1. North South University
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Department of Public Health
Name: Parth Protim Barmon
ID No: 1020688080
Course name and code: Directed studies in Public Health
PBH 705
Course Taken: Summer 2011
Title of the Research: Impact of Antimicrobial resistance (AMR) in developing countries.
Submitted to: Prof. Tahera Ahmed,
Part-time Faculty NSU.
Length: 5,974 Words
Date of Submission: December 30, 2011
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2. Title of the study:
Impact of Antimicrobial resistance (AMR) in developing countries.

3. Back ground of the study:
Antimicrobial resistance (AMR) is resistance of a microorganism to an antimicrobial medicine to
which it was previously sensitive. Resistant organisms (they include bacteria, viruses and some
parasites) are able to withstand attack by antimicrobial medicines, such as antibiotics, antivirals,
and antimalarials, so that standard treatments become ineffective and infections persist and may
spread to others. AMR is a consequence of the use, particularly the misuse, of antimicrobial
medicines and develops when a microorganism mutates or acquires a resistance gene. [10]
Several reports suggest that antimicrobial resistance is an increasing global problem; but like
most pandemics, the greatest toll is in the less developed countries. The dismally low rate of
discovery of antimicrobials compared to the rate of development of antimicrobial resistance
places humanity on a very dangerous precipice. Since antimicrobial resistance is part of an
organism's natural survival instinct, total eradication might be unachievable; however, it can be
reduced to a level that it no longer poses a threat to humanity. While inappropriate antimicrobial
consumption contributes to the development of antimicrobial resistance, other complex political,
social, economic and biomedical factors are equally important. Tackling the hazard therefore
should go beyond the conventional sensitization of members of the public and occasional press
releases to include a multi-sectoral intervention involving the formation of various alliances and
partnerships. Involving civil society organisations like the media could greatly enhance the
success of the interventions.

4. It is difficult to determine the worldwide prevalence of antimicrobial resistance (AMR); but
several reports suggest that it is an increasing problem of phenomenal proportions, affecting both
rich and poor countries [1-8]
. In 2007, the prevalence of Methicillin-resistant Staphylococcus
aureus (MRSA) ranged from 27.4 to 62.4% and Penicillin-nonsusceptible Streptococcus
pneumoniae from 23.3% to 54.5% in the different census regions of the United States [1]
. In the
UK, enterobacteriacea resistance to cephalosporins is on the increase [2]
, as is the prevalence of
MRSA[3]
in hospital and community settings. The recent report of the European Antimicrobial
Resistance Surveillance System showed a rising prevalence of resistance among the seven
bacterial species (Streptococcus pneumoniae, Staphylococcus aureus, Escherichia coli,
Enterococcus faecalis, Enterococcus faecium, Klebsiella pneumoniae and Pseudomonas
aeruginosa) that serve as indicators for the development of antimicrobial resistance in Europe to
many of the mainline antibiotics [4]
. In India, up to 80% of S. aureus strains are resistant to
penicillin and ampicillin[5]
. Of 3362 pneumococcal isolates collected from 69 centres in 25
countries in the PROTEKT (Prospective Resistant Organism Tracking and Epidemiology for the
Ketolide Telithromycin) study between 1999 and 2000, resistance to Penicillin G was 53.4% in
Asia (overall prevalence), France 46.2%, Spain 42.1% and North Korea 71.5%; resistance to
erythromycin varied from 4.7% in Sweden to 87.6% in South Korea; while resistance to
fluoroquinolones in Hong Kong was 14.3% [6]
. And in South Africa, macrolide resistance and
penicillin non-susceptibility were 54% and 74% respectively [7]
. Chloroquine is almost useless as
an antimalarial in most malaria endemic countries, while MDR-TB and XDR-TB are now
assuming frightening proportions [9]
. While AMR is a growing global problem, like most
epidemics, the greatest toll is usually in the less developed countries. Unfortunately, the rate at

