Antimicrobial resistance: the Hydra among us

Antibiotic Resistance With increasing antimicrobial resistance, there is concern that we might enter an era where we lose the essential contribution of antibiotics in treating bacterial diseases.

Marco De Ambrogi

Senior Editor, The Lancet Infectious Diseases

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Thus, to increase awareness of global antibiotic resistance and to encourage best practices among the general public, health workers, and policy makers, WHO has declared World Antibiotic Awareness Week for Nov 16–22, 2015. This initiative follows the endorsement of the Global Action Plan on Antimicrobial Resistance by the World Health Assembly in May, 2015, which calls on all member countries to adopt appropriate strategies within 2 years.

There is a fundamental challenge to any plan to adhere to the call of the World Health Assembly: most low-income and middle-income countries lack national surveillance systems for the prevalence of antimicrobial resistance. Implementation of antimicrobial stewardship plans at a national level is not possible if detailed information on the prevalence of antimicrobial resistance within the borders of a country is not available. Some countries such as India are slowly developing a national surveillance system, but it will take years to gather comprehensive data to develop a global picture of antibiotic resistance that is essential to put in place appropriate measures. But what should be the targets of strategies to fight antimicrobial resistance?

The Centre for Disease Dynamics, Economics and Policy recently published The State of the World’s Antibiotics, 2015, which highlights how the growth of antimicrobial resistance over the past years has been principally driven by the inappropriate use of antibiotics in two main areas: human use without medical prescription or in the presence of alternative measures, and widespread use as growth promoters in animal farming. The indiscriminate use of antibiotics without specific medical control is a problem in countries where private citizens are able to purchase antibiotics over the counter without prescription. This situation can result in overuse of these drugs, use at suboptimal doses, and interruption of therapy courses if an early resolution of the symptoms occur, all situations that favour the emergence of antimicrobial resistance.

Equally problematic as a factor that can promote antibiotic resistance is the use of antimicrobial agents as a substitute for good hygiene standards; this is a particularly sensitive issue in hospitals where the combination of a high density of patients, easy circulation of pathogens, and suboptimal hygiene standards can be explosive for outbreaks of diseases caused by bacteria resistant to antimicrobial treatment. Similarly, the use of antibiotics to promote the growth of farm animals is recognised as a relevant cause for the increase of antimicrobial resistance in recent years: in intensive farming, where animals are often housed in high numbers in limited spaces with poor hygiene conditions, antibiotics are used as prophylactic agents in food and water for the entire life of the animal.

The use of antibiotics in low doses in this context does not have a medical justification, but it is a widespread practice to overcome problems linked to overcrowding and poor hygiene. A ban on antibiotics as growth promoters was introduced by the European Union a decade ago and it did not lead to a substantial economic damage for farmers, especially when they already had good hygiene standards. Although few countries have followed this example, the situation could change very soon: in mid-October, California is expected to be the fi rst state in the USA to pass a similar law banning the use of antibiotics for growth promotion in animals. There is hope that the same legislation will be endorsed by other states of the USA, the country with the highest consumption per person of antibiotics in the world, 80% of which are used for animals. Moreover, banning the use of antibiotics as growth promoters in agriculture will be crucial in those developing countries that are the main producers of meat, eggs, and fish, such as China, India, South Africa, and Brazil, where currently there is a lack of control in the use of antibiotics.

In these countries, the optimisation of farming conditions (separation of animals in age groups, use of vaccines, high hygiene standards) needs to be promoted in parallel with a more rational use of antibiotics.

Globally, rapid action is needed to gather comprehensive information on antimicrobial resistance, optimise hygiene standards in hospitals and farming, limit the use of antibiotics to cases where there is a medical or veterinary prescription, and enhance the awareness of resistance among the general public and the policy makers. Antibiotics are a precious resource that has changed the face of medicine—we cannot afford to lose their effectiveness in the fight against diseases.