The authors turn the spotlight on the root causes of the rise of antibiotic resistance worldwide at a time when a global shortage of antibiotics has been reported by the WHO. Relevantly, the article emphasizes some solutions and calls on philanthropies, non-government organizations, regional institutions, states, and the private sector to work together and defeat the global threat posed by superbugs

By Taye T. Balcha, MD, PhD, MPH

Director of Armauer Hansen Research Institute in Addis Ababa, Ethiopia

Donna A. Patterson, PhD

Director of Africana Studies and Associate Professor of History at Delaware State University, USA

The Global Rise of Antibiotic Resistance

 

In fall 2017, WHO released a report about a global shortage of antibiotics. This crisis has emerged simultaneously with a global rise in antibiotic resistance. Antibiotic resistance is a growing public health threat. Much of this antibiotic resistance is human-made. Shortages of antibiotics led to superbugs and are often caused by the overprescribing antibiotics, improperly taking prescribed antibiotics, and consuming substandard medicines as well as the extensive use of antibiotics in agriculture.

The over-prescription of drugs, improper consumption, parallel drug markets, and rampant antibiotic use all drive the growing global threat posed by antibiotic resistance. These factors are interrelated in different ways. For example, underdeveloped diagnostic facilities combined with overzealous prescription of antibiotics have led to increasing empirical treatment of infections. Responding to pressure from patients, doctors sometimes prescribe antibiotics for viral conditions despite their non-efficacy for viral infections. In certain settings, antibiotics are also used as long-term anti-malarial prophylaxes. This excessive and at times inappropriate use of antibiotics encourages some bacteria to adapt to the condition. Eventually, the bacteria fail to respond at all to the specific antibiotic or even others. The widespread use of antibiotics creates a critical mass of people with resistance to certain antibiotic classes.

It is also not uncommon for pharmaceutical consumers either—knowingly or unknowingly—to fail to take the fully recommended regimen of antibiotics. This self-medication frequently leads to under-consumption due usually to perception of improvement or cure before completing a full course of treatment. Under-use of antibiotics promotes bacterial mutations that contribute to antibiotic resistance.

At the same time, drugs are also sold in extralegal pharmaceutical markets, on the street, or in other undesignated spaces. Vendors selling these drugs are not trained in pharmacology and may or may not know the correct dosage to prescribe. Further, a growing percentage of street drugs are substandard or even counterfeit. At the household level, it is mostly impossible to regulate and test the active ingredients of these drugs prior to consumption. Some drugs purchased in these parallel informal networks contain little to none of the active ingredients.

In some cases, the problem transcends the boundaries of the health sector itself. In the United States (US), for instance, up to 80% of animals including chicken, cows, and pigs are given antibiotics. Therefore, antibiotics are regularly used in animal feed and this fuels the emergence of antibiotic resistance.

If these unbridled trends continue, we may certainly run out of antibiotics. In particular, several countries including India and South Africa have reported tuberculosis superbugs resistant to virtually the entire existing antibiotic arsenal.

Given the slow-moving research and development in antibiotics, this report is alarming. Similarly, outbreaks of sexually transmitted infections that cannot be cured with the available medicines have been reported in the US and other countries.

Currently, global fatality attributed to antibiotic resistance is estimated at 700,000 a year. With doctors increasingly running out of weapons to deploy, this toll could climb to 10 million a year by 2050. This fast spreading threat to humankind deserves immediate interventions at each layer of the health system. We recognize the heightened effort to combat this threat at WHO and other multilateral agencies. Due to the urgency of the threat, our response should be global, comprehensive, and match the threat level. Philanthropies, non-government organizations, regional institutions, states, and the private sector should work together to defeat the global threat posed by superbugs.

We recommend the following solutions:

1. WHO should encourage countries to implement the Global Action Plan adopted at the 68^th World Health Assembly in 2015 to help tackle antimicrobial resistance. It should support nations that conduct regular antibiotics surveillance and take appropriate actions. Diagnostic capabilities including point-of-care identification of resistant types should be in place.

2. Nations have to scale up their regulation of the importation and distribution of pharmaceutical drugs. Sustained and stringent regulation has to be in place so that national borders are more impenetrable to the movement of substandard or counterfeit medicines. Countries such as Kenya and South Africa have done good work curbing the influx of substandard and counterfeit medicines.

3. Nations should implement sustained infection prevention standards in clinical settings and nursing homes. This could intercept spread of resistant strains in high-risk areas and contributes to reduction of incidence.

4. The inappropriate use of medicines in meat production requires greater intervention. Overzealous use of antibiotics in growing/fattening animals drives obesity and attendant complications. Also equally important, repeated consumer exposure to staple antibiotics is a major source of antibiotic resistance. As a consequence, interventions should cross the boundaries between livestock and human health. Antibiotics use should be greatly reduced in livestock. It should not be given with general feed as a preventative on mega-farms but instead only used in cases of infections posing threats to life.

5. Research and development streams should be the major focus of intervention. Limited research underway is also largely focused on repurposing available antibiotics rather than developing novel ones. As the rate of emergence of resistance to available antibiotics is presently unequaled by new discoveries, wider-scale, accelerated efforts are needed. Development of new antibiotics should mainly be enhanced for microbes that currently lost efficacious medicines to resistance.