5. which antimicrobial resistance is developing far outstrips the rate at which new antimicrobials
are being discovered, placing humanity on a very dangerous precipice.
According to WHO (February 2011):
 Infections caused by resistant microorganisms often fail to respond to conventional
treatment, resulting in prolonged illness and greater risk of death.
 About 440 000 new cases of multidrug-resistant tuberculosis (MDR-TB) emerge
annually, causing at least 150 000 deaths.
 Resistance to earlier generation antimalarial medicines such as chloroquine and
sulfadoxine-pyrimethamine is widespread in most malaria-endemic countries.
 A high percentage of hospital-acquired infections are caused by highly resistant bacteria
such as methicillin-resistant Staphylococcus aureus (MRSA).
 Inappropriate and irrational use of antimicrobial medicines provides favourable
conditions for resistant microorganisms to emerge, spread and persist.
Antimicrobial resistance is a global concern because:
 AMR kills
Infections caused by resistant microorganisms often fail to respond to the standard treatment,
resulting in prolonged illness and greater risk of death.
 AMR hampers the control of infectious diseases
AMR reduces the effectiveness of treatment because patients remain infectious for longer, thus
potentially spreading resistant microorganisms to others.
 AMR threatens a return to the pre-antibiotic era
Many infectious diseases risk becoming uncontrollable and could derail the progress made
towards reaching the targets of the health-related United Nations Millennium Development
Goals set for 2015.

6.  AMR increases the costs of health care
When infections become resistant to first-line medicines, more expensive therapies must be used.
The longer duration of illness and treatment, often in hospitals, increases health-care costs and
the financial burden to families and societies.
 AMR jeopardizes health-care gains to society
The achievements of modern medicine are put at risk by AMR. Without effective antimicrobials
for care and prevention of infections, the success of treatments such as organ transplantation,
cancer chemotherapy and major surgery would be compromised.
 AMR threatens health security, and damages trade and economies
The growth of global trade and travel allows resistant microorganisms to be spread rapidly to
distant countries and continents. [10]
Inappropriate and irrational use of medicines provides favorable conditions for resistant
microorganisms to emerge and spread. For example, when patients do not take the full course of
a prescribed antimicrobial or when poor quality antimicrobials are used, resistant
microorganisms can emerge and spread.
Underlying factors that drive AMR include:
 inadequate national commitment to a comprehensive and coordinated response, ill-
defined accountability and insufficient engagement of communities;
 weak or absent surveillance and monitoring systems;
 inadequate systems to ensure quality and uninterrupted supply of medicines
 inappropriate and irrational use of medicines, including in animal husbandry:
 poor infection prevention and control practices;
 Depleted arsenals of diagnostics, medicines and vaccines as well as insufficient research
and development on new products. [10]

7. Research question:
What are the risk factors for Antimicrobial resistance (AMR) in developing countries?
The research will look into the following to arrive at a sound conclusion:
 What are the socio- demographic factors associated with higher Antimicrobial resistance
(AMR) in developing countries?
 Why developing countries are vulnerable for Antimicrobial resistance?
 The role of poverty in antimicrobial resistance
 Burden of Antimicrobial Resistance.
.

8. Literature review:
Antimicrobial resistance (AMR) is an important public health concern shared by developed and
developing countries. In developing countries the burden of infectious diseases is greater and
exacerbated by limited access to, and availability and affordability of, antimicrobials required
treating infections caused by AMR organisms. With drugs not listed on the essential drugs list
(EDL), problems of increased morbidity, costs of extended hospitalization and mortality are
extremely serious. The problem of susceptibility to and spread of infections caused by multidrug-
resistant (MDR) infectious agents is fuelled by factors such as limited access to clean water and
sanitation to ensure personal hygiene, malnutrition, and the HIV/TB epidemic. [12]
In 1990, an estimated 78% of the world's total population lived in the developing world. Of the
39.5 million deaths in the developing world, 9.2 million were estimated to have been caused by
infectious and parasitic diseases. 98% of child mortality occurs in the developing world, due
mainly to infections. Based upon information gathered through searches of the Medline and Bath
Information and Data Services computerized databases, discussions with colleagues, and
personal experiences, the authors consider the progress and impact of bacterial resistance to
antimicrobial drugs in the developing world. While antibiotics are important in developing
countries, they are often scarce commodities which are affordable and therefore available to only
the comparatively wealthy. Because the use of antibiotics is unregulated in many developing
countries, antibiotics are often misused and overused. Such use has provoked the development of
infectious agents which are resistant to antimicrobial drugs, such as strains of pneumococcal
meningitis, tuberculosis, and typhoid fever. Levels of morbidity and mortality are increasing as a
result. Better access to diagnostic laboratories is needed, as well as improved surveillance of the

