The Capacity of Bacteria to Resist Against the Effects of an Antibiotic Is Called Antibiotic Resistance. This resistance is due to the change in nature of the bacteria and becomes severe due to several multiplications of bacterial generations which cause destruction in human body  Another most common cause of antibiotic resistance in Pakistan is that the patients get antibiotics from medical stores without the physicians description . Antibiotic consumption in Pakistan between 2000 and 2015 increased 65% from 800 million defined daily doses (DDD) to 1.3 billion DDD. The antibiotic consumption rate in the country witnessed a surge from 16.2 DDD to 19.6 DDD per 1,000 inhabitants per day . Multidrug resistance (MDR) is increasing day by day in Pakistan . A study found that Pakistan was the third highest consumer of antibiotics after India and China among the 76 low- and middle-income countries it surveyed .
The prevalence of misuse of antibiotics is common in under developed\developing countries as compared to developed countries. Pakistan being a developing country is majorly suffering misuse of antibiotics as a result developing resistant to over the counter antibiotics and playing a part in the evolution of mutated genes with far more resistance than their precursor form of the micro-organism which not only is a problem for Pakistan but for the entire human\animal population. Below are discussed on the issue on causes of antibiotics misusage in Pakistan w.r.t it’s socio-economic and literacy status .
Pakistan is a poor country and the country’s wealth mainly resides in agriculture About 25% of Pakistan's agriculture accounts for about 21% of GDP and employs about 43% of the labour force. No proper prescription is respected in the country for the purchasing of antibiotics. Some of the most commonly used classes of antibiotics in Pakistan are: .
- Penicillins such as penicillin and amoxicillin
- Cephalosporins such as cephalexin (Keflex)
- Macrolides such as erythromycin (E-Mycin), clarithromycin (Biaxin), and azithromycin (Zithromax)
- Fluoroquinolones such as ciprofolxacin (Cipro), levofloxacin (Levaquin), and ofloxacin (Floxin)
- Sulfonamides such as co-trimoxazole (Bactrim) and trimethoprim (Proloprim)
- Tetracyclines such as tetracycline (Sumycin, Panmycin) and doxycycline (Vibramycin)
- Aminoglycosides such as gentamicin (Garamycin) and tobramycin (Tobrex) .
Pakistan has a population of about 184 million, with sex ratio of 105.6: 100. It is estimated that about 62% of the people are residing in rural and 38% in urban areas. 42% population (age 10+) is illiterate. Wide discrepancies persist in education indicators pertaining to provinces/areas, location (urban vs. rural) and gender. At the national level, about two third women of age 15+ cannot read and write, and 35% girls remain out of school. Gender Parity Index in case of participation in primary education is 0.82. It is estimated that over 6.7 million children are out of school, and majority of them (62%) are girls .
World Health Organization has mentioned, according to a survey that self-medication, if administered appropriately and responsibly can help prevent and treat diseases economically and without medical consultation [1,21].
Pakistan is an agricultural country and It is seen in Pakistan that use of antibiotic use is not only restricted to humans only. Sprays of antibiotics used on plants and livestock to increase their mass and yields is increasing the antibiotic resistance among the population.
It is important to note that poor quality medicine can be critically damaging to public health in many ways beyond promoting anti-microbial resistance. Falsified medicines with no active ingredients leave both chronic and infectious diseases untreated, prolonging illness and the expense of treatment, and sometimes leading to death. For many infectious diseases including HIV and malaria, treatment failure leads to increased pathogen loads and thus increases the chance of infections being passed on. Fake vaccines, for their part, allow a person who would otherwise develop immunity to remain susceptible to infection. Poorly made or mislabelled medicines containing the wrong ingredients can be toxic, again killing the people who take them in the hope of a cure. Medication scares undermine public confidence in the health system, and the massive trade in fake medicine fuels and funds criminal networks while siphoning income away from legitimate business. These issues are, however, beyond the scope of this paper; here we focus only on those issues which affect or are affected by antimicrobial resistance . Causes of Antimicrobial Resistance.
Antimicrobial resistance (AMR or AR) is the ability of a microbe to resist the effects of medication that once could successfully treat the microbe [4,5 and 7]. The term antibiotic resistance (AR or ABR) is a subset of AMR, as it applies only to bacteria becoming resistant to antibiotics. Resistant microbes are more difficult to treat, requiring alternative medications or higher doses of antimicrobials. These approaches may be more expensive, more toxic or both. Microbes resistant to multiple antimicrobials are called multidrug resistant (MDR). Those considered extensively drug resistant (XDR) or totally drug resistant (TDR) are sometimes called "superbugs" .
Main article: Antibiotic use in livestock.
