How can we prevent a world of AMR?

Maria Boylan

3rd Year Medical Student

Introduction

Alexander Fleming was awarded the Nobel Prize for "for the discovery of penicillin and its curative effect in various infectious diseases" in 1945[1]. Referred to as the ‘miracle drug’, it was utilised extensively in World War II for surgical and wound infections. In his Nobel Prize acceptance speech in 1945, he warned of Penicillin resistance to bacteria. (Prevention 2017)

Antimicrobial resistance is a continually evolving global issue and one of the greatest threats to human health security, rising to alarming proportions. The World Health Organization (WHO) defines Antimicrobial Resistance (AMR) as the ability of a microorganism (bacteria, viruses, and some parasites) to prevent an antimicrobial (antibiotics, antivirals and antimalarials) from working against it resulting in:

1. Standard treatment becoming ineffective

2. Persistent infections,

3. Spread of infection. (WHO 2015)

Ineffective Treatment

Though a natural evolutionary phenomenon, bacteria that have evolved by new resistance mechanisms can lead to life-threatening infections, rendering the latest generation of antibiotics virtually ineffective. (Jindal et al. 2015)  AMR is a worrisome threat to the advances made in public health. Infections triggered by resistant microorganisms are failing to respond to conventional medicine, leading to prolonged illness, increased mortality and higher costs. (WHO 2017)

Persistent Infections

Many infectious diseases risk becoming untreatable and uncontrollable with the extreme resistance of microorganisms to current antibiotics. When microorganisms are exposed to an antimicrobial, the more susceptible organisms surrender, and those resistant remain, passing on this resistance to their off spring.

Spread of Infections

Drug-resistant infections are accelerated by poor infection control and prevention procedures and antimicrobial misuse. The global distribution of AMR is exasperated by growth of global trade and travel. Infections caused by resistant bacteria can be endemic, or can occur as an epidemic, crossing borders, cultures, health care facilities, leaving long-term devastating effects in the community. Surveillance systems in high income countries have revealed that the problem exists both in hospitals and the community. (Singh 2016)

Consequences of antimicrobial resistance

1. Duration of hospital stay and therapy increases with infected patient with a resistant bug.  

2. Higher morbidity and fatality rates

3. Longer duration of infection – Increased risk of transmission of the microbe

4. Increased rate of colonization and resistance spread in hospital setting

5. Surgical procedures depend on the use of antibiotics pre and post operatively. If the antibiotics are no longer effective, even the routine surgeries will be risky.

6. Increased costs

      a. Expense of drugs which failed to treat microbe, plus the additional drug    (usually more expensive) and inaccessible in under developed countries.

     b. Longer hospital stay = more treatments, therapies etc. (Bairy et al. 2016)

How do we cause a world of Antimicrobial Resistance?

· Misuse of antimicrobials:

        o It’s estimated that up to 50% of worldwide prescriptions are over-prescribed,             under prescribed or unnecessary including: (Bairy et al. 2016)

                    §  Unnecessary polypharmacy (more antimicrobials than required);

                    §  Insufficient dosage of the antimicrobials;

                    §  Non-compliance with existing clinical prescribing guidelines;

                    §  Unsuitable route of administration of antimicrobials;

                    §  Self-medication.

· Prescribing drugs used in humans to animals,

        o  Majority of antibiotics are used for growth promotion in animals causing               resistance in microorganisms, ultimately spreading to humans. (WHO 2017)

· Antibiotic application in the form of sprays in agriculture,

         o Industrial and agricultural misuse are responsible for widespread resistance. (WHO 2017)

·  Using wrong antibiotics or right antibiotics at wrong doses for a wrong duration. (Bairy et al. 2016)

         o In low and middle income countries, where incidence of infectious diseases            such as malaria and pneumonia, the irrational use of antibiotics is unchecked. [2]

What can we do – How can we prevent a world of antimicrobial resistance?

 Education

Spreading awareness of AMR and improving awareness and understanding of the consequences on current and future healthcare to the public through advertisement, social media, street art etc., will assist in prevention of AMR. (Plianbangchang 2007) AMR-related initiatives, such as Antibiotic Awareness Week and other education campaigns target both health professionals and the public. (Bairy et al. 2016) Through these initiatives, the public are advised to use antimicrobials only when prescribed and to complete the course as advised. Informing patients about self-medication of the correct dosage of the specific drug involves input from a variety of stakeholders including prescribers, pharmacists and policy makers.

Infection Prevention & Control

Vaccination programs and strategies for infection prevention, including correct hand washing techniques and basic hygiene would reduce infection control status in hospitals and the community. (Chandy 2015; Singh 2016)

Ensure proper use of antimicrobial medicines

As recommended by the WHO, it is imperative that appropriate antimicrobial prescribing, dispensing and administration procedures are implemented. Appropriate use of antimicrobials will guarantee those who require antimicrobial treatment have access to quality-controlled recommended standard treatment, while eradicating the discerning practice of inappropriate antibiotic use. (Bairy et al. 2016)

It is essential health care professionals adhere to their duty to prescribe and dispense the correct dosage of antimicrobials at the appropriate time and setting to the specific person requiring treatment.

