Improper disposal of unused antibiotics: an often overlooked driver of antimicrobial resistance

KEYWORDS:

• Improper disposal
• unused antibiotics
• driver
• antimicrobial resistance

1. Introduction

While addressing quality use of medications, improper disposal of unused, stored or expired pharmaceuticals is a major concern [1]. The majority of the medication users are unaware of proper disposing methods and thus opt to flush or throw away their unwanted and expired medicines [2]. This inappropriate disposal ends up in landfills, water supplies and drains that lead to contamination of the environment and a wide range of toxicities to humans, animals and marine life. This is true as concerned literature reveals that improperly disposed medicines lead to detrimental health impacts for humans, animals and also to aquatic life [3]. Therefore, proper disposal of medicines is an important component while addressing the medicine management cycle.

Inline with what is reported above, the World Health Organization came up with a practical guide that particularly focused on Health Care Waste Management including disposal of unused and expired medicines [4]. Additionally, the Disposal of Unwanted Medication Properly program in New Zealand and the ENVIRx disposal program in Canada were also initiated to ensure the suitable disposal of pharmaceuticals [5,6]. Shifting our concerns to the developing world, the majority of these countries lack official guidelines and protocols for the disposal of expired, unwanted and unused medications [2]. Furthermore, developing countries are time and again faced with a lack of resources and poor implementation of legislative policies and control. Even though the improper disposal of pharmaceuticals is often the foremost topic of discussion at policy-making forums, it is still facing shortfalls and the progress is significantly unsatisfactory especially among the developing nations.

2. Improper disposal of antibiotics: a driver of antimicrobial resistance

Among all groups of pharmaceuticals, antibiotic use and consumption have augmented in recent years. Klein et al reported a massive increase in the consumption of antibiotics in 76 countries. Expressed and evaluated as defined daily doses (DDDs), antibiotic consumption was increased to 65% (21.1–34.8 billion DDDs) between the years 2000–2015 and 39% (11.3–15.7 DDDs per 1,000 inhabitants per day) in terms of antibiotic consumption rate [7]. The authors also projected an increase in antibiotic consumption rate (200%) when compared with consumption rates of 2015 provided no modification of policies and procedures. Summarizing, reducing global consumption of antibiotics was recommended but by keeping access limitations and global resistance patterns of antibiotics. As expected, the increase was higher among the low- and middle-income countries when compared with the high-income nations. Additionally, the alarming concern of the authors was the use of high-end and last-resort antibiotics that was observed in equal proportion around the globe.

The increase in antibiotic consumption is repeatedly associated with the free availability, accessibility, and incongruous use of antibiotics and the reason for developing antibiotic resistance [8,9]. However, leftover, unused and expired antibiotics, and their improper disposal as a potential driver of antimicrobial resistance is least discussed in the literature. Appropriate disposal of unused and expired antibiotics is of great importance because of the impending environmental hazards and public health risks. Like other unused pharmaceuticals, unused and expired antibiotics are also reported to be thrown in the garbage, water fills, and sewers because of the costs associated with proper disposal of those medications [10]. The disposed of antibiotics when not degraded or eliminated during wastewater treatment reach surface water or are passed into the aquatic environment. Even though the concentration of such disposed antibiotics is negligible; such concentrations are equally capable of promoting resistance either by horizontal gene transfer or by modifying targets [11]. This repositions the host genomes and act as vehicles for resistance acquisition and their consecutive transmission. Hence, this indiscriminate release into the environment compromises the effectiveness of antibiotics and augments resistance as harmless microbes mutate to deadly and resistant pathogens [12]. Consequently, the very bacteria when transmitted to humans are already resistant to the available antibiotics leading to increased morbidity and mortality as well as an increased economic burden to the health care system [13].

3. Addressing improper disposal of antibiotics: the way forward

‘The response toward the failure of antibiotic therapy is simple, and that is to use more antibiotics’. This trend has led to overuse and misuse of antibiotics that has resulted in an increase in antibiotic resistance. Correlating, the more antibiotics are used, more are the chances of improper disposal of antibiotics. However, the development of antibiotic resistance because of improper disposal in the environment is poorly addressed and at times is not on the priority list of policymakers and healthcare professionals. Even though improper disposal of antibiotics is now recognized as a critical concern, improvement strategies to control and reduce this phenomenon have seen poor progress. There have been several awareness programs focusing on proper disposal of antibiotics for the community members through healthcare professionals and policymakers but have produced average results. At the same time, global strategies to improve proper disposal of antibiotics are also abortive in providing positive results. Within this context, a voluntary proposal in the form of an antimicrobial-resistance roadmap was offered by various drug manufacturers to the United Nations in 2016. The proposal offered to limit the release of antibiotics in the environment but failed to produce its impact because of financial issues and barriers [14]. Based on the available evidence, both individualized and collective programs seem to have less effect in improving the proper disposal of antibiotics. Therefore, policymakers should come up with new guidelines and protocols to improve the understanding of proper disposal of antibiotics and the potential complications and contamination related to improper disposal of antibiotics.

Increasing the awareness of antibiotic resistance among the public because of improper disposal of antibiotics is of vital importance to make societies change their approach to the risks posed by antibiotic resistance. Based on our observation and peer-based discussion, the majority of interventions focusing awareness of antibiotic resistance have relied on a top-to-bottom approach following the classical model that begins with healthcare professionals and move downwards to the individual level. We have to remember that at the community level, improper disposal of antibiotics is more of a behavioral issue and a comprehensive yet customized approach is needed to address this concern. Among many possible suggestions, adopting the bottom-up approach is one method that can produce positive results in changing the behavior of society. It is evident that society and her members are impressed by many individuals and certain individuals have a colossal influence on their societal members. The same influence can be utilized to change attitudes and practices regarding the improper disposal of antibiotics. The cascade-training approach has proven helpful where influencers from the society are selected, trained and appointed by healthcare authorities and professionals to educate community members about knowledge, activities, and skills related to proper disposal of antibiotics. We are confident that the message transferred through the influential societal entities will promote proper disposal of antibiotics reliably at the community level, without economical and communal constraints. This is a valuable option that can prove to be helpful in the current scenario where other interventions are not being successful.

4. Future developments and standpoint

Antibiotics are necessary for human survival but they do contaminate the environment when disposed or discarded without care. The improper disposal of antibiotics is an exigent issue that requires immediate improvement to control antibiotic resistance. The future needs and developments are:

1. A thorough assessment of disposal practices of antibiotics among healthcare institutes and community members is required to get a real-time picture of the severity of the issue.

2. A novel approach to address improper disposal of antibiotics is needed. The healthcare system should collaborate with social scientists and civil society organizations to identify the drivers that can lead to behavioral changes while considering the use, misuse and disposal of pharmaceuticals in general and antibiotics in particular.

3. In addition to the development and implementation of the novel approach, financial constraints and sustainability is also to be taken care of. We have to remember that antibiotic resistance is and will be a continuous threat to mankind. Therefore, the sustainability of the intervention will play a key role in our fight against antibiotic misuse and resistance.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was not funded.