Antibiotic resistance refers to the ability of bacteria or other microorganisms to withstand the effects of antibiotics, rendering these medications less effective or completely ineffective in treating infections caused by these resistant microorganisms. The problem of antibiotic resistance has intensified on a global scale due to the impact of the COVID-19 pandemic. Unlike many other European countries, Bulgaria has witnessed a significant increase in antibiotic consumption following the pandemic.
Professor Iva Hristova, the director of the National Center for Infectious and Parasitic Diseases, also addressed this same topic on World Antibiotic Awareness Week, November 18-24. In the interview, she mentioned,
"So, we have exceeded Romania in terms of extensive antibiotic usage, particularly in non-hospital settings. There is a direct link between antibiotic use and the levels of antimicrobial resistance. In this context, we are also positioned at the top or second place in Europe, depending on the specific microbe we're discussing."
(https://www.mediapool.bg/bulgaria-e-vodeshta-po-upotreba-i-rezistentnost-kam-antibiotitsi-v-evropa-news342005.html)
In the following statement, she discusses the impact of the pandemic on antibiotic resistance in Bulgaria
"Unfortunately, during the Covid-19 pandemic, while antibiotic consumption significantly decreased in other countries due to the focus on viral diseases, in our country, primarily one macrolide antibiotic was prescribed. The consumption here is several times higher compared to Western Europe, which also led to antibiotic resistance."
(European Antimicrobial Resistance Collaborators. The burden of bacterial antimicrobial resistance in the WHO European region in 2019: a cross-country systematic analysis. Lancet Public Health. 2022 Nov;7(11):e897-e913. doi: 10.1016/S2468-2667(22)00225-0. Epub 2022 Oct 14. PMID: 36244350; PMCID: PMC9630253.)
She highlighted the dangers of antibiotic resistance by citing a publication from October 2022 year in the scientific journal "The Lancet." According to this publication, the highest mortality rates due to totally resistant Escherichia coli and Klebsiella pneumonia are in Bulgaria – 7.29 per 100,000 for E. coli and 4.59 per 100,000 for K. pneumonie.
Our involvement in social events is one of the methods we use to enhance public awareness about antibiotic resistance. The events on which we have participated are the following:
1. Flora flower festival
2. European Researchers Night
3. Freshers’ Day at the Faculty of Biology
One of the presentations on antibiotic resistance featured a brief experiment in which the audience actively participated. The experiment demonstrated antibiotic resistance using two sets of Petri dishes. The first group contained antibiotics, while the second did not. Beforehand, the agar in the Petri dish had been divided into squares, one of which was assigned a number. Participants who wanted to join left their fingerprints on the agar, and each was assigned a specific square with a corresponding number. When the results were ready, participants could match their assigned number with the bacterial growth results on the agar, posted on our social media. The ultimate outcome revealed that even the presence of antibiotics in the agar did not inhibit the growth of hand microflora. Through this, we emphasized the importance of thorough handwashing to the audience, highlighting its significance for self-protection.
Flora flower festival
Biofest
Our team received an invitation to appear on national television on November 2nd. We took advantage of this opportunity to discuss the critical topic of antibiotic resistance in front of a broad audience. During our segment, we showcased images and the previously demonstrated project results. Furthermore, we elaborated on the advancements in our research and the future potential of our project.
Interview with National TV
We ensured our project presentation was accessible to a wide range of audiences, and, as a result, we consistently included a dedicated segment for children at nearly every event we participated in. During the initial phase of explanation, we presented a video to offer a comprehensive portrayal of bacteria, striving to provide the closest possible illustration. Following that, we provided coloring pages for the children to contemplate the new knowledge and insights they had gained from the video. Finally, we introduced them to color-producing strains that emit blue light, sparking their curiosity and firing up their imagination.
We also conducted a questionnaire to help us understand the community's perception of antibiotic resistance. The questionnaire was distributed in two ways: through our social media and in person, with responses from 1043 participants. The questions aimed to gauge the level of awareness in society. The first question was "Have you ever taken antibiotics?" with 90.8% of the participants having taken antibiotics, while 9.2% had not. The second question was "What are antibiotics?" with four answer choices. More than half of the participants responded that antibiotics fight against infections caused by bacteria, while around one-quarter believed antibiotics fight infections caused by a virus. Approximately 16% of the population believes that antibiotics are used to treat infections caused by bacteria, fungi, and parasites, while nearly 10% think that antibiotics are prescribed for infections caused by all types of germs. This provided us with insights into the areas of public awareness that require our attention and efforts for improvement. The third question aimed to provide additional information about when our society takes antibiotics. Approximately 81% of the population takes antibiotics following a medical prescription. Only about 5% take antibiotics at their own discretion. Our last question aims to understand if society comprehends the seriousness of the treatment duration. One-third of the participants in the questionnaire stated that they follow their doctor's prescription regarding the duration of antibiotic treatment. Conversely, only 5.9% of the participants continue taking antibiotics until they feel better.