Prevention of AMR in agriculture

Measures and controls can be implemented and co-ordinated to prevent AMR spread from industrial food and animal production to humans such as animal vaccination to reduce need for antibiotics, and improved biosecurity on farms for infection prevention. (Prevention 2017) Co-ordinated interventions such as ‘Antibiotic steward programmes’ initiatives can be an effective means of controlling the appropriate use of antimicrobials. (Bairy et al. 2016)

Strengthen surveillance and research

AMR surveillance is crucial for proper monitoring, analysis and regulation of quality antimicrobial use. Transparent accessible policies, using relevant research and development, to optimize antimicrobial use and prevent excess microbial use may help in tackling AMR. (Singh 2016) Investment in research and development in countries which lack laboratory facilities to correctly identify resistant microorganism will strengthen surveillance of AMR. Regular collection and data analysis will improve the ability to detect AMR and take prompt action. Pharmacovigilance[3] could be one of the few solutions to obtain data on the actual scenario of antimicrobial resistance in individual patients. (Bairy et al. 2016). This analysed data could inform National and international policies on appropriate antimicrobial usage.

Equally sufficient research and investment in developing new vaccines, antimicrobials and diagnostics to detect resistant micro-organisms and prevent disease is necessary. 

Global need for antibiotics, and antibiotic resistance

Advances in new antimicrobials has decelerated substantially, while simultaneously increasing resistance among nosocomial pathogens has emerged. Sustainable and responsible investment in new antibiotics is required to minimize antimicrobial resistance and prolong their effectiveness. Scientific innovation in newer techniques and methods of vaccination delivery, infection control programs and diagnostics could reduce the demand for antibiotics. (Gelband and Laxminarayan 2015)

Conclusion

Antibiotic resistance imposes a substantial public health burden. Existing antibiotics, anti-parasitic drugs, and antiviral drugs, are losing their effect with devastating and disturbing consequences.

Co-ordinating and implementing effective and efficient public health programs including enhanced hygiene and sanitation, increasing immunization coverage, and rapid outbreak responses will reduce dependence on antimicrobials. (Jindal et al. 2015) Hand hygiene, antimicrobial stewardship, and education are important strategies to be implemented on an urgent basis to break the chain of transmission of resistant microbes.

Sustainable investment and research into innovative antimicrobials is imperative to prolong their effectiveness and curtail antimicrobial resistance.

References

Bairy, L.K., Nayak, V., A, A. and Kunder, S.K. (2016) 'Advances in pharmacovigilance initiatives surrounding antimicrobial resistance-Indian perspective', Expert Opin Drug Saf, 15(8), 1055-62, available: http://dx.doi.org/10.1080/14740338.2016.1182495.

Chandy, S.J. (2015) 'Antimicrobial resistance and inappropriate use of antimicrobials: Can we rise to the challenge?' in Indian J Pharmacol, India, 347-8.

Gelband, H. and Laxminarayan, R. (2015) 'Tackling antimicrobial resistance at global and local scales', Trends Microbiol, 23(9), 524-6, available: http://dx.doi.org/10.1016/j.tim.2015.06.005.

Jindal, A.K., Pandya, K. and Khan, I.D. (2015) 'Antimicrobial resistance: A public health challenge', Med J Armed Forces India, 71(2), 178-81, available: http://dx.doi.org/10.1016/j.mjafi.2014.04.011.

Plianbangchang, S. (2007) Role of Education in Rational Use of Medicines, New Dehli: WHO.

Prevention, C.f.D.C. (2017) About Antimicrobial Resistance, available: https://www.cdc.gov/drugresistance/about.html [accessed 5th Jan].

Singh, N. (2016) 'Major partnerships are essential to address antimicrobial resistance', Lancet Glob Health, 4(4), e237-8, available: http://dx.doi.org/10.1016/s2214-109x(16)00002-4.

WHO (2015) Campaign toolkit -

Antibiotics: Handle with care, available: http://www.who.int/mediacentre/events/2015/world-antibiotic-awareness-week/toolkit/en/ [accessed Jan 5th].

WHO (2017) Antibiotic Resistance, available: http://www.who.int/mediacentre/factsheets/antibiotic-resistance/en/ [accessed 5th Jan].

[1] Staphylococcal organisms developed resistance to penicillin by producing beta lactamases and destroyed the beta lactam structure, rendering them ineffective. The issue recurred since with newer classes of drugs e.g.aminoglycosides, glycopeptides

[2] In India for example, the infectious disease burden is one of the highest worldwide. Recent report revealed the inappropriate and irrational use of antimicrobial agents against these diseases, which led to increase in development of AMR.

[3] Pharmacovigilance – the science and activities relating to the detection, assessment, understanding, and prevention of adverse effects or other drug-related problems, as defined by the WHO.