Italy, over 33,000 deaths caused by antibiotic resistance in one year: war figures
Antibiotic resistance, for the WHO is the battle of the present and the future. In Italy the scenario is tragic and requires changes in strategy
“The European Centre for Disease Prevention and Control (ECDC) estimated that in 2020 over 600,000 people had serious infections related to multi-resistant bacteria and that there were over 33,000 deaths.
These are war figures’.
Luisa Galli, secretary of the Pharmacology Study Group of the Italian Society of Paediatrics (Sip), associate professor of Paediatrics at the Department of Health Sciences of the University of Florence and director of the Complex Departmental Structure of Paediatric Infectious Diseases of the Meyer Paediatric Hospital, starts from this point to introduce the theme of antibiotic resistance, a topic she will address during the 77th Italian Congress of Paediatrics scheduled in Sorrento from 18 to 21 May.
“Estimates also tell us that 2020 was a special year,” Galli continues, “because due to lockdown and reduced socialisation there was less spread of infections, so we used fewer antibiotics in all age groups, including the paediatric one.
The numbers therefore, although high, are underestimated’.
ANTIBIOTIC RESISTANCE: FEWER WEAPONS TO FIGHT INFECTIONS
In this context, Italy ‘does not rank well’, continues the expert, ‘we are really badly off both in terms of antibiotic use and bacterial resistance.
The sad record concerns certain bacteria such as multi-resistant Klebsielle and methicillin-resistant Staphylococci.
Also widespread are Escherichia coli, producers of extended-spectrum beta-lactamases, whose production of these enzymes nullifies the use of all beta-lactams, among the most widely used antibiotics, especially in paediatric age’.
The problem ‘is that we have so many antibiotics available but then there are so few left to use,’ explains Galli, ‘and so we have fewer and fewer weapons to fight infections.
Certainly,’ he says, ‘new antibiotic molecules are being developed but sometimes they are not sufficient to bypass the onset of resistance and, above all, some ‘new’ antibiotics are not yet authorised for paediatric age.
This leads to an increase in hospitalisations, hospital stays and deaths due precisely to antibiotic resistance’.
THE SITUATION IN PAEDIATRIC AGE WITH REGARD TO ANTIBIOTIC RESISTANCE
A picture in which paediatrics plays an important role.
“All the data tell us that antibiotics are prescribed more in the most extreme ages, i.e. to children and the elderly,’ Galli continues. ‘As far as the paediatric age is concerned, we know that at the moment of socialisation, i.e. from 2 to 6 years of age, when they start living in the community, children get recurrent respiratory infections that are physiological, many of them viral.
Despite this, antibiotics are prescribed, which should not be done, or at any rate, with regard to pharyngo-tonsillitis, otitis, and other upper respiratory tract infections for example, should be done according to national and international guidelines, choosing narrow-spectrum antibiotics.
But the numbers say otherwise, just think that in 2019, 40 per cent of the paediatric population under 13 was prescribed an antibiotic, a percentage that dropped to 26 per cent in 2020 precisely because children had fewer opportunities for socialisation and therefore had fewer respiratory infections’.
“If we think, for example, of the macrolide class of antibiotics, widely used in paediatric settings, we see how it has been burdened by a large percentage of multi-resistant bacteria.
Molecules such as azithromycin, which is convenient for children because it provides only one dose a day for three days, or clarithromycin, which is very well tolerated, are good antibiotics, but their abuse has meant that a high proportion of Gram-positive capsulated bacteria (streptococci, staphylococci and pneumococci) have become largely resistant to this class of antibiotics.
The numbers speak for themselves: in Italy between 2010 and 2020, more than 40 per cent of Gram-positive capsulated bacteria turned out to be resistant to macrolides,’ the paediatrician points out. Fortunately, the decreased use of macrolides has brought down the percentage of macrolide-resistant Gram-positive bacteria, proving once again that by decreasing the abuse of certain antibiotics, resistance also decreases.
ANTIBIOTIC: UNDERDOSING ALSO INDUCES RESISTANCE
The way forward? ‘Making more judicious use of antibiotics and avoiding the most common mistakes,’ says Galli, ‘both by doctors and families. First of all, it is essential to prescribe the drug only when needed.
Parents, for their part, must avoid using the antibiotic they have in their drawer as soon as the child has a fever because they are afraid that there might be a complication or they want the illness to resolve quickly.
If the infections are viral and not bacterial you have to give them time to regress’.
Then it is important to give the right molecule.
‘In Italy, for example, we have always made too much use of protected amoxicillin, so conjugated with clavulanic acid.
But the guidelines tell us that in the case of pharyngotonsillitis, the bacterium is streptococcus, amoxicillin alone works very well, without the need for clavulanic acid,’ Galli points out.
Just as important is the dosage, which must be neither too high nor too low.
“Underdosing also induces resistance,’ explains Galli. ‘Parents, for example, sometimes find it difficult to give the drug three times a day, so they only give it twice, but giving less drug than prescribed causes the bacteria to reproduce in the meantime, and this ultimately encourages therapeutic failure and the emergence of antibiotic resistance.
Finally, the duration.
‘We know that certain infections should not be treated for too long, so it is pointless to continue with antibiotics for 7-10 days of therapy if 5 days are enough’.
THE IMPORTANCE OF VACCINES
All this means ‘that training must be given to both paediatricians and parents, with different methodologies.
Among doctors, the knowledge of the guidelines must be spread because they give awareness and safety.
The problem,’ observes Galli, ‘is that we doctors can sometimes have defensive medicine attitudes, because we know that the medical class in Italy has often been the target of complaints and claims, and so a defensive attitude means that we prescribe antibiotics once more than we need.
But if we have the protection of having done what the guidelines recommend, we are certainly calmer.
On the family side, on the other hand, it is important to trust what the paediatrician says, be patient and wait for the infection to pass, in its own time’.
In the fight against antibiotic resistance, there is also the important role played by vaccines.
‘We have seen this clearly with pneumococcus,’ recalls Galli, ‘we know that it is the causative agent of many infections of the airways, both high and low, and has always been the main aetiological agent of pneumonia in paediatric age.
But since the existence of vaccines, and in particular since the switch from heptavalent to the vaccine against 13 serotypes, there has clearly been a decrease in infections, especially serious and invasive ones, caused by pneumococcal serotypes with reduced susceptibility to several classes of antibiotics.
And then,’ concludes the expert, ‘there is the indirect action of the vaccines, which, by limiting the spread of bacterial infections, decrease the consumption of antibiotics.