August 2017- Antimicrobial Resistance: The Way Forward 2017 (Part I)

Introduction

Antimicrobial resistance (AMR) is the ability of a micro-organism (like bacteria, virus or parasite) to stop an antimicrobial (antibiotic, antiviral, anti-parasitic) agent from working against it. As a result, standard treatment becomes ineffective, infection persists and may spread. An antibiotic is an antimicrobial agent that acts against bacteria. These 2 articles will focus mainly on antibiotic resistant bacteria.

Importance of Antibiotics and Antibiotic Resistance

The development of antibiotics is considered as one of the most important discoveries in mankind. Its widespread use has saved countless human lives but in the past few decades, antibiotic resistance has emerged significantly that has threatened human health. AMR is no longer the intellectual pursuit of the curious scientist. The dramatic increase in the proportion and absolute numbers of bacterial pathogens resistant to multiple antibiotics in recent years has prompted many regulatory agencies including Centres for Disease Control and Prevention (CDC), World Health Organization (WHO) and European Communicable Disease Centre (ECDC) to highlight this issue. Antimicrobial resistance is occurring everywhere and it is compromising our ability to treat infections and undermining our advances in health and medicine. At the 68th World Health Assembly in May 2015, WHO declared antimicrobial resistance as a global health threat and proposed a multi-year action plan to reduce antimicrobial resistance. The “global action plan on antimicrobial resistance” has 5 strategic objectives:

  • To improve awareness and understanding of antimicrobial resistance
  • To strengthen surveillance and research
  • To reduce the incidence of infection
  • To optimize the use of antimicrobial medicines
  • To ensure sustainable investment in countering antimicrobial resistance

Emergence of resistant micro-organisms by mutation and acquisition of mobile transferable genetic elements carrying resistant genes may take place spontaneously or under selective pressure in the presence of antimicrobial agents. In the recent decades, the driving force has been the use and misuse of antibiotics in humans, livestock or leakage into the environment. It has been estimated that antibiotic consumption has increased 30% from 2000 to 2010. AMR has become a global health threat that requires the involvement and commitment of numerous stakeholders. WHO has highlighted the following:

  • Antibiotic resistance is one of the biggest threats to global health, food security, and development today
  • Antibiotic resistance can affect anyone, of any age, in any country
  • Antibiotic resistance can occur naturally, but misuse of antibiotics in humans and animals is accelerating the process
  • A growing number of “common” infections – such as skin infections, pneumonia, tuberculosis, and gonorrhoea – are becoming harder to treat as the antibiotics used to treat them become less effective
  • Antibiotic resistance leads to longer hospital stays, higher medical costs and increased mortality

Put simply, if AMR is left unchecked, common bacterial infections will become difficult to treat and “simple” infections will once again kill many. The sophisticated medical interventions such as organ transplantation, joint replacement, cancer chemotherapy that characterize modern medicine will become more dangerous to perform.

The 3 Main Areas where AMR occurs

AMR in Agriculture

Whilst most of our focus is on human health and illness, a tangible solution cannot be obtained without involving stakeholders involved in animal farming, the food chain and the environment. In livestock, massive amounts of antibiotics are used as growth promoters, for prophylaxis and treatment among farm animals and aquaculture. It has been estimated that antibiotic use in animals constitute 80% of total antibiotic consumption in the US. What are the possible solutions?

  1. Banning use of antibiotics as growth promoters and limiting its use in other nontherapeutic areas
  2. Reducing dissemination of multi-drug resistant (MDR) bacteria through the food chain by improving food biosecurity, improved hygiene conditions along food chain
  3. Educational programmes for veterinarians, farmers, food handlers
  4. Linking surveillance system on antimicrobial resistance for humans and animals

AMR in the Environment

Excessive use of antibiotics in humans and animals has caused accumulation of these compounds in the environment. This may be through sewage, manure and waste bodies. Waste water plants have become a hotspot for horizontal transfer and the co-selection of genetic determinants providing resistance to antibiotics, pollutants, heavy metals, biocides, disinfectants and detergents. In this regard, we need to improve our industrial waste system for sanitation, decontamination of hospital waste water.

AMR within Healthcare Facility Setting

Acquiring multi-drug resistant bacterial infections had been a common occurrence in acute care hospitals and this has led to a public outcry. Health authorities and hospitals have moved quickly to address this problem through antibiotic stewardship programmes and strict infection control measures. It has also become apparent that it is not just acute care hospitals but day care community centres and long term care facilities including nursing homes that also harbour the problems of AMR. Simplistic quality measures do not allow comparison between health care facilities. The intrinsic factors that influence antimicrobial resistance include case-mix, individual vs multi-bed or open ward concept, staffing adequacy, environmental cleaning, adherence to hand hygiene, antibiotic stewardship and the implementation of the infection prevention and control measures.

The Way Forward

The factors have been identified and the measures proposed to reduce antimicrobial resistance are not novel and have shown measurable success in selected settings. Successful implementation requires that all stakeholders (policymakers, public health officials, regulatory agencies, pharmaceutical companies and scientific community) to work together.

Heads of State at the United Nations General Assembly in New York in September 2016 committed to taking a broad, coordinated approach to address the root causes of AMR across multiple sectors, especially in human health, animal health and agriculture. Everyone has a part in the effort against AMR and as an example, it is heartening to know that in August 2017, the fast food chain, McDonalds will be working with its suppliers to remove the use of antibiotics as growth promoters in the chicken food supply chain.