Conducting a Survey
The third question aimed to understand when people in our society take antibiotics. Approximately 81% of respondents follow a doctor's prescription for antibiotics, with only around 5% choosing to take antibiotics independently. The last question explored public understanding of the importance of completing a full course of antibiotics. About one-third of participants indicated they adhere to the prescribed duration, whereas 5.9% stop once they feel better.
OUR HUMAN PRACTICE JOURNEY
Given our multifaceted topic, which encompasses ecology, environmental protection, medicine, microbiology, and social work, we connected with experts from various domains. This approach aimed to ensure that we could gather a wealth of information.
Prof. Kenarova
1. What can you tell us about antibiotic resistance at the moment and how does it affect your field of work?
"In my work, I have investigated the emergence of resistant forms of soil bacteria to antibiotics used in human medicine following the application of fungicides for plant protection. An increase in resistance has been observed, with the degree of resistance varying for different antibiotics. Furthermore, resistance to some antibiotics is reversible within six months, while for others, it is not."
2. How is antibiotic resistance related to wastewater?
"A primary source of antibiotic resistance is the quantities of antibiotics excreted in urine and entering municipal wastewater. When wastewater is discharged directly into water bodies, antibiotics come into contact with aquatic microflora and can act as a selective factor. As municipal wastewater passes through treatment plants, residual antibiotics can also have a selective effect on the active microbiota. To the best of my knowledge, there is no specific step in municipal treatment plants dedicated to removing antibiotics from the overall wastewater flow - this would likely be a very costly facility."
Asso. Prof. Boteva
1. How can the quantity of antibiotics in wastewater be measured?
"It can be determined through microbiological analyses based on antibiotic-sensitive bacterial species to establish whether specific antibiotics are present in a given sample. Chromatographic methods can also be used to detect the presence of antibiotics in water."
2. How can urine and urinary bags be disposed of as medical/biological waste?
"The only method for disposing of these bags, which is in accordance with national legislation, is incineration. In the absence of blood, urine can be disposed of in the sewer system. Pre-autoclaving may be applied to these waste materials before incineration in some cases."
Asso. Prof. Todorova
1. How is antibiotic resistance related to wastewater?
"The field I work in, which involves monitoring water pollution control and treatment processes, is directly related to the problem. It is well-known that one of the primary routes for pharmaceuticals to enter the environment is through the end products of metabolism, which then find their way into wastewater. From there, the transfer and transmission of these contaminants through the different stages of the water treatment cycle is relatively short. Significant efforts are made to purify and eliminate hazardous pollutants, but conventional wastewater treatment plants, particularly those designed for municipal wastewater, often lack specialized technologies for the removal of contaminants falling into the category of emerging contaminants. This issue is not only concerning antibiotics used by humans that end up in wastewater from urban areas but is especially acute for those used in livestock farming. It is no coincidence that one of the key components of the European Green Deal, the "Farm to Fork" strategy, aims to significantly reduce the use of antibiotics, particularly those that end up in the environment. Residual amounts of antibiotics are continuously detected in wastewater, and resistant bacteria to them are frequently isolated in high quantities in wastewater streams from hospitals and healthcare facilities, especially during seasons with increased antibiotic consumption."
2. How can the quantity of antibiotics in wastewater be measured?
"The detection methods are highly diverse, including both quantitative methods (mass spectrometry, various liquid chromatography techniques, and combinations thereof) and qualitative methods that can also assess the presence of antibiotics. The challenge primarily lies in the wide variety of chemical structures among antibiotics and other hazardous compounds, such as per- and polyfluoroalkyl substances, polycyclic aromatic xenobiotics, polychlorinated biphenyls, and more, which enter wastewater streams. In most cases, their concentrations are low, but their effects become apparent through accumulation and environmental persistence. This complexity complicates regular monitoring efforts, which must continually expand to adequately address increasing pollution levels."
Dr. AndreyPetrov, MD
1. How often do you witness Meropenem being prescribed?
"In recent years, there was an increase in the use of meropenem and other carbapenem antibiotics. There are two prerequisites for this. On one hand, the growing resistance of microorganisms to other widely used antibacterial medications and on the other, in a large percentage of cases, Meropenem is prescribed irrationally, without the necessary indications."
2. Have you observed an increase in cases of antibiotic resistance in recent years?
"I can't provide my specific data, but it is definitely increasing. A growing problem is the widespread distribution of carbapenem-resistant gram-negative microorganisms."
