deaths worldwide due to these antibiotic-resistant diseases. Although the number may not seem high, it was reported that if no action is done, the total expected number of deaths from drug-resistant disease could skyrocket to 10 million annually by 2050.

Not to mention the economic damage it may cause, the report also states that antimicrobial resistance could push approximately 24 million people into extreme poverty by the year 2030.  “When there is a spread of [antibiotic-resistant] infection, nagkakaroon tayo ng outbreak na tinatawag (there is what we call an outbreak) and then for hospitalized patients, you will have high medical costs, longer stay in the hospital and eventually, death,” Dr. Jalotjot says. 

If not controlled, antibiotic resistance will horrifically become the major cause of death by 2050, making it one of the top 10 global public health threats at the present time. 

Predicted mortality from AMR compared to common causes of death today (adapted from O’Neill 2016; Murray et al. 2022)

Efforts to combat antibiotic resistance

In 2015, the Department of Health (DOH), together with other government agencies, launched the pioneering Philippine National Action Plan to Combat Antimicrobial Resistance (AMR) (2015-2017) to address the pervasive threat of antibiotic resistance in the country. In this plan, 7 key AMR strategies were developed to support the said national program.

These strategies aim to foster collaboration among involved agencies, strengthen AMR case monitoring, guarantee access to safe antibiotics, ensure proper use of antibiotics, enhance infection prevention and control measures, support research and development in AMR, and raise awareness on antibiotic resistance. With the hopes to mitigate the increasing rate of AMR cases in the Philippines, the National Action Plan also aims to promote capacity building of all concerned medical personnel.

In the battle against antibiotic resistance, doctors play a pivotal role as the guardians of our health. As a healthcare provider, Dr. Jalotjot emphasized their commitment to adhere to the guidelines and protocols under the Antimicrobial Stewardship Program (ASP) as it is mandated by DOH to monitor the use of antibiotics. 

ASP is a program developed by the Pharmaceutical Division of DOH in 2016 that champions responsible antimicrobial prescribing practices and administration across healthcare settings. This is a program designed to mobilize and train physicians, pharmacists, nurses, microbiologists, and medical technologists in the country with the proper admission and use of antimicrobials.

The Philippines continues to strengthen the antimicrobial surveillance system through the education and training of medical professionals across 1,284 licensed government and private hospitals in the country. During the Philippine Antimicrobial Awareness Week (PAAW) 2022, DOH Officer-in-charge Maria Rosario Vergeire said in her speech that “71.32% of licensed hospitals (all levels) nationwide have already been trained on AMS (Antimicrobial Stewardship) [Program].”

The implementation of ASP supports the efforts of the national program toward successfully addressing AMR at the community level. However, in a 2022 study to review the Philippine National Action Plan on AMR, Maria Margarita Lota said that the program tends to adopt a “top-down” approach which means that many local stakeholders, such as community pharmacists and other local government units, were not involved in the said plan. Apart from that, Lota also reported that the plan faces significant challenges in terms of funding streams and allocation of budget.

True to Lota’s claim, the Philippine National Action Plan to Combat AMR (2019-2023) pointed out that there were limited to no subsidies provided by PhilHealth to support the treatment of patients diagnosed with antibiotic resistance across clinical settings. Sadly, for many indigent patients, PhilHealth serves as their sole means to cover their medical expenses.

“That is why for my patients na walang pera, they usually die of complications an untreated infections kasi wala naman silang pambili ng mga ganoong klase ng antibiotics (That is why for my patients without enough money, they usually die of complications and untreated infections because they don’t have the financial capacity to buy those kinds of antibiotics),” Dr. Jalotjot says.

Nurse Bumanlag shared that “a vial of antibiotics costs 3,900 pesos inside the hospital,” and the patient’s inability to buy antibiotics results in an incomplete course of treatment. She said that these kinds of situations are inevitable because even if they try to educate their patients about antibiotic resistance, “there’s a certain blockage pa rin na hindi namin kayang icontrol [which is] financial constraints (there’s a certain blockage that we cannot control [which is] financial constraints).”

With the program’s ultimate goal of combating AMR, the limited funding resources indeed hinders the implementation progress of the program. As mentioned by Nurse Bumanlag, this is an important aspect that needs to be recognized as a significant factor in developing antibiotic resistance. Consequently, the 2019-2023 Philippine National Action Plan to Combat AMR acknowledges this challenge as an opportunity to enhance the Philhealth Outpatient Benefit package and to broaden the implementation of PhilHealth reimbursement programs and benefits for antimicrobial resistance.

