Antibiotic Awareness Day (EAAD), held annually on November 18, is a public health initiative aimed at increasing awareness on antimicrobial resistance and encouraging the responsible use of these medicines among the public. This year’s slogan of the WHO campaign is ‘Antimicrobials: handle with care’.

Antimicrobials are medicines that target micro-organisms. Antibiotics are a subgroup that specifically target bacteria. There are more than 15 different classes of antibiotics, each with a different chemical composition and clinical uses as well as different activity on various bacterial groups. Since their discovery, antibiotics have saved countless lives and have allowed the development of various medical and surgical specialised procedures, which are indispensable at this day and age.

Antibiotic misuse, both in human medicine as well as in veterinary practices and agriculture, has, however, led to the development of resistance among various groups of bacteria. Bacteria have developed various mechanisms, allowing them to evade the effects of antibiotics and also enabling them to destroy the antibiotic molecules in some cases, rendering them inactive.

What was once an easy-to-treat infection has become increasingly complicated due to limited antibiotic choices and treatment failures. Each year, 33,000 people die as a direct consequence of an infection due to bacteria resistant to antibiotics. This is comparable to the total number of passengers in more than 100 medium-sized airplanes.

The burden of infections with bacteria resistant to antibiotics on the European population is comparable to that of influenza, tuberculosis and HIV/AIDS combined. Most of these infections occur in the healthcare environment (source: ECDC). Antimicrobial resistance is thought to be responsible for almost 30 deaths in Malta every year and the loss of 600 years of healthy living among our population (Cassini – Lancet).

The main driver for antibiotic resistance is the inappropriate use of these medicinal agents. One such example is the use of antibiotics as part of the treatment for common colds or other viral infections. Antibiotics have no activity whatsoever against viruses and symptomatic treatment is more effective. In these circumstances, they will alter, unnecessarily, the delicate balance within the beneficial colonising bacterial populations making up the body’s microbiome. Exposure to antibiotics will allow the survival of the resistant bacterial strains which can continue to propagate and become more predominant.

Furthermore, these resistant bacteria can be passed on to other individuals and cause infections in others who may not have taken any antibiotics themselves.

During the current pandemic, it has been noted that patients infected with COVID-19 had low incidence of bacterial infections over and above their viral infection at diagnosis. Despite this, the rate of antibiotic use has increased. This overuse of antibiotics will invariably contribute to the development of multidrug-resistant bacteria and will adversely affect patient outcomes should they progress to develop a bacterial infection eventually.

Antibiotic resistance rates are increasing across the world. Data from the European Antimicrobial Resistance Surveillance Network (EARS-Net) shows that there is a gradient North-South. Lower rates of antimicrobial resistance are reported in Scandinavian countries and the Netherlands, while higher rates are reported in southern European countries, including Malta. This is mirrored by the patterns of antibiotic use in southern European countries, where the prescription rates are higher and the use of broad-spectrum antibiotics is higher both in community as well as in hospital settings.

Unless we act now to curb this increase in resistance, we risk returning to the ‘pre-antibiotic’ era, when organ transplantation, chemotherapy, intensive care and other invasive medical procedures would no longer be possible.

Only a handful of new antibiotic agents are in development. Hence, it is everyone’s responsibility to ensure that these crucial medicines remain effective and available for future generations. Everyone can play an important role: the public and healthcare professionals alike.

Patients need to follow their doctor’s advice when taking antibiotics and ensure that the correct doses are taken for the recommended duration. Any leftover medication needs to be disposed of appropriately and not in general household waste.

Prevention of infections is also an important aspect. Good hygienic practices, infection control as well as vaccination can prevent infections and,  hence, the need for antibiotic use.

Healthcare professionals should ensure that antibiotics are prescribed only when necessary. As much as possible, they should prescribe antibiotics that specifically target the likely infectious agent and that has the least deleterious effect on the microbiome.

Rodianne Abela is a consultant microbiologist and the vice-president of the Malta College of Pathologists.