9. emergence of resistance, better regulation of antibiotics' use, and better education of the public,
physicians, and veterinarians in the appropriate use of drugs. [11]
According to WHO facts on antimicrobial resistance (February 2011):
About 440 000 new cases of multidrug-resistant tuberculosis (MDR-TB) emerge annually,
causing at least 150 000 deaths. Extensively drug-resistant tuberculosis (XDR-TB) has been
reported in 64 countries to date.
Resistance to earlier generation antimalarial medicines such as chloroquine and sulfadoxine-
pyrimethamine is widespread in most malaria-endemic countries. Falciparum malaria parasites
resistant to artemisinins are emerging in South-East Asia; infections show delayed clearance
after the start of treatment (indicating resistance).
A high percentage of hospital-acquired infections are caused by highly resistant bacteria such as
methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococci.
Resistance is an emerging concern for treatment of HIV infection, following the rapid expansion
in access to antiretroviral medicines in recent years; national surveys are underway to detect and
monitor resistance.
Ciprofloxacin is the only antibiotic currently recommended by WHO for the management of
bloody diarrhoea due to Shigella organisms, now that widespread resistance has developed to
other previously effective antibiotics. But rapidly increasing prevalence of resistance to
ciprofloxacin is reducing the options for safe and efficacious treatment of shigellosis, particularly
for children. New antibiotics suitable for oral use are badly needed.

10. AMR has become a serious problem for treatment of gonorrhoea (caused by Neisseria
gonorrhoeae), involving even "last-line" oral cephalosporins, and is increasing in prevalence
worldwide. Untreatable gonococcal infections would result in increased rates of illness and
death, thus reversing the gains made in the control of this sexually transmitted infection.
New resistance mechanisms, such as the beta-lactamase NDM-1, have emerged among several
gram-negative bacilli. This can render powerful antibiotics, which are often the last defence
against multi-resistant strains of bacteria, ineffective. [10]
Figure. A simplified ARCS diagram showing the close relationship between antimicrobial
resistance containment, disease control and antimicrobial resistance surveillance. [48]

11. Global Situation of AMR
 Pathogens causing TB, malaria, sexually transmitted infections, typhoid, bacterial
dysentery, and pneumonia are now resistant or multidrug-resistant (MDR).
 Up to 17% of TB is MDR. And, extensively drug-resistant (XDR) TB is now being
recorded in countries worldwide.
 In 81 of 92 malaria-prevalent countries, chloroquine is no longer effective. [13]
 Salmonella typhi
 Multidrug resistance emerged as a public health problem in Asia.
 Shigella
 Resistance to ampicillin, tetracycline, co-trimoxazole, and chloramphenicol is
widespread in Africa.
 Up to 90% resistance to ampicillin and co-trimoxazole has been found in parts of
Asia.
 Resistance is emerging to fluoroquinolones, the only available option to left for
treatment.
 Vibrio cholera
 Up to 90% of isolates are resistant to at least one antibiotic. [15]
 Streptococcus pneumonia
 Penicillin and erythromycin resistance is an emerging problem in community
acquired pneumonia in Asia, Mexico, Argentina, Brazil, Kenya, and Uganda.
 MDR (penicillin + two other classes) in Africa is 25%; in the Far East, 63%; in
the Middle East, 18%; in Latin America, 20%; in eastern Europe, 12%; in western
Europe, 18%; and in the United States, 26%. [15]

12.  Widespread resistance to penicillin and tetracycline resulted in replacement with more
expensive first-line medicine. Penicillin resistance ranges from 9 to 90% across Asia and
is over 35% in sub-Saharan Africa and the Caribbean.
 Replacement medicines also developed resistant problems, azithromycin resistance was
found in 16%–72% in the Caribbean and South America and quinolone resistance is
commonly reported in Asia and Africa.
 The only option remaining may be a very expensive third-generation cephalosporin. [14]
The Burden of Resistance
For most diseases, the burden of the illness consists entirely of treatment costs, morbidity and
mortality among the ill, and the costs of public prevention efforts. Infectious diseases are
different. Because they often are communicable, fear of contagion may induce even uninfected
individuals (and their physicians) to alter their behavior [31]
. The financial and psychological
costs associated with these behavioral changes add to the burden of infectious diseases. Philipson
and Posner [32
] argue that in the case of AIDS, for example, some individuals living in areas with
a high prevalence of infection will avoid risky sexual activities
Use of an antibiotic in a disease outbreak or in an individual infection is often commenced
before the diagnosis is confirmed and almost always before the susceptibility pattern to the
pathogen can be fully ascertained. To choose an antibiotic, the important consideration is the
level of resistance to that antibiotic.[41]
On the contrary, irrational prescribing, dispensing
and consumption of medicines remain widespread, especially in the private sectors, despite
having so many efforts. Such irrational use can also be a major source of impoverishment