Preserving our lifesaving weapons

With drug-resistant organisms on the rise, scientifically-proven prevention and reduction strategies to combat AMR should be strictly followed and implemented if we want to preserve the effectiveness of antibiotics for future generations. They are, in fact, our lifesaving weapons. Without them, as simple as an infected wound, can already lead to death. 

It may just be a matter of time before new strains of antibiotic resistance emerge. This is why continuous research and development is a crucial prevention strategy amidst the evolving challenges of AMR. Through this, emerging resistance patterns are identified, existing treatment options are improved, and new interventions to reduce AMR are developed. 

A recent study published in the Proceedings of the National Academy of Science of the United States of America explored the use of nanomachines — tiny machines which can only be viewed through a microscope, that can be used to combat AMR. In the study, the nanomachines acted as drills which broke down the cell walls of bacteria. When tested on MRSA-infected moth larvae, it was found that the treatment was able to extend the survival of most of the infected larvae past a week, whereas none of those without treatment survived. 

Nanomachines have significant potential in fighting antimicrobial resistance (AMR) because, unlike conventional antibiotics, they don’t allow bacteria to develop resistance even after repeated exposure. This makes them a promising tool in combating AMR.

Locally, an ongoing project on the use of marine bacteria to develop a beta-lactamase inhibitor to boost antibiotic effectiveness is being led by Dr. Julius Adam Lopez. The project makes use of the marine-sediment bacteria found in the Tubbataha Reef, in Palawan. Beta-lactamase is an enzyme produced by some bacteria which acts as a shield making them immune to certain antimicrobials. The use of Beta-lactamase inhibitors along with antibiotics to break down these shields, ensure that the antibiotic is able to function and successfully defeat the antimicrobial resistant bacteria. Furthermore, the presence of the inhibitors locally could make its price more affordable. 

Research also helps in debunking misconceptions about antibiotic use. At present, Nurse Bumanlag still believes that misinformation and lack of knowledge and awareness about antibiotic resistance are still prevalent in the country. In a 2022 study from Lancet Microbe, Janine Patricia Robredo and her co-authors say that 29 – 95% of adults are still misinformed about the proper use and possible health consequences of misuse and overuse of antibiotics.

Moreover, Dr. Jalotjot says that many Filipinos mistakenly believe that all infections are caused by bacteria and automatically require antibiotics. They also think that once their symptoms improve, they can stop taking antibiotics. This belief undermines the advice of medical professionals and disregards the importance of proper diagnosis by taking and abruptly stopping medications without any medical advice from a physician.

In an article published by Philippine News Agency in 2019, the Philippine National Formulary (PNF) and National Antibiotic Guidelines (NAG) representative Cecilia Maramba-Lazarte said that “patients don’t go to the doctor, they self-medicate, they ask their neighbor.” Developed by the Philippine National Drug Formulary Committee (PNDFC), PNF provides a compiled list of essential drugs in the Philippines that are chosen based on evidence of their effectiveness, safety, and cost-effectiveness compared to other options.

In 2016, a study by Daniel Alexander Barber found that in many communities in the Philippines, the availability of antibiotics in sari-sari stores greatly contributes to the common practice of self-medication. In particular, these antibiotics were reported to be sold in incorrect dosage, usually expired, and occasionally improperly stored which may have been associated with the development of antibiotic resistance cases in the country. 

Similarly, a 2022 study by Janine Patricia Robredo and her co-authors from Lancet Microbe, says that antibiotic sharing, especially among family members and neighbors, is also considered socially acceptable in the Philippines which further worsens the antibiotic resistance problem in the country. 

Dr. Jalotjot says there is a need to put an end to the notion of one-antibiotic-fits-all. She urges patients to encourage their relatives and neighbors to seek advice from their doctor first before taking any medications, especially if it’s antibiotics. For her fellow healthcare practitioners, she also encourages them to educate their patients and to “tell them that we need to give the right antibiotic to the right patient with [the] right timing with the right diagnosis.

Dennis, as someone who has experienced taking multiple and longer use of antibiotics, shared some advice for all Filipinos out there. “[Sa laboratory results], palagi nakalagay sa ilalim, “always seek medical advice,” ganun lang pala dapat talaga (In the laboratory results, “always seek medical advice,” is always written at the bottom. That’s just how it should be),” he said.

As cliche as it may sound, the fight against the spread and emergence of AMR is extremely challenging if collective action is not taken. Individual efforts may only work to an extent in this long-standing battle. It requires an aggressive, multi-faceted effort from all stakeholders involved  – individuals, healthcare professionals, policymakers, and the global community.