When medicine fails: How antibiotic resistance nearly took Dr Kariuki's life

Dr John Kariuki, Veterinarian, antimicrobial resistance survivor. [Courtesy] On October 6, 2020, veterinarian Dr John Kariuki fell in his bathroom. It took one year of excruciating pain, surgeries and a myriad of drugs before healing. What almost ended him was not the fall but an unseen enemy known as the silent pandemic that refused to bow even to medicine: antimicrobial resistance. Antimicrobials are drugs that treat infections. Resistance occurs when the germs have become stronger than the drugs. The body becomes resistant if you use antibiotics too much or the wrong way, like not finishing the dose or taking them when you don't need them. After Dr Kariuki fell, he rested for three days, then decided to go to the hospital after experiencing excruciating pain. "It began with a misdiagnosis. When they took an X-ray, they were unable to identify the problem. Or rather they misdiagnosed because they gave me muscle relaxants and painkillers." Ten days later, when the pain did not subside, he went back to the hospital for a CT scan. That showed a complete fracture of the hip. The femur, the long bone of the leg, was completely separated from the pelvis. On November 18, 2020, he went for hip replacement surgery. However, he never recovered and his health deteriorated. "The antibiotics were not working. Three weeks later I was again hospitalised in ICU. They inserted a negative pressure therapy machine which was supposed to suck up all the effluents from the surgical sites. The infection was still going on despite the antibiotics I was taking," says Dr Kariuki. In January 2021, he was rushed to Kijabe Hospital. This was during the COVID period and, due to lack of bed space, he spent the night at a motel. "I remember that night, all the bandages, towels, sheets got soaked with the discharge from the surgical site. And the following morning the hospital told me the kidneys were almost failing. So they referred me back to Kenyatta National Hospital. Again, there was a problem of accommodation," he says. He spent the night in the corridors. There was a nurse who was giving him intravenous fluids. A day later he was taken to a high-dependency unit where he was stabilised. However, the infection was still on. He was then taken to the general ward, all the while taking a very high-powered antibiotic. He underwent another surgery to control the infection. "So this is now 1st of February. And I remember the orthopaedic surgeon said he had never removed dead tissue from a human body like the much he removed from me. And that was what was causing the illness. Then I continued to recuperate in the ward, but still the infection was not going away," he says. He got COVID while in hospital and he recovered in May. He went home in a wheelchair. After five weeks the wound had not got better. He went for a culture sensitivity test, a lab procedure that involves growing germs from a body sample to diagnose an infection and identify the most effective medicine to treat it. The results indicated that out of 18 antibiotics he was taking, only one was working. They administered one antibiotic. "Towards the end of October, I did another culture sensitivity testing. The infection was gone. By the beginning of November, while I was still doing physiotherapy, I had graduated from walking two metres using a walker, four-legged walker. And now I could begin walking with double crutches. That was a journey that took a year to recover." So, how did he become resistant to antibiotics? "I acquired the infection in the theatre. So this was what we call a hospital-acquired infection. When I had the fracture, I had no part of my body that was open. I didn't get a wound," says Dr Kariuki. "They are hardcore organisms that live in hospitals. Hospitals use a lot of antimicrobials every now and then, so there are some organisms that have become hardcore resistant." Medics are encouraged to do antimicrobial susceptibility testing before they administer antibiotics."What we missed in the beginning was antimicrobial susceptibility testing. If this was done early, I would not have gone into sickness. We would have administered the right drug at the right time," says Dr Kariuki. Prof Margaret Oluka, the antimicrobial use technical lead at the University of Nairobi, says the antimicrobial resistance (AMR) prevalence in the country is 44%. Following research that was done in the country, Ceftriaxone was position one, among the most commonly used antibiotics at 23%. "This is an antibiotic that should not be used commonly in our hospitals. Because according to WHO, it is in the group called WATCH antibiotic. It should be used for very serious infections." According to the World Health Organization (WHO), antibiotics are classified into three groups: Access, Watch and Reserve, taking into account the impact of different antibiotics and antibiotic classes on antimicrobial resistance, to emphasise the importance of their appropriate use. "We should be using more commonly antibiotics in the Access category, but we are unfortunately using an antibiotic that we should use for very serious infections. Already it is showing that about 70% resistance has developed from Ceftriaxone," says Prof Oluka. Another top 10 antibiotic is meropenem at position six. Meropenem is in the Reserve category. It should be used for very serious bacterial infections. "Therefore, we are going to work hard to generate or formulate interventions to address this anomaly. So another outcome that we also came across is the fact that most of the patients who are being treated with antibiotics, they were the neonates." Dr Loice Ombajo, Infectious Diseases Specialist, says globally, the trends of antimicrobial resistance (AMR) have been rising over time. These trends seem to be higher in resource-limited settings, for example: Southeast Asia, South American countries, and Sub-Saharan Africa. "But beyond having the highest rates of AMR, they're also the least equipped to manage AMR because managing AMR means, one, you're able to detect it, and to detect it, it means you need to have well-established laboratory systems." Dr Ombajo adds that once detected, it needs to be contained. Which means within hospitals, you must have the capacity to ensure that it doesn't spread from patient to patient. But then you also need to have the capacity to treat it, which means access to antibiotics that are not routinely available. According to WHO, antimicrobial resistance (AMR) would lead to 10 million deaths by the year 2050, with Africa accounting for 4.5 million if nothing is done to combat the silent pandemic. Over the years AMR has been referred to as the silent pandemic. However, Dr Ombajo says that it is no longer a silent pandemic. The reason AMR has been silent is because it is not detected enough. "So patients die in hospitals, and we don't know why they die. It's time that we now identified what is ailing us," says Dr Ombajo. Dr Ombajo talks about misdiagnosis and patients being told they have blood infections, while probably 60 to 70% are resistant to the common antibiotics used. So far, as a country, Kenya is able to know the level of resistance across healthcare facilities. Dr Emmanuel Tanui, National AMR Focal Point, says they are guided by a national action plan for prevention and containment of antimicrobial resistance, which identifies the things that need to be prioritised. "One of them is creating awareness across the communities, as well as professionals. Once people are aware about the level of resistance and the impact that it causes, then they can be able to start the journey of behaviour change. The other factor is reducing infections," says Dr Tanui. Are laboratories equipped? According to Dr Ali Kassim, Clinical Microbiologist, the Ministry of Health, through partnerships, has been able to equip a lot of microbiology facilities across the country. "Equipment that is able to detect, do blood cultures, detect the bacteria, and do the resistance patterns or the resistance testing of various antibiotics," he says. One Health Approach The One Health Approach means that people's health, animals' health, and the environment's health are all connected. If one gets sick or damaged, the others can be affected too. According to Dr Maurice Karani Murungi, a veterinarian and epidemiologist, when affected animals are treated with antibiotics, residues can remain in their meat if not well managed. When humans consume this, they ingest the antibiotics. "Over time, this exposure can contribute to the development of antibiotic resistance, as it may not be sufficient to kill bacteria found in humans completely, but would be enough to encourage bacteria to adapt and become resistant. This means that when humans become ill and use antibiotics to treat infections, they become less effective," he says.

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