As the COVID-19 pandemic continues to consume the world’s attention and resources, a looming and burgeoning global catastrophe is emerging alongside: antimicrobial resistance (AMR) or ‘the silent pandemic’.
What are antimicrobials and AMR?
Antimicrobials are drugs that are prescribed to prevent and treat infectious diseases. Antibiotics, antivirals, antifungals and antiparasitics are collectively referred to as antimicrobials [1].
AMR occurs when, over time, bacteria, viruses, fungi and parasites change in such a way that antimicrobial drugs no longer effectively halt their growth or kill them. AMR therefore renders infections more difficult – or even impossible – to treat, and infections end up persisting for longer periods of time, increasing the risk of transmission, severe illness and death.
Although the emergence of AMR is a natural phenomenon, it has been accelerated by human action, primarily through the misuse and overuse of antimicrobials in human medicine and food production [2]. The threat of AMR is not new; Alexander Fleming, the scientist famous for his serendipitous and transformative discovery of penicillin, presciently warned about the misuse of penicillin and the selection of resistant microorganisms in his 1945 Nobel lecture [3].
World AMR Awareness Week (WAAW) runs from 18 to 24 November every year. The 2023 event embraces the theme ‘Preventing Antimicrobial Resistance Together’, encouraging best practices to further reduce the emergence and spread of drug-resistant microorganisms [4].
Why is AMR a threat?
Access to efficacious antimicrobial drugs underpins modern medicine as we know it. With the rising emergence and transmission of antimicrobial-resistant microorganisms, procedures we currently consider routine may become riskier. Our ability to perform surgery, such as hip and knee replacements, caesarean sections and organ transplants, and provide treatments, such as cancer chemotherapy – all of which carry an increased risk of infection – depends on having access to effective antimicrobials [5]. This is in addition to the fact that more people will die from common infections such as urinary tract, lower respiratory and bloodstream infections if antimicrobial-resistant microorganisms continue to emerge and spread [6].
The threat of AMR would be less daunting if we had novel, effective antimicrobials in the pipeline to replace those that no longer work against drug-resistant microorganisms. However, as it stands, the development of new drugs cannot keep pace with the rate at which agents are rendered ineffective by AMR [7]. Historically, there has been a lack of investment in the research and development of novel antimicrobials compared with other drugs, owing to challenging regulatory requirements and a lack of economic incentives [7, 8]. In 2021, for example, just 30– 40 new antibacterial drugs were in the clinical trial stages of development, compared with ~4,000 immuno-oncology agents [9, 10].
Although strategies to reduce resistance are useful and necessary, such initiatives effectively serve to buy us time. Novel drugs and strategies should be implemented sooner rather than later to combat the almost inevitable increase in resistance.
What is the scale of the problem?
AMR is a problem now, not a problem of the future. In 2019, there were an estimated 6.22 million deaths either associated with, or attributed directly to, bacterial AMR across the globe [11]. A 2016 independent review commissioned by the UK government estimated that, globally, 10 million deaths would be attributable to drug-resistant infections each year by 2050 if global policies are not implemented [12]. Already, some common infections such as HIV/AIDS, TB, urinary tract infections and sexually transmitted infections are not treatable with existing medicines [1]. In addition to the risk that AMR poses to human health, the global economic impact may be staggering, with predicted costs of 100 trillion USD by 2050 if we do not act now [11].
What can we do about it?
AMR poses a major threat to humans, animals and the environment; it is a global threat that affects us all [13].
Microorganisms travel freely (and do not respect borders!), especially in the globalised, connected world that we live in today. Therefore, support and action must be galvanised at all levels of society, from the individual right through to the global level. Underpinning all action must be an understanding and awareness of the threat itself, which is aided by campaigns such as WAAW.
