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Antimicrobial resistance is a huge burden in Nepal, particularly in hospitals where many nosocomial infections are caused by resistant pathogens. With limited resources, little infection controls and proper guidelines in place, finding out the main risk factors helps reduce infection rates within a hospital and better target vaccination campaigns.

My name is Abhilasha Karkey, I am a medical microbiologist by training and I work at the Oxford Research Unit based in Nepal in Kathmandu.

In Nepal we have a lot of burden of infectious diseases like typhoid, TB, pneumonia etc. The increase in antimicrobial resistance in these infections has been a huge burden on an already very poor health care system. My research in Nepal focuses on looking at how these infections are spread particularly in hospital settings and finding out about what we call nosocomial infections.  If you look at hospital settings, it’s very complex: you have people who already carry resistant bacteria, and then you have people who are very weak because of various reasons. Because it’s a very resource limited hospital, we don’t have infection controls and proper guidelines in place. There’s a lot of infection, people come in to treat, say, a simple cold, but then they pick up a resistant infection when they’re weak, and then that develops into a resistant infection that you can’t treat any more, or you treat with very expensive medicine which the local population can’t afford.

In developed countries, about 7% of all infections in hospitals are from resistant pathogens, and they say about 10% in developing countries are from resistant pathogens. But in my hospital, from our data we see that about 40% of all infections that happen in the hospital are with resistant pathogens, and in those 40% more than half have been hospital acquired. We see a huge burden of that, it’s almost more than 25% of all positive infections that we see.

I started working on antimicrobial resistance 15 years ago and when I started I used to say this will become a big problem. That’s what everyone used to say, if we’re not careful it will be a big problem. Two weeks ago I attended a conference and I reported 700,000 people died because of resistant pathogens. According to WHO at the rate that it’s going will go up to 10 million by 2050, and that means more people will die of resistant pathogen infections than what cancer kills today.

Because it’s such a multifaceted problem, there’s lots going on. Something that got my attention was the discovery of what they call a patch: you don’t need to take the medicines orally, like you do with most of the antibiotics you take now, you just put it on and it goes directly into the bloodstream. How that helps resistance is the antibiotic does not go to the gut where, we think, because there are a lot of bacteria there that gives rise to resistance. The whole idea is that you wear the patch, it goes directly into the blood and you somehow delay resistance developing in an individual.

The hospital lacks resources, there’s absolutely limited resources. In our research, I take a particular population in a hospital, for example I do one study just with the neonates, just with the paediatric group, I find out the main risk factors for them, then inform the hospitals. If I give them the top two risk factors, then they will use their infection control just for those top two and that will bring down the infection rate in the hospital. We’ve been doing this with neonates, with adult ICU (intensive care unit), the wards in the hospital that are most affected by resistant pathogens. For Nepal it’s a huge problem because 70% of revenues for Nepal comes from tourism, and travellers play a huge role in spreading infectious diseases and resistance as well, so controlling it locally actually helps the global picture a lot.

In Kathmandu for the last 13 years we’ve done a lot of studies on typhoid fever which is very endemic and a lot of people die because of complications from typhoid. Recently we’ve had a lot of increase in the resistance for typhoid which is very worrying because from every 5 patients that come in to the hospital, 4 of them have typhoid fever, which is a huge burden. One of the things our study has shown, because we saw resistance rising up so quickly, is we got in touch with the IVG group (the Oxford Vaccine Group) and they have started massive vaccination campaigns. Our study has been able to show which population to target, and I think that shows a very nice collaboration of how we can do research and it goes on to intervention, and the number of typhoid cases has gone down in the last year I’m happy to say.

Abhilasha Karkey

Dr Abhilasha Karkey is a medical microbiologist at OUCRU-Nepal. She is involved with infectious disease research projects including enteric fever, central nervous system infections, hepatitis E, tuberculosis, and antibiotic resistance. She looks at nosocomial infections and antibiotic resistance patterns within the population, as well as molecular epidemiology of enteric fever in Kathmandu.

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