Containing Global Antimicrobial Resistance

Antimicrobial resistance (AMR) is a quieter catastrophe that has been shadowed by pandemics, wars, and economic crises. AMR rises slowly and steadily, unlike the new virus. Its impact is already devastating, and it is time to rethink our strategy to contain it. Unless we collectively rethink how to rationally use antibiotics, we are rapidly reaching the point when ordinary infections become untreatable, surgeries may become life-threatening, and we head towards the dark ages of medicine.  The Lancet (2019) reports AMR kills over 1.27 million people directly each year and is associated with nearly 5 million deaths globally. The number is rising incrementally and deaths associated with AMR are also expected to increase by 74.5 per cent, from about 5 million in 2021 to 8.22 million deaths in 2050. 

Antimicrobials are the backbone of the treatment of infectious diseases. These medicines make cesarean deliveries safe, enable cancer patients to withstand chemotherapy, protect patients during organ transplants, and treat commonly encountered bacterial infections such as pneumonia, typhoid, or meningitis. These drugs remain effective only when microbes remain sensitive to them. Every course of antibiotics exerts selective pressure by killing sensitive bacteria and leaving those that are resistant. 

Irrational use 

The resistance traits can quickly pass on to future generations of the same bacteria or even to different species of bacteria. The process is called evolution and natural, but also inevitable. The speed with which resistance is spreading is worrisome. The process of resistance is being accelerated owing to misuse, overuse, and even underuse. Antibiotics are often prescribed for viral infections, which is irrational. In many developing economies, antibiotics are available over the counter, and in some countries, counterfeit or substandard drugs are available widely. 

On one hand, even a rational use increases antibiotic resistance owing to natural evolution, but on the other hand, its irrational use accelerates resistance among microbes. The problem of antibiotic resistance is not only due to its misuse, overuse, or underuse, but also its use in other areas such as growth promoters in animals, and use in other areas of agriculture. The amount of antibiotics consumed as an animal growth promoter is massive. All these uses provide microbes with an enormous opportunity to develop antibiotic resistance. 

Hospitals across the world are reporting cases of “superbugs”. These superbugs are resistant to nearly all available antibiotics. The cases of tuberculosis are rising. Once easily treatable cases of gonorrhea are edging closer to being untreatable. Even fungal infections are emerging as untreatable and spreading through hospital settings. 

The antibiotic resistance is spreading invisibly, and most people are unaware of its consequences. When first-line drugs are ineffective, the prescriber has to use second- or third-line drugs, and patients have to stay longer in the hospitals, adding economic burden to them. The security that was provided by the discovery of antibiotics is slowly eroding and may reach a catastrophic level in the future, and options may become extremely limited. 

Even though the severity of the problem is known to us, the global response is not sufficient. The healthcare system, particularly in developing countries, lacks an antibiotic surveillance mechanism. The funding for new antibiotics is not sufficient, as the return on investment is not on par with other drugs, such as diabetes or hypertensive medicines, where the return is enormous. Unlike drugs for chronic diseases, antibiotics are taken for a short period of time and antibiotic stewardship programmes rightly encourage rational use to preserve antibiotic effectiveness. At this time, many pharmaceutical companies have abandoned antibiotic research.  

The use of antibiotics in the agriculture sector remains another obstacle. Some countries have taken strong steps to limit the use of antibiotics in livestock, whereas many have not. In this situation, a coordinated step is warranted to contain antibiotic resistance, as resistant bacteria can travel freely across borders through food, animals, people, and water systems. The problem of antibiotic resistance, thus, is not a national problem but is a global one, as the misuse in one place can be felt in other places. 

However, there is a possibility of containing the spread of AMR. A robust stewardship programmes reduce unnecessary use of antibiotics. Now, we have rapid diagnostic tools to distinguish between bacterial and viral infections, thus limiting their use in cases of viral infections. The different approaches of infection control, from vaccination to sanitation, good hygienic practices to the use of clean water, can significantly reduce the need for antibiotics. Similarly, in the agricultural sector, better farming practices and regulations in the use of antibiotics as a growth promoter can curb misuse. The pharmaceutical companies should be encouraged through different policies to invest in the field of antimicrobial research. 

Comprehensive solution 

However, we need to promulgate a comprehensive solution for the problem. AMR has posed both cultural and political challenges. Antibiotics are not a cure-all medicine and its use is finite. Oftentimes, prescribers face patient pressure for antibiotic prescriptions. Hence, educating the public of its rational use is equally important. Global cooperation is paramount as resistance anywhere is a risk everywhere. 

It is time to invest in protecting the power of antibiotics with the coordinated efforts from all stakeholders from the government to the healthcare professionals to consumers. Unless we coordinate, surgeries may become riskier, childbirth may become dangerous, and those bacterial infections we thought long conquered may return. The economic cost of inaction is massive and human cost is immeasurable. Therefore, the way forward is scientific endeavor, political will, and cultural change.  

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