Tackling Antimicrobial Resistance

Dr. Shyam P Lohani 

Antimicrobial resistance (AMR), the tendency of bacteria and other pathogens to evolve so they fight or evade lifesaving drugs, is a long-term threat to modern medicine. Bacterial diseases were the biggest cause of human mortality before the discovery of antibiotics. The finding of antibiotics, the “miracle drugs”, sharply reduced morbidity and mortality owing to bacterial infections. 

Antibiotics have become foundation of modern medicine, but their overuse and/or underuse is leaving healthcare professionals in every country unable to treat common illnesses such as urinary tract infections to sepsis, and pneumonia.  Antibiotics have transformed medical practice and saved incalculable lives over the past eight decades. Now, extensive overuse and the lack of new drugs in the development process threaten to undermine their effectiveness.

Gravity

Over the past two years, however, the world has been brought to standstill for months and faced a surprise by a constantly mutating virus. But while our attention remains fixed on COVID-19, another more deceptive health crisis slyly plots its course i.e. antimicrobial resistance. It is natural phenomenon that microorganisms adapt and become resistant to medicines used to treat bacterial, viral, parasitic, and fungal infections. Many bacterial species evolved naturally the ability to resist antibiotics long before humans started to manufacture them to prevent and treat infectious diseases.  In addition, overuse and misuse of antibiotics in human, veterinary and agriculture have significantly contributed to the gravity of the problem.

Sometimes labelled as the silent pandemic, AMR has slipped from the headlines due to the COVID-19 pandemic but remain among the biggest threats to public health throughout the world. If the present trends of antibiotics resistance continue, a post-antibiotic era, in which common infections and minor injuries can kill, is instead a very real possibility for this century. Top six pathogens leading to deaths in terms of drug resistance include Escherichia coli, Staphylococcus aureus, Klebsiella pneumoniae, Streptococcus pneumoniae, Acinetobacter baumannii and Pseudomonas aeruginosa.

In 2019, AMR caused an estimated 700,000 deaths worldwide, and no country has now remained untouched. The death toll attributed to AMR in 2019 exceeded the combined deaths due to HIV/AIDS and malaria. Only ischemic heart disease and stroke accounted for more deaths in that year. The number could increase to 10 million per year by 2050 if not addressed timely. The growing evidences indicate that some of the developing countries are suffering the highest burdens of AMR.

There has been increasing concern on evidences that quality of medicine is a significant factor for the development of AMR besides our much attention on the improper use of antimicrobials. Poor quality medicines with a lower dose of the active ingredient can lead to resistance.

The consequences of evolution of antibiotic resistance pathogens are many, ranging from more resistant cases to inability of common antibiotics to kill bacteria, the risk of spreading resistant infections and illnesses and prolonged hospital stays. All of these increase the costs of treatment of illnesses and also increases chances of death.

The approaches to contain antimicrobial resistance have been clear for some time. It is clear that we need better stewardship of antibiotics such as avoiding overprescribing, under prescribing or wrongly prescribing them for viral infections. Our attention should focus largely on preventing resistant infections in the first place. Strategies aimed at addressing AMR include ensuring broad access to antibiotics at affordable price, proper stewardship of existing antimicrobial treatments, and investments in the development of new treatments. And the role of medicine quality should never be underestimated. Another most urgent need is to minimise the overuse of antibiotics in medicine and agriculture, which accelerates the development of resistant strains.

Accelerated development of new antibiotics has become essential to counter increasing AMR. New drug development process requires large investments; however, antibiotics yield smaller returns because they are used for a limited period of time. Unlike drugs to treat chronic diseases like cancer and cardiovascular ailments, antibiotics are typically taken for a short period of time, and any new drug is often used sparingly and held in reserve to treat patients who are resistant to existing drugs.

Stewardship practices

Unfortunately, resistance inevitably develops through the evolution of the targeted bacteria in months to years even after the introduction of a new antibiotic. It is important to know the global context of AMR such as pathogens are the biggest threats in each country, and how they are spreading in order to develop harmonized policy to tackle it globally.

We must preserve the power of antibiotics that still work by strengthening stewardship practices besides continuous encouragement for the development of new drugs. Antibiotics are too often used as a cheap replacement for addressing structurally fundamental issues. By improving access to clean water and sanitation, strengthening public health systems, implementing infection control and changing food production practices, we can reduce unnecessary use of antibiotics. We must intensify efforts to strengthen infection control procedures in hospitals to reduce the spread of resistant microbes. The public needs to be aware of issues of AMR and acknowledge the efforts to promote prudent use of antibiotics. 

(Dr. Lohani is the clinical director at the Nepal Drug and Poison Information Centre. lohanis@gmail.com)