Infectious disease control through improved water, sanitation and hygiene (WASH) infrastructure needs to be placed at the center of the antimicrobial resistance (AMR) agenda. The spread of infectious diseases caused by inadequate WASH standards is a major driver of antibiotic demand in developing countries . Growing usage of antibiotics together with persistent infectious disease levels have led to a dangerous cycle in which reliance on antimicrobials increases while the efficacy of drugs diminishes . The proper use of infrastructure for water, sanitation and hygiene (WASH) can result in a 47–72 percent decrease of diarrhea cases treated with antibiotics depending on the type of intervention and its effectiveness . A reduction of the diarrhea disease burden through improved infrastructure would result in large decreases in the number of diarrhea cases treated with antibiotics. Sanitation and water for all by 2030 is Goal Number 6 of the Sustainable Development Goals.
An increase in hand washing compliance by hospital staff results in decreased rates of resistant organisms. Antibiotic resistance is a growing problem among humans and wildlife in terrestrial or aquatic environments. In this respect, the spread and contamination of the environment, especially through water pollution "hot spots" such as hospital wastewater and untreated urban wastewater, is a growing and serious public health problem [15,13]. Antibiotics have been polluting the environment since their introduction through human waste (medication, farming), animals, and the pharmaceutical industry  .The contribution of the pharmaceutical industry is so significant that parallels can be drawn between countries with highest rate of increasing antibiotic resistance and countries with largest footprint of pharmaceutical industry
Important strategies needed for minimising antibiotic resistance are as follows .
- Antibiotic stewardship to maintain the value of existing and future antibiotics
- The timing of prescription to use the effective antibiotics sooner rather than later
- To develop and approve ten new antibiotics by 2020 Development of a molecular method for detecting antibiotic resistance genes
It has been noted and observed by many experts that overuse and misuse of antibiotics has lead to resistance all over the world specially in the developing countries like Pakistan. Due to this reason most of the patients are not getting cured by previously used antibiotics. While addressing a National antimicrobial resistance (AMR) organized by AKU. It was said by Dr Sadia Shakoor (assistant professor of pathology and laboratory medicine at AKU). "Antibiotic resistance is a much problem in Pakistan as in the western hemisphere'' .
Many PDR microorganisms have been identified in Pakistan. These organisms include Pseudomonas, Enterobacter, Enterococcus, Acinetobacter and E coli. Resistant staphylococcus aureus has also been treated as PDR. After the discovery of PDR. Bacteria TDR bacteria have also evolved .
Seventy one percent of the new born infections in Pakistan are a result of Antibiotic Resistant Bacteria (ARB) Control : A step should be taken in order to prevent medical store employees to give antibiotics without the physician’s prescription . Fearing widespread deaths because of PDR and TDR bacteria, leading Pakistani surgeons to form the Surgical Infection Control Society of Pakistan and prepared a set of guidelines for surgeons all over the country to deal with the phenomenon . Elimination of over-dose of antibiotics should be a major priority in every country .
Figure 4: How Antibiotic Resistance Spreads.
|Poor drug quality||Sales of counterfeit, adulterated and poor quality antibiotics||These poor-quality antibiotics can produce sub-inhibitory concentration in vivo, which increases the selection of resistant strains|
|Regulators||While most developed countries have developed AMR action plans, this is still lacking in many developing countries especially in Africa||Most countries lack the resources to enforce policies regarding the manufacture and distribution of sub-standard drugs|
|Prescribers||Excessive clinical use and misuse is partially responsible for increase rate of resistance||Variation in prescription practice among health care provider. Sometimes there is prescription of a wrong drug, wrong doses, or antimicrobial not necessary at all|
|Dispensers||Drug vendors usually have little or no knowledge of the required dosage regimen, indication, or contraindications||Medications are usually purchased in small aliquots from roadside stall and storage and distribution is usually done under inadequate conditions|
|Users (patients)||High rate of self- medication and lack of treatment compliance.||Patients fail to adhere to dosage regimens and discontinue treatment when symptoms subside before pathogen is eliminated|
|Factor(s) contributing to poor-quality drugs|
|Reduced stability of drugs in developing countries due to environmental conditions and poor storage|
|No good manufacturing process in developing countries|
|Poor quality control during manufacture|
|Poor surveillance about expiration dates and storage conditions in poor settings|
|Use of no standardized pharmacopoeias by many developing countries|
|Financial interests: crime, corruption of politicians and industry|
|Inadequate resources dedicated to control manufacture, import, and export activities, complex transactions, inefficient cooperation among stakeholders|
|High demand for antimicrobials and vaccines exceeds supply|
|High prices of original drugs.|
|Development of Internet.|
|High rate of illiteracy and very low income of population in less-developed countries.|
|Lack of sensitization of people in less-developed countries to the impact and dangers of counterfeit drugs purchased from unauthorized salesmen.|
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