Over the past month, I reviewed recent findings and advancements in the diagnosis and treatment of infectious diseases, particularly bacterial infections.
Kabul 24: What struck me most was that despite extensive progress in antibiotic development, major international guidelines still recommend older, narrower-spectrum antibiotics—such as penicillins, first-generation cephalosporins, tetracyclines, and co-trimoxazole—as first-line therapies for many bacterial infections.
Broad-spectrum and advanced antibiotics, especially certain injectable forms reserved for resistant organisms, are meant for severe infections, immunocompromised patients, and specific clinical scenarios strictly governed by antibiotic stewardship principles.
In Afghanistan, however, the reality is starkly different. Older, narrow-spectrum drugs recommended as first-line treatments in global guidelines are largely ignored.
Instead, clinicians frequently prescribe expensive, broad-spectrum antibiotics like piperacillin/tazobactam and linezolid upon initial patient contact, bypassing logical step-by-step selection and ignoring stewardship principles.
A decade ago, we saw a similar trend with ceftriaxone. Once a highly effective and relatively expensive drug, it was overused so indiscriminately that hospital admission alone often seemed enough to start a patient on ceftriaxone, regardless of whether a bacterial infection was proven.
Today, culture and susceptibility tests consistently reveal significant resistance to ceftriaxone.
The primary concern is repeating this mistake with newer antibiotics. Uncontrolled, off-guideline use without culture results or local resistance tracking will erode their efficacy.
When we face sepsis, hospital-acquired infections, multidrug-resistant (MDR) pathogens, or life-threatening conditions, we will be left with few working options.
Root Causes and the Structural Role of Health Insurance
Why does this inappropriate prescribing persist in Afghanistan? A major driver is the flawed structure of the healthcare system and the absence of health insurance.
In organized health systems—particularly those with universal coverage or public funding—physicians and hospitals are held accountable for treatment costs and drug choices. Structural oversight ensures prescribing is driven by clinical evidence rather than a drug’s novelty or price tag.
For instance, if an infection responds to amoxicillin, prescribing piperacillin/tazobactam instead prompts insurers to reject the claim, forcing the hospital or provider to justify the decision.
In Afghanistan, patients pay out of pocket. Without enforced stewardship, prescription oversight, or financial accountability, some private hospitals prescribe high-cost, broad-spectrum drugs unnecessarily to maximize revenue. In-house pharmacies frequently sell these medications at inflated prices, exploiting vulnerable patients.
The Broader Impact
This practice extends beyond financial strain. Unnecessary broad-spectrum antibiotic use directly harms patients and accelerates antimicrobial resistance, posing a severe public health risk.
Establishing an effective health insurance system in Afghanistan would transform health economics and enforce professional, evidence-based care.
When a third-party payer covers treatment costs, it requires clinical justification for expensive broad-spectrum drugs—preventing providers from imposing financial burdens on families and public health risks on the community for commercial gain.
While health insurance alone is not a complete solution, daily clinical practice makes one thing clear: without fundamental reforms to healthcare structure and health economics, practicing ethical, evidence-based medicine in Afghanistan remains nearly impossible.
Jamshid Mehrpoor — Kabul
