What is antimicrobial resistance? (AMR)
Our collective overuse of antibiotics is causing one of the most urgent global health problems. This overuse of antibiotics in humans, animals and plants is accelerating the development and spread of drug-resistant infections.
Antimicrobial resistance (AMR) has often been framed as a matter of people making ill-informed choices, culminating in over- and irrational use of antimicrobial medicines (Leung et al. 2011, Laxminarayan et al. 2013). In fact, there are many and complex drivers of behaviour around antimicrobial usage, and the solutions will be similarly complex and interconnected. What is clear is that change needs to occur at all levels of society from users to policy makers.
In order to effect change we must use clear, effective language appropriate for the audience in question, which will only be achieved by undertaking contextually-appropriate communication research (Wellcome, Reframing Resistance; AMR Dictionary).
The following text is abridged from an article by Wellcome on drug resistant infections.
What are drug-resistant infections?
Infections become drug-resistant when the microbes that cause them adapt and change over time, developing the ability to resist the drugs designed to kill them. One of the most common types of drug resistance is antibiotic resistance. In this process bacteria – not humans or animals – become resistant to antibiotics. These bacteria are sometimes called ‘superbugs’. The result is that many drugs, such as antibiotics, are becoming less effective at treating illnesses.
What is the difference between antibiotic resistance, antimicrobial resistance and drug-resistant infections?
Antibiotic resistance is the ability of bacteria to change in a way that makes antibiotics ineffective.
Antimicrobial resistance (AMR) is a broader term, which includes antibiotic resistance and other types of drug resistance developed by viruses (such as HIV), fungi (such as Candida) and other microbes.
Drug-resistant infections is a term we use to describe illnesses that have been caused by resistant microbes, resulting in an infection that is much harder – or potentially impossible – to treat.
Why are drug-resistant infections dangerous?
Drugs like antibiotics are a vital tool for modern medicine, used to prevent and treat infections. But drug-resistant infections are becoming more common place, putting the achievements of modern medicine at risk. Without antibiotics that work, routine surgery, common illnesses like diarrhoea, and minor injuries from accidents, even cuts, could become life-threatening. Without effective antibiotics, common infections that were once easily treatable – such as gonorrhoea and urinary tract infections – are becoming untreatable or need lengthy hospital stays.
Childbirth is also becoming riskier, as without working antibiotics it is more difficult to control infections around the time of birth. This is already a huge problem in countries like India, Pakistan and Nigeria.
Other drugs are at risk of becoming less effective due to resistance, including antifungals, antiviruses and antimalarials. This makes it harder to treat fungal infections, HIV or malaria, for example.
Who is affected by drug-resistant infections?
Drug-resistant infections can affect anyone, anywhere. We are all at risk of infections from drug-resistant bacteria. Globally, at least 700,000 people die every year because of drug-resistant infections.
Children and drug-resistant infections
The consequences and impact of the infection in children and young people have far-reaching implications, including school absences, spread of infection to siblings or grandparents and, for parents, time lost from work, however, children and young people are stakeholders who are often missed from behaviour change initiatives, and knowledge transfer and partnerships tend to focus solely on adults. There are also few effective platforms that bring their voices and insights to the fields of research, science and public health and their role as social activists is also often overlooked. These disparities are heightened in many low- and middle-income countries, where access to information and civic networks may be limited.
How does drug resistance happen?
Like all living things, microbes evolve over time in response to their surroundings. Antibiotic resistance is an example of this evolution, occurring when bacteria change in a way that makes antibiotic substances harmless to them.
They do this in several ways. Some bacteria can ‘neutralise’ the antibiotic before it can do harm. Others have learned to quickly pump the antibiotic out of their cells. And others can change their outer structure so the antibiotic cannot attach to the bacteria and kill them.
The resistant bacteria survive and multiply. If they are passed on to other people, animals or the environment, resistant infections can spread rapidly.
Why are we seeing more drug-resistant infections?
Drug resistance is a natural phenomenon, but its recent growth is largely driven by human activity. Unnecessarily exposing bacteria to medicines creates more opportunities for drug resistance to develop and spread. Globally, the World Health Organization estimates that only half of antibiotics are used correctly. Antibiotics are used in huge quantities as growth promoters, prophylactics and therapeutic treatments in livestock, fish and crop farming.
