Antimicrobial resistance is an existential threat on par with climate change

Modern medicine on the brink

AMR is the ability of microorganisms – including bacteria, fungi, viruses and parasites – to resist the effects of antimicrobial medications, such as antibiotics. Alexander Fleming himself hinted at the risk of penicillin resistance during his 1945 Nobel Prize speech (3). But we never could have predicted the global catastrophe that is unfolding today.

A growing list of unsettling statistics paints the picture of a world on the brink. According to the World Health Organization (WHO), antibiotic-resistant bacterial infections were estimated to be directly responsible for 1.27 million deaths, and associated with 4.95 million deaths, in 2019 alone (4). Globally, there were an estimated 450,000 incident cases of multi-drug-resistant or rifampicin-resistant tuberculosis (MDR/RR-TB) with increasing trends in many regions (5). These numbers are staggering, and are expected to increase as antibiotic resistance continues to accelerate (1).

AMR is a complex global problem with no single cause – and no single, easy solution. But the COVID-19 pandemic showed us what we can achieve when governments, international bodies and industries set clear priorities and cooperate on shared goals. The same approach must be applied to the AMR crisis.

To effectively tackle AMR, we first need to understand the full scope of the problem. We can’t develop effective intervention strategies until we are able to fully understand the mechanisms that drive AMR and the epidemiological pathways of AMR.

Of great importance, we need to invest in long-term, global strategies to enable routine molecular surveillance, especially in low- and middle-income countries (LMICs). This will require a global commitment to boost surveillance capacity so that all countries can provide quality-assured data.

We should consider innovative and effective approaches to surveillance, such as wastewater analysis using whole genome sequencing and digital PCR. These approaches have been invaluable for tracking and predicting SARS-CoV-2 outbreaks during the COVID-19 pandemic (7).

An equitable approach

The burden of AMR is especially severe in LMICs where there is limited access to quality healthcare and antimicrobials, poor sanitation and hygiene and the overuse of antimicrobials in agriculture and animal husbandry. While AMR is a global threat that requires a global response, it is essential to focus on the needs of LMICs in order to reduce the burden of AMR worldwide.

We need to ensure that everyone has access to the benefits of research and development, not just people in wealthy countries. The global community must invest in programs to improve affordable access to new and existing life-saving antibiotics to people in LMICs (8).

The WHO promotes a “One Health” approach to tackling AMR,  which acknowledges that human, animal and environmental health are intrinsically linked (9). A major focus of this approach is tamping down the overuse and misuse of antibiotics in agriculture, livestock and animal husbandry (10).

However, the important role that animal agriculture plays in livelihoods in LMICs is often unknown or underestimated. It is therefore important to find ways to reduce the use of antibiotics in animal agriculture without jeopardizing food security or animal welfare. This will require a collaborative effort from all stakeholders, including governments, farmers, industry and consumers (10).

Responsibility in the clinic

Inappropriate use of antimicrobials in the clinic is yet another factor driving resistance. When antimicrobials are used unnecessarily or incorrectly, like when an antibiotic is used to treat a viral infection, it allows resistance to emerge. However, clinicians on the frontlines of care often lack the tools needed to differentiate between viral and bacterial infections. A recent study found that without laboratory diagnosis, clinicians could only identify respiratory tract infections 37% of the time (11). 

When AMR threatens modern medicine, we can no longer afford to guess when it comes to diagnosis – we must adhere to a “test and then treat” approach. Hospitals and other healthcare settings should invest in rapid, accurate diagnostic technology that can be used at the point of care.

Many studies show that rapid diagnostics are most impactful when implemented in the context of an antimicrobial stewardship program. These programs, which support the judicious use of antimicrobials, are a linchpin of the World Health Organization’s Global Action Plan on AMR.

They foster comprehensive policies and procedures to guide antimicrobial prescribing, track antimicrobial use and resistance patterns and help to identify areas where antimicrobials are being used inappropriately. Stewardship programs must become a global health priority, and be strengthened through adequate funding and resource allocation. 

Economic change and acting as one

The creation of new antimicrobials has long lagged behind demand. This is due, in part, to the current economic model incentivizing drug development. Antibiotics are significantly less lucrative than other treatments, such as cancer drugs, and their development has been deprioritized by pharmaceutical companies (12). As a result, there is a shortage of new antimicrobials in the drug development pipeline. The last novel antibiotic class, oxazolidinones, was discovered in the 1980s, and the first antibiotic from this class, daptomycin, reached the market in 2003 (1). 

Some countries are creating new economic models for incentivizing de novo antibiotic development. In the US, a piece of legislation called the PASTEUR Act would pay pharmaceutical companies to invest resources into innovative antibiotic research (1).

The AMR crisis is a complex global problem that threatens modern medicine and has no single, easy solution. It requires a coordinated global effort, involving healthcare, governments, industry and academia. We need to invest in research, improve access to antimicrobials and diagnostics, promote responsible use of antimicrobials and develop new economic models to incentivize the development of new antibiotics and diagnostic tools. By acting together as one, we can protect modern medicine and ensure that everyone has access to the healthcare they need.