Antimicrobial resistance is undoubtedly a major public health concern, but it can be easy to overlook the much larger crisis (at present) of unnecessary deaths worldwide due to inadequate access to these drugs (WHO Bulletin). 700,000 children under 5 die each year from pneumonia, sepsis and meningitis. While data are not complete, most of these infections appear to be susceptible to many existing antibiotics. Hundreds of thousands of children are dying for lack of inexpensive generic antibiotics, the same ones that are $4 at Walmart. Key barriers include the cost of bringing your child to a hospital in low-income settings, the difficulties in training community health workers to give injectable drugs, as well as the cost of the drugs themselves. Could there be better ways to get antibiotics to these children?
The Gates Foundation has funded a remarkable series of very practical studies (the African Neonatal Sepsis Trial, also sponsored by WHO), two of which were published in The Lancet this week. The studies identify sick infants in the community (in 5 locations in Africa) and refer to the local hospital when appropriate. But many parents refuse that referral on financial grounds. From this population, the studies randomize treatment with two sets of antibiotics, given in the community setting. One is typically the injectable antibiotic that would have likely been given in hospital; the other is the oral antibiotic amoxicillin. The study question is whether the treatments are equivalent. This matters because oral antibiotics can be given more easily in the community, with less well trained workers.
The first study compared oral amoxicillin (twice a day for seven days) with injectable procaine benzylpenicillin plus gentamicin (once a day for seven days) in children suspected of pneumonia (with very simple protocols). The second study looked at other serious bacterial infections, comparing the same injectable antibiotics with three other options that included oral amoxicillin replacing some of the injections.
Both studies concluded that all of the tested regimes were equivalent. Switching to oral amoxicillin can therefore be expected to save many children in low-income settings where referral to hospital is not possible and use of injectable antibiotics in the community is not feasible.
My bottom line: we should do everything possible to preserve oral amoxicillin for these populations. But resistance to beta-lactams is growing, and the drugs are not being preserved for the best human uses: amoxicillin is routinely prescribed in the US for otitis media (ear ache), which is largely self-resolving. And on US farms, more than 800,000 kgs of drugs in this class were given to animals in 2013 (the last year data is available).
Yet another reason for a comprehensive reform of how we create and use antibiotics (see the Administration’s plan here).