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Increasing risk of antibiotic resistance demands immediate global action
Resistance trends may be moving at a faster pace than previously believed.
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A return to pre-antibiotic conditions may occur as a result of antibiotic abuse and declining development of new medicines, according to an analysis published in the British Medical Journal.
The phenomenon of antimicrobial resistance involves a cross-section of medical, governmental, organizational and economic factors. An international panel of researchers attempted to target several elements of the problem. They narrowed the action points to three key areas: leadership on international and national levels, change in the behavior of consumers and providers, and the development of antibacterial agents to match current public health needs.
Otto Cars, MD, PhD, professor of infectious diseases in the department of medical sciences at Uppsala University in Uppsala, Sweden, discussed the urgency of the problem of resistance. “It is quite evident that resistance trends are moving at a faster pace than anyone could expect,” he told Infectious Disease News. “Even a few years ago, I would not have said something like that. But the reality is that, at the moment, there may very well be a gloomy picture for the future of antibiotics.”
Government intervention
The researchers wrote that the ultimate responsibility for coordinating strategies to fight resistance lies in government hands. However, policymakers at national levels appear to be unable to accept the problem of resistance as a legitimate threat, according to the researchers. WHO and the World Health Assembly have offered resolutions and strategies for combating resistance, but there has not been satisfactory follow-through from governmental organizations. Nor has there been enough financial or human resource support to implement the initiatives.
A ground-up approach to solutions likely may be most effective. Although nongovernmental organizations can create plans and conduct research, governments at all levels need to provide opportunities for implentation of policies, and then to monitor and execute the programs. National and local officials should be aware of surveillance policies and intervention strategies recommended by the scientific community.
Government agencies also should ensure that basic human needs are taken care of to help promote general public health and prevent disease. Safeguarding drinking water and sanitation as well as encouraging good nutrition practices all are effective preventive measures well within the scope of civic jurisdiction.
The report provides examples of countries that have taken the problem of antimicrobial resistance seriously. Sweden has instituted a multidisciplinary program to fight resistance; Chile conducted a media campaign and regulatory measures. Both programs have been successful.
Economic factors
A unique quality of antibiotic resistance is that it does not always conform to economic boundaries. The researchers wrote that in hospitals in low- or middle-income countries, 70% of neonatal infections were untreatable using antibiotic regimens recommended by WHO. However, they also wrote that the European Centre for Disease Control and Prevention recently reported that resistant micro-organisms are the most important threat across Europe.
In developing countries, weak health care systems treating poor patients contribute most significantly to the problem. In high-income nations, strategies for implementing regulations and policies are not coordinated. For example, antibiotics are still sold over-the-counter in certain European Union nations, according to the researchers. Cars said that in some South American countries, antibiotics are delivered right to one’s door by local pharmacies.
There are tangential factors related to economics that are no less important. The increasing accessibility of air travel has allowed resistant bacteria to migrate quickly. Global distribution of food has made resistant foodborne pathogens a worldwide threat. Poor hygiene, both in hospitals and in the community at large, has facilitated the spread of resistance in many populations. Though people in developing countries are often more vulnerable to infections related to hygiene, nosocomial infections like methicillin-resistant Staphylococcus aureus are developing all over the world, regardless of economic borders.
Another factor that has developed recently is that of patients becoming consumers. The availability of health-related information has made the general populace more knowledgeable about diseases and treatments. The scientific community must make accurate information regarding antibiotic resistance readily available.
Economic factors also have influenced research into antibiotics. The scientific community and the pharmaceutical industry simply are not developing antimicrobials quickly enough to keep pace with the rate of resistance. The reason, largely, is that the market for antibiotics is small and the development of resistance has exacerbated that problem. Resistance has increased the demand for new antimicrobials but decreased the market value for such drugs. Many antibiotics have a finite period of efficacy, so the incentive to develop new ones is weak.
The researchers offered possible models that may help to increase the incentive to produce these drugs. Partnerships between public organizations and private companies may be effective. Economic mechanisms for guaranteeing revenue return for new products are another possible solution.
The researchers wrote that “a fundamentally changed view of antibiotics is needed.” This includes patient behaviors. Patient attitudes toward medications often are dictated by information from their health care providers. The public demand for antibiotics may decrease if this information includes data on resistance and viable alternatives to antimicrobial treatments.
This information needs to be disseminated delicately. “Creating a doomsday scenario will likely do more harm than good,” Cars said. “We need to move cautiously and patiently. Changing 60 years of behaviors cannot happen overnight.”
Patients cannot be expected to limit their antibiotic use to promote the greater common good of resistance prevention, according to the researchers. Members of the scientific community must highlight real risks for individuals abusing antimicrobials. One possible way of conveying this message is to conduct studies demonstrating the possibility of individuals becoming carriers of resistant bacteria. People need to know that antibiotic overuse may put them at risk for more invasive resistant infections in the future. Cars also said that studies painting a real portrait of the adverse events caused by antibiotics may be helpful. Data supporting this thesis are available — they need to be collected and published.
In the end, Cars stressed that the responsibility for meeting the challenge of resistance is universal. “We all have contributed to the problem, so we all must contribute to the solution,” he said. “We all have been fooled, even those of us in the medical and scientific communities. It is as though there has been some great self-deception. Governments need to take the lead, but everyone has a part.” – by Rob Volansky
Some of us have been preaching about antibiotic resistance for the past 40 years. It is not a new phenomenon. What is new is that we are running out of new drugs.
– Theodore C. Eickhoff, MD
IDN Chief Medical Editor
For more information:
- Cars O, Högberg LD, Murray M. et al. Meeting the challenge of antibiotic resistance. BMJ. 2008;337:726-728.