In the narrow corridors of a Tirana health center, a troubling pattern emerges: antibiotics are being handed out like candy. The elderly line up, papers in hand, for medication reimbursements while a tall woman in her thirties, clutches her feverish daughter, wrapped in a blanket. Despite cycling through over-the-counter meds, her child’s fever persists. This is a snapshot of a deeper crisis where misuse and over-prescription of antibiotics are cultivating a dangerous resistance, rendering these critical drugs ineffective. A national health concern is unfolding: the rampant and unchecked consumption of antibiotics is setting the stage for a potential public health disaster.
Authors: Ilir Karabrahimi and Bledar Zaganjori
On the left side of the narrow corridor of the Health Center in Selitë, Tirana, a long line of elderly people has gathered in front of the family doctor’s door. With papers in hand, they wait for prescriptions and medication reimbursements. Among the queue stands Rajmonda Caco, a tall woman in her thirties, holding her daughter in her arms, wrapped in a blanket.
“She has a temperature of 39.2,” she says, even though she switched from Tachipirina to Nurofen, from Paracetamol to Ibuprofen, to bring it down.
“Well, Nurofen takes time to take effect,” intervenes a woman in age.
She is alarmed. Ema, the four-year-old girl she holds in her arms, had a fever for four to five days that wouldn’t go down from 38. The doctor had prescribed Augmentin, a broad-spectrum antibiotic containing amoxicillin; later, they had given her Cefaclor. None of the antibiotics yielded results.
“I will ask the doctor to give me another antibiotic. My husband is working abroad, and I will get it from there. I have visited different doctors for my daughter, given her two antibiotics so far, and I don’t know what’s happening. Maybe in Albania, the medications are expired and not effective,” Mrs. Caco raises doubts about the effectiveness of antibiotics.
According to the doctors, the main problem Ema might have encountered was medical treatment with antibiotic resistance.
“There’s a terrible urge from patients who insist on using a specific antibiotic. Every day we encounter cases where parents demand antibiotics for their children because they may have had positive results with an earlier use,” says Dalina Raseni, a family doctor at the Health Center in Selitë.
It seems that antibiotic resistance is a disease that has coexisted for years in our country, as the cases are numerous and similar to each other.
Sadete Byku is a 75-year-old from the village of Synej in the Kavajë district. She shares the challenges she faced five years ago at the hospital doors during a difficult time related to her six-month-old granddaughter’s health.
“I had my granddaughter with a fever; her diapers and socks soaked in vinegar dried very quickly. From the window, I saw that it was getting light; I covered the girl with a blanket and headed to the hospital,” begins the story of the woman from Kavajë.
She says that her granddaughter’s health did not improve, even though she had been treated several times with antibiotics.
“The doctor said the medicine had no effect; we changed it three times. Who was asking about the money! I only had to worry about the girl.”
The girl from the village of Synej was affected by a severe urinary infection, causing a temperature of 39-40 degrees, thirst, and spots on the skin. She was initially treated with amoxicillin and later with cefaclor, but the situation remained the same.
“It was the third time the patient was affected by urinary infections; I had to admit her to the hospital twice, and I couldn’t diagnose it properly, even though I consulted with colleagues. I decided to send her to the Pediatric Emergency in Tirana. There, colleagues, through ultrasound examination, discovered that the little girl had urinary reflux,” describes the case, considered one of the most challenging in her ten-year career, Greta Haxhi, a pediatrician at the Regional Hospital in Kavajë.
She further adds that such cases are encountered every day, not only at the Kavajë Hospital but also at her private clinic in Tirana.
“From the data I have kept in the clinic, every year we encounter 5-6 cases of bacterial resistance only in children.”
Dr. Haxhi emphasizes the need for accurate examinations, ultrasound, laboratory analysis, and reducing the indiscriminate use of antibiotics.
“Antibiotics are everywhere today, especially in children. People take them in different ways. Just look at the routine tests performed, a throat culture or urine culture, to understand if we are dealing with a urinary infection or streptococcus. In fact, in the laboratory antibiogram, we encounter a lot, a lot of resistance.”
Bacterial resistance is also encountered in children who have never been treated with antibiotics. According to Dr. Haxhi, parents insist and use any form to get an antibiotic prescribed by the doctor.
“The parent often demands antibiotics for the child, even for a mild throat infection. – This worked for me, and I want this – is the sentence I hear every day in the clinic. Under no circumstances can a third-generation antibiotic be used for an infection that may be viral, which will run its course, and the start of the antibiotic coincides with the onset of clinical signs, and then trust is created because you think, as soon as I started this, it worked. Then the chain of parents and mothers recommending to each other begins,” Greta Haxhi concludes.
The continuous increase in resistance.
Specialists affirm that the situation regarding antibiotic use is alarming, and there is a need to increase continuous monitoring of the over-the-counter sale of antibiotics. Pharmacist Erblina Bozo shares that in her daily work, she is a witness to a concerning reality.
“Many patients, when they encounter obstacles in my pharmacy to buy an antibiotic without a doctor’s prescription, blame me, claiming that in another pharmacy, they managed to get the same medication.”
Doctors and specialists acknowledge the mass use of antibiotics, especially during the Covid-19 pandemic. However, another concern about the antibiotic use situation, raised by microbiologist Koraqi, is related to the lack of control over antibiotic use.
“The lack of health protocols, the non-performance of laboratory analyses, the ease of obtaining an antibiotic without a doctor’s prescription, and the use of antibiotics even for the treatment of common viral infections are giving bacteria the opportunity to develop resistance year after year,” says Koraqi.
The microbiologist goes further and tells INA Media that treating antibiotic resistance in our country is becoming an impossible mission because antibiotics in Albania are not only obtained from pharmacies.
