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Antibiotic Resistance | Why bacteria love war wounds
By the year 2050, antibiotic resistance is projected to kill the same number of people annually as cancer does today. Find out how MSF is working to tackle this global problem...
It’s 2016 in war-torn Yemen.
Waleed is walking down the street in the town of Ibb when an aircraft opens fire on the building next to him.
A wall collapses, and Waleed is severely injured.
Fast-forward to 2019 and Waleed has still not made a full recovery.
This is not because of the damage inflicted by the collapsing wall, but because his wounds were infected by bacteria that became resistant to the very drugs that were supposed to heal him.
The effects of war
“A war wound has an enormous potential for bacterial infection,” says Dr Jorgen Stassijns, who is coordinating MSF’s efforts to get a grip on the problem of antibiotic resistance.
“A bullet or a piece of debris rips the skin apart and rips the flesh open, allowing bacteria to get in. The risk of an infection is huge.”
At the same time, when an area is hit by conflict, health systems often break down. Hospitals may not be open, training can come to a halt, expert medical staff can be forced to flee.
“I was treated in Ibb, but received poor medical care,” says Waleed.
“Then I moved to the capital, Sanaʽa, for further treatment. I had a number of surgeries, but the medical care was still poor.”
Waleed was eventually referred to MSF’s hospital in Amman, Jordan, where doctors discovered he had a severe, antibiotic-resistant infection in his bones.
“The doctors at MSF told me that I got this because of the misuse of antibiotics,” says Waleed.
“Before I came here, many doctors had given me a lot of antibiotics, and that’s what caused the antibiotic-resistant bacteria.”
How resistance happens
Bacteria, like all living things, adapt to new environments.
Every time they are exposed to antibiotics, there is a small chance that they will adapt and survive. And with the widespread use of antibiotics over recent decades, bacteria have had a lot of opportunities to increase their resistance.
In places where there is violent conflict – such as many locations in the Middle East where MSF works – the problem is even more complex.
A crucial question
Fortunately for Waleed and the many patients like him, there are different types of antibiotics, and a bacteria that is resistant to one won’t necessarily be resistant to another.
But this process of choosing the right drug is crucial.
A more effective course of antibiotics will eliminate more bacteria, thereby decreasing the chance that resistance will develop. An ineffective course, on the other hand, can strongly stimulate the bacteria’s resistance.
How to decide
A laboratory can determine the exact type of bacteria causing an infection, as well as which antibiotics it is resistant to.
The hospital where Waleed is being treated is one of the few MSF facilities in the region with such a laboratory. MSF is currently working to expand this capacity, but in places which have been impacted by violent conflict, setting up a lab for microbiology tests is not easy.
While the necessary equipment is not particularly expensive or complex, processing the potentially dangerous samples requires specialist knowledge and exceptionally rigorous protocols.
Whilst , staff training in antibiotic stewardship can also have an impact.
"We’ve learned to follow a protocol that defines the type of antibiotic that should be used for different infections,” says says Dr Marwa Qasim Mohammed who works at MSF’s hospital in Aden, Yemen.
The spread of bacteria means that even people who haven’t been mis-prescribed antibiotics can still pick up a resistant infection.
This risk is amplified in hospitals facing overcrowding, or a lack of staff or supplies – common challenges in conflict zones.
“The main principle of infecton prevention and control is hygiene,” says Fatima Salim Younis who oversees the programme at MSF’s post-operative hospital in Mosul, Iraq.
Some measures can seem quite drastic to patients, such as being isolated for several weeks at a time rather than staying in a shared ward. But they are crucially important to protecting the staff, the other patients and visiting family members from contracting resistant bacteria.
Antibiotics are sold without prescription in many countries, particularly in the Middle East. Patients can have their own ideas about how and when they should be taken.
“Lots of people think an infection means they need any kind of antibiotic from the pharmacy,” says Amal Abed, a health promoter in one of MSF’s hospitals in Gaza.
"The doctors at MSF told me that I got this bone infection because of the misuse of antibiotics"
MSF health promoters help patients understand their treatment and accept the necessary infection prevention and control measures at the hospital.
“I always explain that antibiotics should only be prescribed when they are really useful for your body,” says Amal.
A global health issue
Back in Amman, Waleed is recovering in hospital and has started walking again.
He has suffered from the bone infection for more than three years, and it has taken months of specialist care in MSF’s hospital to reach this stage.
“Thanks to God and the efforts of the doctors, I am now 90 percent cured,” says Waleed.
While Waleed’s treatment has been a success, the challenges of tackling antibiotic resistance extend far beyond MSF’s hospital wards.
“MSF can only try to address a small part of the problem,” says Dr Stassijns.
“We have very little influence on private healthcare providers, which make up the biggest part of the healthcare system in many countries. And the vast majority of antibiotics are not even used in medicine but in livestock breeding and agriculture, over which we have no say.
“What we’re trying to do across MSF projects can make a big difference in our own facilities, but much more is needed to tackle the problem of antibiotic resistance as a whole.”
Despite the complexity of the issue and despite the many challenges we face, MSF is trying to play its part in the worldwide battle against antibiotic resistance and is committed to doing more in the coming years.
Antibiotics are just too important – to our patients and to our doctors – for us to lose this fight.