What we can do as individuals [14, 15] :
• Only take antimicrobials when prescribed and adhere to the prescribing information, never sharing antimicrobial drugs with others or saving them for use later
• Prevent infections via hand washing, avoiding contact with others when sick, practising safe sex and ensuring that vaccinations are up to date
• Prepare food hygienically and (where possible) choose food that has been grown without antibiotic use
• Discuss with those around you the dangers of antibiotic misuse, AMR and the importance of infection prevention practices
What we can do as policy makers / healthcare professionals / industries [14, 15] :
• Improve surveillance of AMR
• Implement and strengthen AMR awareness programmes and policies
• Implement and promote infection prevention and control measures
• Invest in the research and development of novel antimicrobial drugs, diagnostic tools and vaccinations, at the public and the private level
• Implement rational antimicrobial prescribing practices
• Regulate and reconsider antibiotic use in the agriculture sector
Reducing the further emergence and spread of antimicrobial-resistant microorganisms is the responsibility of us all – we must work on ‘Preventing Antimicrobial Resistance Together’.
References
1. World Health Organization. Antimicrobial resistance. Available at: https://www.who.int/news-room/fact-sheets/detail/antimicrobial-resistance. Accessed October 2023.
2. Holmes AH, Moore LS, Sundsfjord A et al. Understanding the mechanisms and drivers of antimicrobial resistance. Lancet 2016; 387 (10014): 176–187.
3. Fleming A. Sir Alexander Fleming: Nobel Lecture; 11 December 1945. Available at: https://www.nobelprize.org/prizes/medicine/1945/fleming/lecture/. Accessed October 2023.
4. World Health Organization. World Antimicrobial Awareness Week (WAAW) will now be World AMR Awareness Week. Available at: https://www.who.int/news/item/06-06-2023-world-antimicrobial-awareness-week-(waaw)-will-now-be-world-amr-awareness-week. Accessed October 2023.
5. Shallcross LJ, Howard SJ, Fowler T et al. Tackling the threat of antimicrobial resistance: From policy to sustainable action. Philos Trans R Soc Lond B Biol Sci 2015; 370 (1670): 20140082.
6. University of Oxford. An estimated 1.2 million people died in 2019 from antibiotic-resistant bacterial infections. Available at: https://www.ox.ac.uk/news/2022-01-20-estimated-12-million-people-died-2019-antibiotic-resistant-bacterial-infections. Accessed October 2023.
7. World Health Organization. 2019 antibacterial agents in clinical development: An analysis of the antibacterial clinical development pipeline. Available at: https://iris.who.int/bitstream/handle/10665/330420/9789240000193-eng.pdf?sequence=1. Accessed October 2023.
8. Plackett B. Why big pharma has abandoned antibiotics. Nature 2020; 586: S50–S52.
9. Xin Yu J, Hubbard-Lucey VM and Tang J. Immuno-oncology drug development goes global. Nat Rev Drug Discov 2019; 18 (12): 899–900.
10. Beyer P and Paulin S. The antibacterial research and development pipeline needs urgent solutions. ACS Infect Dis 2020; 6 (6): 1289–1291.
11. Antimicrobial Resistance Collaborators. Global burden of bacterial antimicrobial resistance in 2019: A systematic analysis. Lancet 2022; 399 (10325): 629–655.
12. O’Neill J. Tackling drug-resistant infections globally: Final report and recommendations. Available at: https://amr-review.org/sites/default/files/160525_Final%20paper_with%20cover.pdf. Accessed October 2023.
13. Laxminarayan R, Duse A, Wattal C et al. Antibiotic resistance—the need for global solutions. Lancet Infect Dis 2013; 13 (12): 1057–1098.
14. World Health Organization. Antibiotic resistance. Available at: https://www.who.int/news-room/fact-sheets/detail/antibiotic-resistance. Accessed October 2023.
15. Ashiru-Oredope D. What is antimicrobial resistance and why do we need to take action against it? Available at: https://ukhsa.blog.gov.uk/2021/11/17/what-is-antimicrobial-resistance-and-why-do-we-need-to-take-action-against-it/. Accessed October 2023.
Author: Isabel Levy PhD | Porterhouse Medical |Intern
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