Small plastic packets filled with a mix of pills of various sizes, shapes and colours sit piled on the counter of a pharmacy in Phnom Penh’s Meanchey district, home to several large garment factories.

At 2,000 riel a pop, about 50 cents, these packs are sold as a cheap remedy for fevers, coughs or any number of ailments from which the young and mostly female workers living nearby suffer. They’re designed to get them back on their feet as quickly as possible.

“I always mix these together and give these to customers to take three times a day. My husband is a doctor and he taught me,” says Pheap, a kindly 67-year-old who dispenses the medicine at the pharmacy licensed under her husband’s name.

Customers buy as many packets as they need, or can afford, and often stockpile them at home to start using again the next time they get sick, she says.

But among the jumble of six pills in each packet, cobbled together from various unlabelled plastic tubs, one large blue and yellow pill stands out from the assortment of aspirins, vitamins and other over-the-counter medicines.

It is cloxacillin, a penicillin-class antibiotic for bacterial infections that should be prescribed by a doctor and is wholly ineffective for treating viral infections like the common cold or flu. When used, a prescribed course is meant to be followed – and completed.

But Yu Manith, a 25-year-old factory worker, says she buys such mixed-medicine packets directly from pharmacies whenever she gets ill, and simply takes as many as are needed to make her feel better.

“Oh, I don’t know what antibiotics are, and I don’t care. I just follow the instructions to take whatever the pharmacy gives me until I get better. It works so fast. I don’t want to go to the doctor, because I don’t want to spend money.”

Whenever antibiotics are used – especially if improperly or unnecessarily – there are risks that some bacteria, due to a genetic mutation, won’t be killed by the medicine.

These “resistant” bacteria can quickly replicate and spread, creating a vicious cycle where different, stronger and more expensive antibiotics might be needed for effective treatment, possibly inducing further resistance.

The World Health Organization has warned that antimicrobial resistance (AMR), which encompasses antibiotic, antiviral and anti-malarial resistance, puts “the achievements of modern medicine” at risk and requires urgent global action.

An estimated 25,000 people die each year in Europe from antibiotic-resistant bacteria, according to medical journal The Lancet.

Though a lack of data exists for poorer nations, it is expected that the costs are greater in developing countries like Cambodia due to a higher burden of infectious disease and less access to new antibiotics.

“A crisis looms. In the very near and rapidly approaching future, the wonder drugs of the 20th century, antibiotics, may cease to be useful,” the journal warned in an editorial last year.

Everything starts with using antibiotics’

Easy, unrestricted access to antibiotics over the counter is fuelling AMR in Cambodia, health experts say.

“Everything starts with using antibiotics. Over the past decade, people have become a little bit richer, access to drugs has become more easy … the idea has grown that when you are sick you need an antibiotic,” says Erika Vlieghe, a researcher from the Institute of Tropical Medicine (ITM) in Antwerp, Belgium.

A particular problem is that people “buy only as much as they can afford instead of what they need”, she says, with low doses of just a few pills creating the ideal circumstances for resistant bacteria to flourish.

Pheap, who prepares the packets that each hold one tablet of cloxacillin, agrees, saying that how much customers take depends on “how serious or not serious their illness is and whether they have money or no money”.

Appropriate antibiotic treatment must account for the presence of resistant bacteria, public health researchers say, but little is known about patterns of resistance in poorer countries like Cambodia, which lack well-functioning laboratories.

As part of her PhD research, Vlieghe studied blood samples from all patients who checked in to the Sihanouk Hospital Center of Hope between 2007 and 2010 with fever – the first time such large-scale blood sampling had occurred in Cambodia, according to ITM.

Roughly 500 patients had bloodstream infections, most of which were caused by E. coli and other intestinal bacterium, but many could not be treated with commonly used antibiotics.

“Sixty to 70 per cent of patients who attended with a serial bacterial infection could not be treated anymore with a general, broad-spectrum antibiotic, which was pretty shocking,” Vlieghe says.

Such resistant bacteria, which render first-line treatments ineffective and increase the financial burden on families and societies – can quickly spread in densely populated areas, including crowded hospital rooms and family homes, she adds.

The customer’s always right

According to the Ministry of Health, there were 1,795 licensed pharmacies operating in Cambodia last year, with no illegal pharmacies operating since 2011.

Several pharmacists around Phnom Penh the Post spoke to said they were well aware that it was dangerous to give out antibiotics without a prescription or in incomplete doses, and that they tried to avoid doing so when possible.

