CITATION: Bartoloni A. 1998. Antimicrobial use and antimicrobial resistance among healthy children in Bolivia. APUA Newsletter 16(3): 1-2.

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Antimicrobial use and antimicrobial resistance among healthy children in Bolivia
Alessandro Bartoloni
Clinica Malattie Infettive, Università di Firenze, Italia

Resistance to antimicrobials is now a world-wide problem which may be particularly serious in developing countries, where alternative antimicrobials are often not available or are too expensive (1). Inappropriate use of antibiotics is probably the main responsible factor for the bacterial resistance problem. Other factors include the self-administration of antibiotics, as well as the availability of drugs without prescription for purchase in pharmacies or open-air markets. If inappropriate use of antimicrobial agents favours the emergence of resistant bacteria, crowding, poor sanitary conditions, and sexual contact are responsible for their rapid spread in poor and developing areas (2). Epidemiological studies of bacterial resistance are difficult to carry out in developing countries, and only limited data are available from these areas. Most studies of antibiotic resistance have included strains isolated from patients attending hospital. Fewer studies have been conducted in healthy people. The commensal flora of the gut are considered the most important reservoir for antimicrobial resistance genes in both the community and hospital environments (3,4). These genes can be transferred from commensal to pathogenic organisms (5), as well as from one host to another (6).

The prevalence of antimicrobial resistant non-pathogenic
Escherichia coli among healthy children, aged 6-72 months, was determined in a study carried out in urban and rural areas of the Cordillera province, south-eastern Bolivia (7). Camiri, the urban town has a population of approximately 28,000, has 3 main hospital, 12 smaller hospitals and 12 private pharmacies. Javillo, rural community of about 100 people, is situated in an isolated area of the jungle north-east of Camiri. A selective screening method employed in earlier studies was used to detect resistant bacteria in stool samples from these areas (3,8). Stool samples were collected from 321 children (296 in Camiri and 25 in Javillo). Children were eligible if they had no gastrointestinal symptoms on the day of enrollment and had no personal history of hospitalization, antimicrobial therapy or travel outside the country within the last 4 months. The similar resistance rates in children who received no antibiotics within the past 4 months and children who never received antibiotics, suggested that the former are representative of health members of the community (3).

A very high prevalence of children from the urban area carried
E.coli resistant to the commonly dispensed antimicrobials (Table 1): 97% to ampicillin, 94% to trimethoprim-sulfmethoxazole (TMP/SMX), and 92% to tetracycline. Resistance was also high to chloramphenicol (69%) and piperacillin (54%). Lower prevalence of resistance was found to cephalotin (10%), gentamicin (5%), nitrofurantoin (5%), nalidixic acid (4%), amikacin (0%), cefotaxime (0%), and ciprofloxacin (0%). In the rural area the prevalence of resistance was also high although significantly lower than that of the urban area for ampicillin (87%), TMP/SMX (71%) and piperacillin (33%). Overall, 63% of children carried E.coli with multiple resistance to ampicillin, TMP/SMX, tetracycline and chloramphenicol.

An additional arm of the study examined antibiotic usage patterns using simulated patient scenarios. Study personnel presented one of six clinical scenarios at each of the district pharmacies in Camiri. In each case they recorded the name and quantity of the medications dispensed by the pharmacist and any advice given. The six scenarios included:1) a 6-month old with acute watery diarrhea without fever, 2) an adult with acute watery diarrhea without fever, 3) a 2-year old with low grade fever and rhinorrhea, 4) an 8-year old with fever and sore throat, 5) an adult female with acute dysuria and fever, and 6) an adult male with purulent urethral discharge. In this simulated patients study, over two-thirds of the pharmacies dispensed antimicrobials without a medical prescription, and the quantity dispensed varied according to the patient's ability to pay.

Antimicrobials were dispensed inappropriately for 92% of adults and 40% of children with watery diarrhea. Sixty percent of the pharmacies also gave antidiarrheals to children while none gave oral rehydration salts. Tetracycline was the most commonly dispensed antimicrobial in adults with diarrhea and in one case it was given to a six-month old child. Furazolidone, sulphoguanide, sulphathiazol, neomycin, and streptomycin were the other antimicrobials dispensed. All pharmacies only dispensed enough antibiotics for two days or less. For the mock illnesses for which antimicrobial therapy is indicated, antimicrobials were dispensed to 67% of males with purulent urethral discharge. Ciprofloxacin was the most commonly dispensed drug; benzathine penicillin, procaine penicillin, TMP/SMX, and spectinimoycin were also dispensed. Only spectinomycin was given in appropriate dose. Only fifty-eight percent of pharmacies dispensed antimicrobials (pipemidic acid, sulphametizol, nitrofurantoin, nalidixic acid, norfloxacin) to women with fever and dysuria. The recommended duration of therapy ranged from 1 to 5 days but in all cases the quantity of tablets dispensed were four or less. Thirty-three percent of pharmacies dispensed only phenazopyridine, a urinary analgesic with no antibacterial activity.

This study documents several problems associated with the use of antimicrobials, including inappropriate and ineffective regimes dispensed at pharmacies, widespread use of antimicrobials even in a remote rural area of Bolivia, and widespread carriage of resistant commensal gut bacteria in urban and rural areas. The prevalence of resistance to ampicillin and TMP/SMX was higher than that previously reported in developing countries. Reports from Chile, Honduras, Costa Rica, Brazil, and Thailand have reported 38-50% prevalence of resistance to TMP/SMX (9). Our findings for ampicillin resistance are as high or higher than those reported from India, Venezuela, and China, which have previously documented some of the highest frequencies of antimicrobials resistant commensal bacteria within a healthy developing country population (3,10).

Our study confirms that resistance to antimicrobial drugs is particularly troublesome in developing countries. As infectious diseases are still the major health problem in these areas, indigenous people will most feel the consequences of this situation. However, considering the increasing mobility of the world population, the existence of a large reservoir of resistance genes in commensal bacteria of healthy individuals from developing countries represents a threat for people throughout the planet. Resistant genes can spread easily from commensal faecal flora to pathogenic bacteria and difficulty in treating patients infected with such strains may occur in both developing and developed countries. The prevention of infection and the reduction of transmission are the most effective methods to address the problem of antimicrobial resistance in developing countries. However, urgent measures are needed now to implement effective drug policies aimed at more rational use of drugs and the development of implementation programs which include the private sector.


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