13. for poor populations as well as a hazard to health. It is particularly a serious public
health problem in developing countries (like Bangladesh) where between 50-90% of drug
purchases are made in the private sector without any prescription. Therefore, selling of
antibiotics has become an unauthorized right of the druggists that has been silently creating
devastating nature of bacterial drug resistance. [42]
Bangladesh. Pattern of resistance in E. coli was as follows: resistance towards ampicillin,
cephradine, nalidixic acid, co-trimoxazole, ciprofloxacin and ceftriaxone were 84.6%, 64.1%,
62.6%, 51.5%, 37.8% and 19.6% respectively. Whereas, 69.9% and 66.6% of strains were
sensitive to gentamicin and nitrofurantoin, respectively. Though resistance to ceftriaxone
was the lowest (19.6%) but 36.4% trains were intermediate. In addition, over 50% strains
appeared to be resistant towards combination of at least 2antibiotics.[43]
In another report from the same settings, it was found that above 85% and 23% isolates of
S. aureus showed resistance to penicillin and oxacillin, respectively indicating existence of
methicillin-resistant S. aureus (MRSA).5 More than 32% isolates appeared as intermediate
towards erythromycin. Ciprofloxacin resistance was noticed in 15% isolates, whereas >75%
isolates were sensitive to gentamicin. Another study reported of having quite high percentage
of Pseudomonas strains sensitive towards ceftazidime (>71%), but over 30% strains
showed intermediate sensitive pattern against ceftriaxone and resistance to ciprofloxacin.
Sensitivity value towards gentamicin was good (>60%). [43]

14. The Role of Poverty in Antimicrobial Resistance
Antimicrobial resistance is a worldwide problem that has deleterious long-term effects as the
development of drug resistance outpaces the development of new drugs. Poverty has been cited
by the World Health Organization as a major force driving the development of antimicrobial
resistance. In developing countries, factors such as inadequate access to effective drugs,
unregulated dispensing and manufacture of antimicrobials, and truncated antimicrobial therapy
because of cost are contributing to the development of multidrug-resistant organisms. [16]
More than any other issue, poverty and inadequate access to drugs continue to be a major force
in the development of resistance. In many developing nations drugs are freely available – but
only to those who can afford them. This means that most patients are forced to resort to poor
quality counterfeit, or truncated treatment courses that invariably lead to more rapid selection of
resistant organisms. A patient infected with a resistant strain may endure prolonged illness (often
resulting in death) and hospital stays which in turn result in lost wages, lost productivity, family
hardship and increased infectiousness. Treatment with second and third-line drugs is costly, more
often toxic to the patient, and increasingly ineffective owing to the speed with which mutant
organisms develop resistance. In India, the past five years has seen 20% of typhoid isolates
become resistant to ciprofloxacin, a relatively recent and expensive third-line drug.[40]
In developing countries with high mortality, infectious diseases remain the main cause of
death.[20]
In 1990, an estimated 78% of the world's population lived in developing countries. In
those countries, 23% of deaths were attributable to infectious and parasitic disease.[21]

