Visit an emergency ward in Nepal with high fever running for several days with no apparent cause, and chances are you will receive an intravenous drug called ceftriaxone.

Ceftriaxone, often referred to as the 'silver bullet', is a very effective, life-saving drug. Unfortunately, it is overused not only for fever of unknown origin, but also for urinary tract infection, pneumonia, meningitis, and many other infections. Even where alternative medicines are available, most doctors have come to rely heavily on ceftriaxone. However, misuse of the drug means that many organisms are now resistant to ceftriaxone and infections are harder to treat.

Ceftriaxone falls under the group of antibiotics called third- generation cephalosporins. Cephalosporins are classified into four generations based on their activity against bacterial organisms, specifically gram-negative organisms. The third generation cephalosporins are much more active than the first or second generation cephalosporins against many dangerous gram-negative bacilli.

The overuse of ceftriaxone has caused common gram-negative bacteria, for example Klebsiella and Escherichia coli to produce 'extended-spectrum beta-lactamases' ( ESBL) strains. These ESBL strains of Klebsiella and Escherichia coli are now no longer susceptible to ceftriaxone. It is as if the bugs have found an armour to defend themselves against a very powerful enemy. As a result, more potent antibiotics have to be deployed to fight against the same infection and these new drugs are usually more expensive.

ESBL strains have been increasingly documented in Nepal and indeed treatment of patients with infections caused by these strains has been challenging whether it is a neonatal sepsis, pneumonia or urinary tract infection. What is the solution?

Sensible use of third generation antibiotics is the first step in tackling this problem. Hospitals need to introduce a policy to cycle antibiotics so that another substitute antibiotic is used in place of third generation cephalosporins like ceftriaxone.

Currently ceftriaxone along with its oral form (cefixime) are easily available over-the-counter so patients don't even need a prescription. Some degree of government control in the sale of these life-saving antibiotics is essential in avoiding the dangerous spread of ESBL strains. If precautionary measures are not taken soon, we may be faced with a medical crisis in the near future.