When we go to seek healthcare in hospitals or other healthcare settings, getting infected with hospital-acquired infections instead, is not part of the deal. “Why are hospital-acquired infections so acceptable?” rightly questions Dr Nour Shamas, a Lebanese infectious disease clinical pharmacist, who is also part of the World Health Organization (WHO) Task Force of Antimicrobial Resistance (AMR) Survivors.

The issue of AMR got personal for her when her mother developed a hospital-acquired urinary tract infection caused by a drug-resistant microbe in 2018 - and continues to battle antimicrobial resistance even today. Even before this happened, Dr Nour Shamas has led antimicrobial stewardship programmes and knows how to dispense drugs to treat infections, keeping in mind the threat of AMR.

Her mother had gone to the hospital for a spinal column surgery in 2018 – not to get infected with hospital-acquired infection in return. Getting a drug-resistant infection while in hospital was the beginning of a series of hospitalisations and treatment failures that were complicated by the fragile healthcare system in Lebanon- a country beset with economic challenges, and conflict. Nour felt helpless about her mothers’ situation. This feeling of helplessness inspired her to champion the cause of AMR in the Middle East and now globally.

"I am a carer of an AMR Survivor (my mother)"

“I am from Lebanon where the economic situation is generally tough. In addition to that, healthcare infrastructure is severely compromised. In 2018 when I was in the USA at an infectious disease conference, I got a call that my mother had to undergo an emergency spine surgery. It was scary. We had to spend a lot of money as healthcare is out of pocket back home. A couple of months later, she started complaining of back pain. For a very long time it was thought to be back or age-related. But her back pain actually turned out to be a urinary tract infection that had affected her kidneys,” said Nour.

Things became even more serious when Nour and family learnt that her mother had sepsis as a drug-resistant strain of bacteria had gotten into her blood stream. “This could be just any other story, because all of us are at risk of going through antimicrobial resistance (AMR). But it is also important to understand that it was the failure of the healthcare system which impacted our ability to take care of my mother because we could have afforded it if the standard service was available,” said Nour.

Nour and family had to bring the antibiotics to Lebanon from abroad. “My mother had to be administered these antibiotics (to which she was sensitive to) at home because of the limited hospital capacity locally,” she said.

“I do not understand why we accept hospital-acquired infection when we can do so much more to prevent it,” said Nour.

Nour shared that many people may not understand urinary tract infection – and especially an infection which is a recurrent one (like her mother’s). Her mother dealt with a lot of internalised stigma too- as she (wrongly) thought it could be a sexually transmitted infection, which it was not. “It was very new for me as a healthcare professional who works on infectious diseases, to perceive urinary tract infections as a source of stigma.”

Scars of war destroy more than lives

Conflicts in Lebanon have resulted in over half a million internally displaced people who are from Lebanon, Syria and Palestine. “In each room there could be 2-5 such families living,” she said.

“I came to the 79th United Nations General Assembly High-Level Meeting on Antimicrobial Resistance, with high hope . But looking at the impact of war and conflict on Lebanon and on the region, I think it is very important to think from multiple perspectives - and not just think about AMR in a very siloed manner. We have to complement AMR work with peace, prosperity and health system strengthening to make healthcare accessible to all. We also must make disease prevention possible with optimal infection control, water, sanitation and hygiene,” said Nour.

“We were very lucky to be able to afford the diagnostics so drug sensitivity testing was done for my mother. But the question is why the healthcare workers took a long time to ‘think UTI (urinary tract infection)’ and test her and then why the test results took a long time to come to us? After getting diagnosed my mother was given antibiotics that did not work on her as the disease-causing bacteria was resistant to those antibiotics. “But in many conditions, people in Lebanon may not even be able to get a culture done (to test if a medicine will work on them or not),” said Nour.

Currently, her mother is alternating between the two different medicines that her disease-causing bacteria is sensitive to. “I am always terrified of the moment that we are going to look at the culture (a test that tells if a medicine works or not) and we are going to have a completely resistant organism.”

She added: “We had to tell her that this could be a possibility at some point of time, because we need to prepare people, and she needs to be empowered to understand what her infection is about. I also hope more research happens on preventing long-term colonisation of disease-causing microbes and looking at reasons for recurrence, especially in the elderly.”

Go back to the basics

“I think that we really need to go back to the basics when it comes to training of healthcare workers early on about infections, including hospital-acquired infections,” says Nour.

She added: “We all go in the healthcare to do no harm first. We have to include risk and harm reduction into medical curriculum in the context of infection prevention for pharmacists, nurses, physicians and other healthcare workers.”

Airplanes do not crash as much as we get hospital-acquired infection, says Nour – because all safety precautions are in place in an airplane with utmost sincerity to prevent any such eventuality. “We need to put a lot more work into making sure there are enough fully trained and skilled nurses, none of them are overworked, and all of them are well paid, as they are the power houses of our healthcare system.”

Educate. Advocate. Act.

“Educate. Advocate. Act.” Is the theme of the upcoming World AMR Awareness Week (WAAW: 18-24 November 2024).

Nour also echoes this message: Raising awareness of people about infection control (in homes, communities and society) is vital. Patient education is important. Integrating AMR infection control in general patient safety principles is so essential as AMR programmes are not vertical or standalone programmes. AMR is a responsibility of all healthcare workers.

Mentorship of pharmacists, nurses, physicians and other healthcare workers for AMR stewardship can make a huge difference, feels Nour.

Early and accurate diagnostics in people-centred manner

“We need to find ways to make diagnostics accessible to everybody so that we do not have to go for ‘empirical therapy approach.’ We have to find more rapid diagnostics and make them available at the bedside of those-in-need and in the healthcare facilities. While people rightly focus on restricting the sale of over-the-counter antimicrobials, but before that we have to make sure that universal healthcare is accessible and a reality for everyone – and everyone can have access to clinics,” rightly says Nour.

Humanise AMR

Empowering people who deal with AMR and are surviving it will help humanise the issue as everyone is at risk if medicines stop working. “If our stories are amplified to other people then we can find faster solutions that are possible. In addition, we have to think about stopping conflicts and its impact on refugees,” said Nour.