15. Resistant bacteria have emerged in these developing countries. In 1996, in Bangladesh, over 95%
of Shigella dysenteriae isolates were resistant to ampicillin, co-trimoxazole, and nalidixic acid,
and up to 40% were resistant to mecillinam.[22]
In Quetta, Pakistan, 69% of Salmonella typhi
isolated from blood were multidrug resistant.[23]
In tropical countries, there has been an
emergence of Streptococcus pneumoniae that is resistant to penicillin, cefotaxime, and
chloramphenicol.[24]
Neisseria gonorrhoeae has developed strains resistant to penicillin,
sulfonamides, tetracyclines, and fluoroquinolones.[25]
This problem of multidrug-resistant organisms in developing countries can also directly affect
and threaten more developed countries (such as the United States) because international travel,
driven by globalized trade, allows for easier dissemination of these strains. For example,
penicillin-resistant and multidrug-resistant pneumococci, like the serotype 23F clone, have been
found not only in Mexico, South Africa, South Korea, and Croatia, but also in Portugal, France,
and the United States.[26]
Reasons for multidrug-resistant organisms in developing countries are numerous, but the
inadequate access to effective drugs, the unregulated manufacture and dispensation of
antimicrobials, and the lack of money available to pay for appropriate, high-quality medications
are some of the major poverty-driven factors contributing to antimicrobial resistance.[17-19]
In some developing countries, regulation of the manufacture of antibiotics may not exist to any
extent that would assure the quality and potency of the medications. A 500-mg capsule of
ciprofloxacin that was acquired locally in Vietnam was analyzed and found to contain the
equivalent of only 20 mg of ciprofloxacin.[18]
Studies conducted in several other developing
countries have also demonstrated counterfeit drugs with few or no active ingredients.[19]

16. Many developing countries allow the dispensation of antibiotics without a prescription; this can
lead to self-medication and dispensation of drugs by untrained people. In one survey from the
Rajbari district of Bangladesh, 100,000 doses of antibiotics had been dispensed without a
prescription in 1 month.[27]
In another study from Bangladesh, 92% of medications dispensed by
pharmacies were dispensed without a prescription.[28]
In Manila, Philippines, a survey of
drugstores showed that 66% of antibiotic purchases were made without a prescription.[29]
The
ease of obtaining an antibiotic without a prescription was directly experienced by this author,
who was able to purchase antimicrobials without a prescription from local pharmacies in both
Lahore, Pakistan and Iquitos, Peru.
Comparison of resistance pattern of E. coli in different years shows gradual increase in
resistance against almost all the antibiotics except imipenem (2% in 2001 and 1% in
2003) and pefloxacin (40% in 2001 and 17% in 2003). Mentionable increase was noted against
ceftazidime (47% in 2001 and 77% in 2003) and ceftriaxone (43% in 2001 and 71% in
2003). (Table I) [44]
.
Data are collected from Aerobic culture and sensitivity tests were done in the department of
Microbiology, Mymensingh Medical College (MMC) including specimens sent from
outpatient (OPD) and inpatient department (IPD) of the same Medical College Hospital, during
the period from April' 2001 to December' 2003.

17. Comparison of resistance pattern of S. aureus in different years shows gradual increase in
resistance against almost all the antibiotics except co-trimoxazole, where it was found to be
55% in 2001 and 57% in 2003. Mentionable increase was noted against ciprofloxacin (17% in
2001 and 43% in 2003) and ceftriaxone (28% in 2001 and 83% in 2003). Although,
oxacillin resistance increased from 22% in 2001 to 42% in 2003, but no resistance against
vancomycin was noted in any year. (Table II)

18. Resistance pattern of Pseudomonas species in different years shows gradual increase against
almost all the antibiotics except carbenicillin (92% in 2001 to 50% in 2003). Resistance
of mentionable increased from 2001 to 2003 as noted against ciprofloxacin (47% to 71%),
ceftriaxone (50% to 74%) and ceftazidime (39% to 58%). None of the strains showed
resistance against imipenem. (Table III)

19. [44]
Poverty-stricken patients may forgo the cost of a physician consultation and self-medicate.[19]
They may be more likely to purchase the least expensive (and possibly least potent drug) under
the assumption that they were all bioequivalent. Furthermore, these people may only complete a
truncated course of therapy because of their inability to pay for the full course of medications.[29]
Such inappropriate use of antibiotics for inadequate periods of time can exert strong selective
pressures on bacterial populations and can contribute to resistance.
A cross-sectional survey was conducted between Mayto July 2007 to identify commonly used
antimicrobials especially cefuroxime sensitivity and/or resistance in respiratory tract pathogens
in Bangladesh.