According to one Tonle Bassac commune pharmacist, “It’s up to the customer ordering, if they ask for one they know works, we give it to them. But without the customer asking specifically or without a doctor’s prescription, I do not dare to give it to them.

“This is the culture. So if the customers want to buy it, I have to sell it. Most pharmacies do like this; it’s OK under the law,” she said.

According to Dr Chou Monidarin, vice-dean of the faculty of pharmacy at the University of Health Sciences, 400 students were admitted to pharmacy training courses in Cambodia this academic year, 160 of those at UHS.

Although his university is confident that its graduating students fully understand the risks of dispensing antibiotics without a prescription, he admits he cannot be sure that those who go on to open private pharmacies will follow what they have learned.

“When they finish pharmacy school and open private pharmacies, they really respect and abide by what they have learned. But unfortunately, if they respect everything, they will lose a lot financially, because they must not sell any antibiotics without a prescription, and almost no customers come in with a prescription.”

Government policy states that “all levels of pharmacies will sell medicines only with prescriptions, except over-the-counter medicines as specified by the Ministry of Health”.

But according to Dr Or Oudam Roath, head of the Essential Drug Bureau at the Department of Drugs and Food, this policy has yet to be fully implemented at private pharmacies.

“In the policy, it is already mentioned like this. But now we cannot do this yet at all privately owned pharmacies,” she says.

“The role of the pharmacy in the private sector cannot continue to be directly treating people…. In the future, step-by-step, this should change when people understand they should see the doctor first before going to buy medicine.

“But in the public sector, we have guidelines already, and they are respected.”

Overused, misunderstood

Public health facilities have doctors prescribing medicines, Roath says, meaning patients receive appropriate antibiotics and proper guidelines for use.

But hospitals contribute to AMR mainly through poor infection prevention and control (IPC) practices, researchers say.

Dr Chhorvoin Om, who is researching antibiotic prescription practices in Cambodia at the University of New South Wales, said that “awfully poor IPC in almost all Cambodian hospitals”, which includes hospital hygiene, medical equipment sterilisation and health waste management practices, means that antibiotics are over-prescribed.

“This is an important factor to push physicians to unnecessarily and excessively prescribe antibiotics … physicians are scared of treatment outcomes if they don’t prescribe antibiotics.”

Inappropriate use of antibiotics, however, is not limited to humans.

With Cambodia transitioning into more organised methods of farming, a wide range of antibiotics are starting to be used on animals, Vlieghe, of the ITM, says.

“There is a lack of hard data on the use of antibiotics in animal sectors. But we suspect that all types of combinations are being used, with a strong overlap in antibiotics used for humans and in agriculture.”

Drug-resistant bacteria are passed on to humans through direct contact with animals and animal products, including at markets, through faecal products and waste, and through the environment, including water sources.

“In Cambodia, certain specific pathogens which we know are typically infecting pigs are also now entering humans,” she said.

As complex as climate change

While the main driver of AMR appears to be pretty clear-cut – inappropriate and overuse of antimicrobials – the solutions are complex and the scale of the problem daunting.

With its global consequences and need for action at all levels, The Lancet Infectious Diseases Commission goes so far as to compare it to climate change.

An AMR working group was established under the Ministry of Health in 2012 and is in the final stages of reviewing both a national policy and five-year strategic plan to combat AMR, with the assistance of the World Health Organization.

“MOH regards AMR as a priority and fully abides by the 6-point policy package of the WHO,” working group chairman Dr Sok Touch said, adding that members from 19 entities, including the Ministry of Agriculture, were part of the group.

The WHO policy package includes regulating and promoting the rational use of antimicrobials, including in animal husbandry, and enhancing infection prevention and control in healthcare settings.

But according to Vlieghe, Cambodia needs a national program.

“A working group doesn’t have the power or line management such as you have with national programs for tuberculosis, HIV or malaria. It’s a big challenge and many actors need to be involved,” she says.

“They should be getting more money and more power to work. It’s quite urgent and a very complicated problem.”

While addressing AMR will take time, pushing Cambodians to stop buying and selling antibiotics without a prescription would go a long way in addressing a major root cause, says UHS’s Monidarin, who sits on the AMR working group.

“We would like to push and include in the strategy one issue in particular. No prescription, no antibiotics. We need to work a lot on this point and express [its importance] to all stakeholders – patients, clinicians and pharmacists.”

Given the lax attitudes of pharmacists who should know better but aren’t forced to comply with the medicines policy, Monidarin might have his work cut out.

As one Tuol Tom Poung pharmacist says: “We should sell antibiotics according to a doctor’s prescription, but here, people can mostly still buy it. If they want to get it, I’ll still sell it.”