Some 1.27 million people died in 2019 directly as a result of infection because the bacteria causing the infection were resistant to the drugs designed to kill them, according to a recent study in The Lancet; overall, antimicrobial resistance (AMR) is estimated to have contributed directly or indirectly to the premature, preventable deaths of nearly five million people in 2019.
In fact, AMR has become a leading cause of death worldwide, killing more people than HIV/Aids and malaria. By 2050, the number of deaths associated with AMR could reach 10 million and cost more than US$100 trillion (3.6 quadrillion baht) without collective action.
For people living with cancer, AMR poses a particular threat due to compromised immune systems resulting from chemotherapy and other treatments, which makes them even more vulnerable to infections. About one in 5 cancer patients undergoing treatment are hospitalised due to infection and antibiotics are a key line of defence in cancer care. AMR is therefore undermining key advances being made in cancer care by threatening the survival of people with cancer: it is estimated that 8.5% of deaths among people being treated for cancer are due to severe sepsis or blood poisoning.
Overuse and misuse of antimicrobial medicines in people as well as in farm animals are major factors that have contributed to the development of drug-resistant pathogens. For instance, they are too often prescribed for viral infections such as colds and flu, which are unaffected by antibiotics, and given preventatively and as growth promoters to healthy animals.
Another major reason for the development of drug resistance, especially in low- and middle-income countries (LMICs), is the lack of access to timely and appropriate treatments for infections. There is also a lack of access to affordable rapid diagnostics tests that can give accurate and real-time results, enabling healthcare practitioners to prescribe antibiotics efficiently and appropriately.
For these reasons, LMICs carry the highest burden of deaths due to AMR; for example, the mortality rate attributable to AMR is more than four times as high in sub-Saharan Africa than in Australasia. Another contributing factor includes the difficulty in implementing methods to control and prevent infections that have been used effectively in high-income countries: hospital hygiene, improved water and sanitation, and investments in public health.
Finally, according to the study conducted by The Lancet, "Global burden of bacterial antimicrobial resistance in 2019: a systematic analysis" -- the first comprehensive assessment of the global burden of AMR -- there is a significant lack of high-quality data on infectious disease, pathogens and AMR in many low-income settings.
Decreasing AMR-related mortality will require more investment in resilient health systems, greater political will and action by individuals.
In 2015, the World Health Assembly adopted the World Health Organization (WHO) global action plan on antimicrobial resistance. It outlines five objectives encompassing education and training, evidence gathering and sharing, sanitation and infection prevention measures, optimised use of antibiotics in humans and animals and economic arguments for sustainable investment in new medicines, and diagnostic tools and vaccines.
Only 25 new antibiotics were developed from 1999 to 2014; of these only 12 were registered in more than 10 countries. Thus it is essential to develop not only new medicines but also affordable alternatives, as well as rapid diagnostic testing at point of care to ensure diagnostics are more accessible and antimicrobials are used appropriately.
Another line of defence is the prophylactic use of vaccines to prevent the most common pathogens that contribute to antimicrobial drug-resistant diseases from causing life-threatening infections. Vaccines can also be used in animals to reduce the spread of diseases and the misuse of antibiotics.
At the country level, public health authorities should design and implement national action plans that address infection and prevention control. These plans should align available resources with specific country needs using the WHO costing and budgeting tool. They should also be aligned and integrated with other health programmes, including national cancer control plans, to optimise the use of resources.
Also needed are country-level antimicrobial stewardship programmes as well as establishment of a global framework for guidance on principles. Such a framework will take in: governance and accountability, improved data collection and progress monitoring, standard setting of regulations, and targets for greater access to and the responsible use of antimicrobial medicines.
To this end, of course, any global framework should ensure that adequate and sustainable financing is included and that AMR efforts are resourced. Furthermore, all relevant stakeholders must be included: government ministries -- encompassing not only health but also the economy, education, agriculture and the environment -- civil society organisations, academia, professional associations and private-sector companies.
Often the misuse of antibiotics starts at the community level. Change can be achieved by improving the capacity and training of pharmacists and primary care physicians in the use of antimicrobials. For instance, according to a report in The Lancet, while Covid-19 has exacerbated AMR -- with data showing that some 7% of Covid-19 diagnoses were associated with bacterial infections -- a US study reported that 72% of Covid-19 patients received antibiotics even when not clinically indicated.
Fighting AMR also involves mobilising the general public. Individuals likewise can act by using antibiotics only when prescribed by a certified health professional, not sharing unused medicines, and regularly washing hands, preparing food hygienically, practising safe sex and keeping vaccinations up to date to prevent infections.
Dr Sonali Johnson is Head of Knowledge and Advocacy at the Union for the International Cancer Control and a frequent contributor of medical publications such as 'The Lancet'.