20. RESULTS
As shown in Table IV, a total of 384 clinically suspected cases of upper respiratory tract
infections, among them only 383 throat swab samples were considered for final analysis. Mean
age of the patients was 23 years and half of them were children and others were teenagers and
adults. Among all the samples, one among every four cases showed growth of any pathogenic
bacteria in culture and sensitivity test.
Table IV: Distribution of bacterial growth among all participants. Cross sectional study, Dhaka,
Bangladesh
According to the report of culture and sensitivity test, the isolated pathogens in the aggregates
were β hemolytic streptococci (28.7%), Klebsiella pneumoniae (28.7%), Staphylococci (25.7%),
Pseudomonas (4%), E. coli (2%), Pneumococcus (2%) (Table V).
Among the commonly used antimicrobials in URTI, sensitivity profiles were observed with
amoxycillin (7.9%), penicillin (33.7%), ampicillin (36.6%), co-trimoxazole (46.5%),
azithromycin (53.5%), erythromycin (57.4%), cephalexin (69.3%), gentamycin (78.2%),
ciprofloxacin (80.2%), cephradine (81.2%), levofloxacin (86.2%), ceftazidime (93.1%),
ceftriaxone (93.1%). Sensitivity to cefuroxime was reported in 93.1% cases. However,
antimicrobial resistance was observed most against amoxycillin (90.1%). Resistance to others

21. was as follows, penicillin (61.4%), ampicillin (64.1%), co-trimoxazole (43.6%), erythromycin
(39.6%), and azithromycin (34.7%) (Table VI).
Table V: Bacterial isolates in culture
Table VI: Commonly used antimicrobial sensitivity and resistance status in URTI. Cross
sectional study, Dhaka, Bangladesh

22. Among 383 reports, 101 (26.3%) were growth positive, while 282 (73.4%) did not show any
growth of pathogenic bacteria. Of the respondents, about 93.1% cases reported sensitivity to
cefuroxime (Figure 1). [19]
Mal. J. Microbiol. Vol 5(2) 2009, pp. 109-112

23. Scenario in Africa and Asia
 Antibiotic resistance is particularly important in developing countries
 There are similarities and differences in developing countries
Similarities:
 High serious infectious disease burden
 Erratic access to effective antibiotics
 No local guidelines for antibiotic use (or not followed)
 Weak antibiotics policies
Differences:

24. The major barrier in recognition of antibiotic resistance as a serious global public health threat
sub-Saharan Africa and Southeast Asia continents is…
 The lack of comprehensive burden data that illustrates not only the true prevalence of
resistant infections and their impact on health outcomes, but also the associated economic
costs.[46]
The WHO has identified antibiotic resistance as one of the major emerging public health
problems and established monitoring system in different countries. The figure and tables that
given bellow will represent the fats about antimicrobial resistance. This tables and figures are
collected from different journals research papers.
Figure 2. Patterns of antimicro-bial resistance in Shigella species atthe rural diarrhea treatment
center in Matlab, Bangladesh, 1987-1992.Antimicrobials (ampicillin = I; tri-methoprim
sulfamethoxazole = ;nalidixic acid = q; and pivmecilli-nam = M) were tested by the disk
diffusion method.[47]

25. Figure 3: Patterns of antimicrobial resistance in Shigella dysenter-iae type 1 at rural (Matlab; ■)
and urban (Dhaka; q) diarrhea treatment centers in Bangladesh during 1993. The differences in
pivmecil-linam susceptibilities were statistically significant (P < .001). TMP-SMZ =
trimethoprim sulfamethoxazole. [47]
Figure 4. Patterns of antimicrobial resistance in Shigella flexneriat rural (Matlab; MI) and urban
(Dhaka; q) diarrhea treatment centers in Bangladesh during 1993.TMP-SMZ = trimethoprim-
sulfamethox-azole. [47]

26. Table VII. HIV Resistance to any Antiretroviral by Region [49]
Figure 5. The median percentage of clinical failure rates of chloroquine for several East, Central,
and Southern Africa Region countries (represents the median of the rates indicated by different
studies.[50]

27. Figure 6. Trends in Resistance of H. influenzae to Several Antibiotics at a Hospital in Kilifi,
Kenya. [51]
Table VIII. Global AMR Rates for Diseases of Major Public Health Importance. [52]