“We continuously take antibiotics from milk, eggs, meat, and vegetables. Over 80% of antibiotics are used in veterinary and agriculture services. Antibiotics are used throughout the food chain, mainly as a growth factor, primarily for the increased body mass of animals,” says Koraqi.
Professor of the Faculty of Medicine, Andi Koraqi, further emphasizes the need for a national registry for the quantity of antibiotics used for humans and animals, as well as increased controls over agricultural and veterinary pharmacies.
“The veterinary sector is entirely uncontrolled. You can take whatever you want. Veterinary pharmacies sell whatever they want. In about one ton of tetracycline, only 0.5% is used for humans, the rest is used in animals. Animals don’t even have fixed doses, and the quantity the animal receives is transmitted to humans through the products they consume,” expresses the concerned microbiologist Koraqi.
Despite the concerns of specialists and the situation of bacterial resistance in the country, INA Media requested specific data from the Ministry of Health and Social Protection regarding the level of resistance in the population and received the following response:
“After reviewing the National Action Plan last year, guidelines and protocols for AMR surveillance in human health have been developed, and we have finalized and distributed guidelines and protocols for the prevention and control of hospital infections,” the response says in an email communication.
Resistance in the population
Denada Laçej, a microbiologist doctor, says that the most significant period of antibiotic use was during the pandemic caused by the Covid-19 virus, but the greater threat comes from multi-resistant strains; strains that make medicine lose its purpose and feel helpless.
“These strains are growing every day; the patients affected are destined to die, and this situation is turning antibiotic resistance into the most dangerous global disease. Mortality will no longer come from cancerous or cardiovascular diseases but from antibiotic resistance,” says Denada Laçej.
Health specialists claim the lack of a policy that prohibits the dispensing of antibiotics without a prescription, as well as the absence of national studies on the level of resistance in the population.
A study by microbiologist Koraqi in 2006 speaks of high figures of bacterial resistance. Specifically, the study addresses the resistance of Escherichia coli bacterial flora in a specific sample of children aged 6-14 in a school in Tirana.
“It was entirely a personal initiative, and I conducted it in three different periods. In 2006, in about 100 samples, excluding children who had taken antibiotics in the last six months, the resistance to antibiotics reached up to 42%, a very high level that would increase significantly in the next study,” Koraqi expresses.
Driven by curiosity to know the level of bacterial resistance, even in a small sample, microbiologist Koraqi decided to repeat the study after more than five years. In the 2012 study, the results of bacterial resistance increased to 45%.
“I repeated this study three times, and in 2020-2021, the result was frightening; the resistance rate had exceeded all predictions. When it comes to children who have never taken antibiotics, the resistance is 65%, imagine what happens with patients who have been treated with antibiotics at least once,” cites Koraqi’s study data.
Microbiologists Laçej and Koraqi, from the study on antibiotic resistance, conclude that these are individual initiatives, and the need calls for a national plan of emergency measures and a regulator of this chain that jeopardizes society.
“The lack of a guideline for antibiotic treatment in the primary care system allows doctors to recommend any antibiotic they want. Thus, there is no hierarchy that dictates using older antibiotics first and then newer ones. Besides, family doctors do not have a patient’s history, there is no system to monitor resistance, what strains exist…” Denada Laçej concludes.
In addition to the need to monitor this important chain, Koraqi adds that control over the sale of drugs in Albania should be increased.
“In all these problems, pharmacies are another concern; there are cases where they don’t even provide the antibiotic without a prescription, but it is easily obtained.”
Apparently, the links of the chain have not worked properly, despite the alarm raised by the WHO. The Ministry of Health and Social Protection, when asked by INA Media about monitoring and the plan of measures to combat antibiotic resistance, emphasizes:
“Antimicrobial resistance is a global threat today, which is trying to be addressed with concrete actions, such as global and regional strategies, national action plans, and continuous reporting to WHO, CAESAR, and soon to GLASS, and the implementation of activities has brought together all actors for this fight to be in line with the One Health approach.”
On the other hand, in September 2022, during a meeting with the National Committee of Experts on Antimicrobial Sensitivity Testing, then-Minister Manastirliu called for an increase in measures and controls in pharmacies and pharmaceutical warehouses.
“Zero tolerance for pharmacies that violate the rule of selling antibiotics and other drugs, which should only be sold through a prescription issued by a doctor,” declared Ogerta Manastirliu at that time.
Furthermore, the Ministry of Health, in response to our request for monitoring reports and encountered problems, states that continuous inspections have been carried out in regional hospitals, where reports on hospital infections from resistant strains have been made.
“We are working on the introduction of non-reimbursable prescriptions into the system, so that attention is paid to both the quantity and the type of antibiotics used in primary care.”
On the other hand, specialists report a high number of antibiotics withdrawn from use due to the low level of effectiveness, and the production of new antibiotics not only requires time but also incurs high costs.
“The World Health Organization has listed antibiotics that can be used and those that cannot. We are at a stage where we need to give importance to disease diagnosis and especially viruses or micro-bacteria, to have a more sustainable resistance,” concludes Andi Koraqi for INA Media.
Ky shkrim është pjesë e projektit që mbështetet financiarisht nga Zyra e Mardhënieve me Publikun e Ambasadës së SH.B.A. në Tiranë. Opinionet, gjetjet, konkluzionet dhe rekomandimet e shprehura janë te autor-it/ve dhe nuk përfaqesojnë domosdoshmërisht ato të Departamentit të Shtetit. / This article is part of a project that is financially supported by the Public Relations Office of the US Embassy in Tirana. The opinions, findings, conclusions, and recommendations expressed are those of the author(s) and do not necessarily represent those of the Department of State.