3. If so, what do you think it is due to?
"The main reason is the irrational use of antibacterial agents - lack of need for application, inadequate dose and/or dose interval, incorrect duration of therapy."
Dr. Kolevski-microbiologist
1. In what cases carbapenem gets prescribed for?
"In the case of proven sepsis, both in the laboratory and clinically."
2. Do you have observations regarding an increase in cases of antibiotic resistance in recent years?
"There is a growing resistance observed in multidrug-resistant hospital strains."
3. If yes, to what do you attribute this?
"Due to improper COVID treatment practices."
4. In your opinion, do patients follow the prescriptions for antibiotics given to them by their doctor?
"There are four groups of patients:
- Those who take antibiotics for every illness.
- Those who discontinue after the third day.
- Those who do not use antibiotics.
- Those who take antibiotics consistently. Patients in the latter group follow their antibiotic therapy according to the prescribed regimen.
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Dr. Tsvetkova, MD
1. In what cases is meropenem mainly prescribed?
"Mainly in patients with agranulocytosis following treatment with other antibiotics, without effect, or as a first choice in septic shock."
2. Do you have observations regarding an increase in cases of antibiotic resistance in recent years?
"Yes. "
3. If yes, to what do you attribute this?
"In clinical practice over the past three years, a regimen of broad-spectrum antibiotics has become a common prescription for severe infections, including the treatment of severe COVID cases."
4. In your opinion, do patients follow the prescriptions for antibiotics given to them by their doctor?
"Our patients tend to comply with the prescribed treatments."
We've effectively integrated human practices into our project, encompassing both scientific and social aspects in our educational and outreach efforts.
Social Integration. Integrating advice from Ms. Elena Koleva and Dr. Tatjana Aleksovska.
Ms. Elena Koleva
During the development stage of our project, which aimed to raise social awareness about antibiotic resistance, we wanted to connect with elementary school students. We reached out to elementary school teacher Ms. Elena Koleva. We received valuable input and guidance to design and effective approach for children within the age group of 6 to 10 years.
The advice was to incorporate simple vocabulary and clear questions and explanations.
Ms. Koleva requested that we create a clear and concise definition for the word "bacteria." These explanations should be child-friendly and relatable, enabling children to grasp and absorb the concept easily.
Implementation of advice
We followed her advice, and as a result, we've included visual aids and illustrated images. In the initial explanation phase, we presented a video to provide a detailed representation of bacteria. With this we tried to give closest illustration of the bacteria. In the next stage, we have given them painting pictures, on which they could reflect the new information and understanding which they have gained from the video. In the end, we introduced them to color-producing strains that emit under blue light, which heightened their curiosity and fired up their imagination.
Dr. Tatjana Aleksovska
During the initial phase of the project, dedicated to enhancing awareness of antibiotic resistance, we collaborated with neuro-psychiatrist Tatjana Aleksovska. We received valuable insights and recommendations on how to design an effective approach for different age groups and how to adapt the language to suit each group. She has shared valuable information regarding the social and psychological issues people are facing in the post-pandemic era, including a reluctance to discuss diseases and medications, as well as significant skepticism about the current state of the pandemic.
The advice was to structure the questionnaire in various ways, allowing people of different age groups to provide answers.
Dr. Tatjana Aleksovska suggested that the questions be formulated in a straightforward manner to avoid any confusion in the responses and also recommended having both an online questionnaire and a face-to-face questionnaire.
Implementation of advice
We followed her recommendations, which led to several positive outcomes. Firstly, we restructured the questionnaire to include four simple and straightforward questions, ensuring that participants wouldn't be confused by any ambiguity in the questions. Secondly, we implemented the questionnaire in two ways: online through social media and in a face-to-face format. This approach ensured that people without access to social media could still participate.
Prof. Kenarova
We contacted Professor Kenarova, an expert in the field of ecology, to help us understand the process of urine and urinary bag disposal. She advised us to establish a network with individuals directly involved in biomedical waste management and disposal.
Implementations of advice
Following Professor Kenarova's recommendations, we connected with Ms. I. Doicheva, the director of an incinerator in Sofia. During our meeting with the director of the incinerator at Alexandrovska Hospital, Iliyana Doycheva, we gained valuable insights into the treatment and disposal of hospital waste, including a practical demonstration of the facility's operations. Our discussion also encompassed budgetary and legislative aspects related to this field, where we identified several deficiencies and limitations that impact the efficient execution of the process. This meeting generated new ideas for potential future implementation of our project in real-world conditions.
This meeting inspired us to gather concrete information for the development of our future business plan. We discovered that the price for 1 kg of medical waste varies between 1.50 BGN/kg and 1.65 BGN/kg for public hospitals, while private hospitals charge 2.25 BGN/kg.