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Srey Leak, a 29-year-old mother living in Phnom Penh, has a cold. Like many Cambodians, she goes to the nearest pharmacy depot in the area and asks for a "healing medicine", the generic term for Khmer antibiotics.
After a few minutes, a pharmacist delivers a colorful cocktail of pills in a small plastic bag - none of them can be identified because they are tablets taken out of their original packaging. All smiles, Srey Leak will pay two dollars without asking any details on the identity of drugs, without asking questions about possible side effects, or the duration of treatment.
This method of drug delivery is still quite common among pharmacy depots in Cambodia. But, it is also a dangerous practice. Largely because of the misuse of antibiotics, drug-resistant bacteria’s have become one of the biggest risks to public health in the world. And, Cambodia is not spared.
Antibiotics are essential tools for killing bacteria and have saved millions of lives since their introduction in the 1940s. But, misused, they can be at the origin of their own destruction. Bacteria exposed to small amounts of antibiotics often evolve to resist the mechanism of action of the drug, becoming more and more resistant.
This may be stimulated by taking the wrong antibiotic, not having a full course of treatment, or taking an antibiotic when it is not needed - for example, treating a common cold caused by a virus and not by a bacterium. These three practices are still prevalent in Cambodia.
The Kingdom was one of the first countries in the region to develop an antimicrobial resistance program. Guided by the World Health Organization, this program is comprehensive and includes a three-year implementation plan. But this has not always been applied in the field. A key component of the program was a 2016 directive directing pharmacists to stop dispensing antibiotics without a doctor's prescription.
Om Chhorvoin, a researcher and co-author of a paper in 2017 entitled "Generalized Antibiotic Abuse in the Cambodian Community," says that few pharmacists are aware of the ban. '' ... Today, we have regulations and laws, but they are not put into practice in real life ... '', writes Chhorvoin.
In fact, apart from large drugstore chains like Ucare Pharmacy and a few others who follow the government's guidelines to the letter, many other pharmacists say they are not constrained by official guidelines and even say they feel under pressure from the public.
"... Most of the clients who come here say that they mainly use this drug in other pharmacies and want to continue using it ...", says a pharmacist from Phnom Penh, adding that "... this puts the pressure on pharmacists ... "
Dr. Ly Sovann, a spokesperson for the Ministry of Health and Chair of the Ministry's Technical Working Group on Antimicrobial Resistance, says that the department has established its rules and that it is the responsibility of pharmacists to comply.
"... If our managers discover pharmacies that do not comply with our regulations, pharmacists will be liable to criminal penalties ...", he says. "... This includes the confiscation of their license ...", he concludes by stating that the public has the opportunity to denounce the issuance of antibiotics without prescriptions via the ministry's hotline.
According to the 2017 Chhorvoin document, antibiotics are widely distributed in urban and rural areas by everyone, from nurses to unofficial village doctors called "pett phum", who often have only piecemeal medical training going back to the time of the Khmer Rouge. Chhorvoin has discovered that these "pett phum" practitioners often dispense powerful antibiotics such as fluoroquinolones and cephalosporins for no good reason.
He met Cambodian villagers so familiar with antibiotics that they give nicknames to drugs: "pen" (penicillin), "amoxicillin" (amoxicillin), "ampi" (ampicillin), "tetra" (Cotrimoxazole) ... Many think that antibiotics should be taken for all health problems, including vague undiagnosed symptoms.
Many Cambodians also believe that "healing medicine" is simply a substance that heals faster and more effectively than other medicines.
This negligent use of antibiotics contributes to the global crisis of antimicrobial resistance. Approximately 700,000 people die each year from antibiotic-resistant infections, and the World Health Organization (WHO) predicts that this number will reach 10 million deaths annually by 2050.
Insufficient data means that the scale of resistance in Cambodia remains unclear and a new effort of surveillance by the authorities seems necessary. A ten-year study conducted at Angkor Children's Hospital in Siem Reap, conducted from 2007 to 2016 and published in May, revealed that 82% of the samples of E. Coli and K. pneumonia collected at the hospital are resistant to several drugs.
The Pasteur Institute of Cambodia also sounded the alarm, noting in a recent statement that it detected alarming levels of resistance from several types of bacteria.
Over a four-year period beginning in 2012, it was found that the frequency of Enterobacteriaceae producing extended-spectrum beta-lactamases that yield bacteria resistant to many types of antibiotics increased from 23.8% to 38%. 4% in the analyzed samples. Surprisingly, 80% of pregnant women and 42% of infants tested by the Institute had ESBL-producing enterobacteria, compared with less than 5% in Europe.
"... The increase of these resistant bacteria can lead to a therapeutic impasse ..." Alexandra Kerleguer, a biologist at the Institut Pasteur, said in a statement. The biologist adds that when she first arrived in Phnom Penh, she was shocked to see how much more severe antimicrobial resistance was in Cambodia than in her country of origin, France.
All studies on antibiotic resistance in Cambodia have highlighted the urgent need for a comprehensive surveillance system at the national level. But its start is slow. Although the program has been in existence for years, Cambodia began collecting data only in January 2018. There are still only eight hospitals in the country with the necessary facilities to carry out the tests necessary to detect resilient bacteria, highlighting the magnitude of the challenge.