In human healthcare too, antibiotics are widely misused. Of the 150 million prescriptions for antibiotics written by doctors in the USA every year, 50 million were not necessary. In OECD countries, 50% of antibiotics prescribed by general practitioners are thought to be inappropriately used – either not needed, or the wrong antibiotic was prescribed.
In some countries, regulation on antibiotic use is poorly enforced or doesn’t exist at all. People can buy antibiotics over the counter to treat viral infections, instead of bacterial ones.
Although there is an urgent need to limit the inappropriate use of antibiotics, currently more lives are lost because of lack of access to life-saving antibiotics. Globally, almost 6 million people die each year from treatable infectious diseases.
Using antibiotics appropriately – and making them available and affordable where they’re needed – are both important for improving health globally, now and in the future.
When will drug-resistant infections be a problem?
Drug-resistant infections are already a problem. At least 700,000 people die because of drug-resistant infections every year. If we don’t act now, this number is projected to rise to 10 million by 2050. This means that globally more people will die because of drug-resistant infections than cancer.
All countries are – and will be increasingly – affected. But the greatest health burden will be in low- and middle-income countries where health systems are not as strong.
Drug-resistant infections could also have wider impacts on livelihoods. Resistant infections can put additional burden on vulnerable people living in poverty. And spread of resistant infections in livestock animals could affect availability of meat and dairy products.
Are drug-resistant infections a global problem?
Yes. In an era of increased mobility and globalisation, microbes cannot be contained within national borders, spreading between people, animals and through environmental channels like water or soil.
Across the world drug resistance is very common. In 2017 around 17% of bacterial infections in OECD countries were resistant to antibiotics. In low- and middle-income countries, resistance is even higher. For example, in India, Brazil and the Russian Federation, 40% to 60% of infections are resistant.
Can we stop drug-resistant infections?
We can’t completely stop drug-resistant infections from happening but, by taking action now, we can slow them down. Drug resistance is a natural evolutionary process. Although we can’t stop it, we can control the pace of resistance development and spread – for example, through better use of existing antibiotics and the development of new ones.
How can we slow down drug-resistant infections?
As a global problem, drug-resistant infections need a worldwide response. Better use of existing antibiotics across human healthcare and the animal sector is vital. With limited exposure to antibiotics, bacteria will have fewer opportunities to develop resistance.
Healthcare communities around the world are making concrete efforts in this area. For example, Tanzania is changing the way antibiotics are dispensed through a national network of accredited drug dispensing outlets. South Africa is training hospital pharmacists in antimicrobial stewardship and Ghana uses dance to educate communities about when to take antibiotics. In Tanzania an innovative national network is transforming how antibiotics are dispensed.
In Europe, the UK has managed to cut the amount of antibiotics used since 2014, and it is now implementing a five-year action plan to reduce this even further.
Alongside ‘antibiotic stewardship’, we need robust surveillance in all countries and across sectors. This is to better understand the presence and spread of resistance and take actions where and when they are needed.
It is also important to develop new low-cost, fast diagnostics. This will help doctors and pharmacists distinguish between bacterial and viral infections and prescribe the correct medication, in the right dose.
To slow down resistance, we need new antibiotics too. Developing new drugs comes with scientific, economic and regulatory challenges, as it’s a very long and expensive process. For these reasons, no new classes of antibiotics have been approved for use in decades.
Preventing infections is another route for curbing drug resistance. Developing new vaccines, access to clean water, better sanitation and hygiene are effective ways of doing that.
Wellcome: Reframing Resistance – how to communicate about antimicrobial resistance effectively
Wellcome: Reframing Resistance Toolkit
UNICEF: Time is Running Out – Technical Note on Antimicrobial Resistance
E-bug: Public Health England's infection prevention and control teaching resources for the educational sector
Nuffield Council on Bioethics: Children and Clinical Research – Ethical Issues
Bacteria Combat digital antibiotics game produced by Game Doctor, and accompanying consultation report
Photograph copyright Pearl Gan
Photograph copyright Pearl Gan
Photograph copyright Pearl Gan