28. Table IX: Antimicrobial resistance in Vibrio cholerae isolated at the ICDDR,B laboratory in
Dhaka, Bangladesh, 1991-1993.[47]
Findings:
In many developing countries the use of antimicrobial drugs for treating people and animals is
unregulated; antibiotics can be purchased in pharmacies, general stores, and even market stalls.
In the Rajbari district of Bangladesh, a survey of rural medical practitioners (barefoot doctors)
with an average of 11 years' experience showed that they each saw on average 380 patients per
month and prescribed antibiotics to 60% of these patients on the basis of symptoms alone.[30]
In
one month 14 950 patients were prescribed antibiotics—a total of 291 500 doses. Only 109 500
doses had been dispensed by pharmacies, and a further 100 000 doses had been dispensed
without a prescription.[30]
Thus there is widespread and uncontrolled use of antibiotics, and patients often do not take a full
course of treatment if they are unable to afford it. Another problem in developing countries is the
quality and potency of antimicrobial drugs. In some countries many different antimicrobial drugs
are produced locally. In India, for example, there are over 80 different brands of the

29. fluoroquinolone ciprofloxacin. In Vietnam a locally acquired 500 mg capsule of ciprofloxacin
costs 400 dong (about 2 pence). The average weight of the capsules is 405 mg with a potency
equivalent to 20 mg of pure ciprofloxacin (J Wain, personal communication)
Inappropriate and irrational use of medicines provides favorable conditions for resistant
microorganisms to emerge and spread. For example, when patients do not take the full course of
a prescribed antimicrobial or when poor quality antimicrobials are used, resistant
microorganisms can emerge and spread.
Poor prescribing practices by Health Professionals
Unnecessary prescription of antibiotics has been documented in many developing countries and
in Bangladesh as well. This is due to poor clinical judgment, lack of updated standard treatment
guidelines or in-service training. In the end, scarce essential antibiotics are wasted on wrong
patients thereby misusing the meager resources and facilitating development of AMR.
Use of antimicrobials in growth promotion
In some communities, poultry farmers use antimicrobials (even antiretroviral drugs) to enhance
chicken growth (verbal information). Resistant bacteria of animal origin have been detected in
humans, making treatment difficult.
Poor quality antimicrobials
Developing countries is threatened with the influx of poor quality antimicrobials which contain
little or none of the active ingredients needed for treatment. Lack of appropriate laboratory
facilities to test the quality and quantity of drugs, limited financial resources to procure good
quality antimicrobials from reputable firms, poor pharmaceutical procurement practices and

30. weak regulation of drug production, imports and sales have contributed to the massive presence
of substandard antimicrobials. The move made by Pharmacy, Medicine and Poisons Board in
developing countries on drug donation policy and importation will assist in reducing influx and
flushing out poor quality drugs.
Poor Infection Control Practices
Improper practices and non compliance to infection control are commonly seen in most health
facilities in Malawi. This result in spread of resistant microbes among patients and to health
professionals. Promotion and compliance to simple practices such as hand washing, contact
control, disinfection of surface, and isolation of infectious patients are essential in controlling
resistant microbes.
Poor Laboratory Infrastructure
Lack of well established laboratory facilities in developing countries and skilled trained
technicians have led to development of experimental, problem-oriented management strategies
for administering antimicrobials. This has contributed to over prescribing of antimicrobials for
prophylaxis which has contributed to the emergence of AMR Proper lab infrastructure is critical
in diagnosis and treatment of common microbial infections.
Lack of Research activities and Surveillance of AMR
Surveillance is necessary to detect, monitor and document emergence of any AMR in any
locality. This will help in putting in place measures for containment. Findings from studies on
AMR would go a long way to improve care and contain further spread of resistant microbes. [39]

31. Conclusion
At present, and as a closing example, of the $60 billion (US) spent worldwide annually on health
research by both the public and private sectors, only approximately 10% is devoted to issues that
represent 90% of the world’s health problems. This so-called 10-90 gap has direct consequences
in the poorer populations, where antimicrobial resistance may become a more severe problem. [53]
It has been seen from the study that developing countries are vulnerable for resistant to
antibiotics. Many bacteria (for example, Chlamydia trachoma is and Streptococcus pyogenes)
remain predictably sensitive to routinely available antimicrobial drugs. AMR is of global
concern and some of the issues and solutions that we mention may be significance for
developing countries. But the fact is that, developing countries are suffering most about the bad
impact of antimicrobial resistance because of lack of knowledge, education and overall lack of
proper guidelines of government and non government organizations. Developing countries
should develop protocols like- restriction of dispensing antimicrobials; promote community-wide
education about the responsible use of antibiotics to minimize the risk of antimicrobial
resistance. So maintaining the useful life of antibiotics is relevant in all countries and for all
peoples.

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