Is Antimicrobial Resistance (AMR) the Next Pandemic?

The synthesis of salvarsan, a treatment for syphilis, by Ehrlich in 1910 and the discovery of penicillin by Fleming in 1928, heralded the golden age of antimicrobials. In the decades that followed, remarkable advances in modern medicine led to the development of hundreds of antibiotics, antivirals, antifungals, and antiparasitics. In the post-antibiotic era of the 20th century, there was a sense of hope that humankind would conquer infectious diseases. Yet, this turned out to be a prematurely optimistic view because today we are grappling with record numbers of drug-resistant infections.

Researchers at the University of Washington in Seattle looked at estimates from more than 200 countries and found that in 2019 at least 1.27 million people died directly as a consequence of bacterial infections caused by drug-resistant bacteria. This is almost twice the number of deaths attributed to AIDS-related illnesses worldwide (680,000).

Experts warn that antimicrobial resistance--the ability of microorganisms to grow despite the presence of drugs designed to kill them--could be the next pandemic. It’s a global health crisis that has been put on the backburner by COVID-19, but it is a problem that is simmering and one we cannot afford to ignore.

The World Health Organization lists antimicrobial resistance among the top 10 global health threats facing humankind. The need to tackle AMR is one of the WHO’s sustainable development goals. Overuse and misuse of existing antibiotics and other antimicrobials is the main reason cited for the emergence of antibiotic-resistant bacteria and other drug-resistant pathogens. Antibiotic resistance is a huge concern because it makes common bacterial infections harder to treat. AMR results in prolonged illnesses, longer hospital stays, chronic infections, disability, financial risk, and even death.

While pharmaceutical companies continue to develop new antibiotics, new antimicrobial drugs, and new treatments against infectious organisms, the organisms themselves are mounting a countercharge on humanity by undergoing mutations that help them escape previously effective antibiotics.

Some parts of the world are doing worse in tackling AMR than others. Experts estimate that in the Australasia region, the incidence of deaths directly attributable to antimicrobial resistance is 6.5 per 100,000, one of the lowest globally. But in Western Sub-Saharan Africa, this number is almost five times higher, with 27.3 deaths per 100,000 attributed directly to antibiotic resistance. While the problem is significantly worse in low-income and middle-income countries, high-income countries like the US are also at high risk due to the indiscriminate use of antibiotics.

Just a handful of pathogens account for over 70% of deaths attributed to an antibiotic-resistant bacterial infection: Escherichia coli, Klebsiella pneumoniae, Staphylococcus aureus, Streptococcus pneumoniae, Pseudomonas aeruginosa, and Acinetobacter baumannii.

E. coli--the bacteria that causes the majority of urinary tract infections--tops the list and is responsible for the most deaths due to antimicrobial resistance. E. coli is developing widespread antibiotic resistance to fluoroquinolone antibiotics like ciprofloxacin, commonly used to treat urinary tract infections. In some countries, treating E. coli UTIs with ciprofloxacin is ineffective in over half of all patients.

The Global Antimicrobial Resistance and Use Surveillance System (GLASS) also reports rising antimicrobial resistance rates of up to 80% in some areas for Klebsiella pneumoniae to ciprofloxacin. K. pneumoniae is a bacteria that can cause life-threatening intestinal, bloodstream, and hospital-acquired infections such as pneumonia, as well as neonatal sepsis (infections in newborns). The last resort treatment for K. pneumoniae, carbapenem antibiotics, is fast becoming ineffective in almost every part of the world.

Previous estimates had indicated that we could be looking at 10 million deaths due to untreatable infections by the year 2050, but the newest surveillance results show that we may breach that number much sooner.

Antimicrobial innovation and new drugs in clinical development do not offer a great deal of hope for infection control in the future. In the race between new antibiotics and antimicrobial resistance, the latter is winning—the WHO lists only 32 antibiotics in the research and development pipeline that could potentially treat priority pathogens. While research efforts are ongoing, there is the additional problem of drug shortages and lack of access to quality drugs in many parts of the world.

Timely course correction is critical to address AMR and ensure that common, easily treatable infections do not become life-threatening and fatal infections in the future. The key is to stop the inappropriate use of antibiotics and other antimicrobials. There’s a need for creating greater awareness in community settings, i.e., helping people understand that antibiotic use does not treat viral infections. Indeed, studies in patients with COVID-19 have shown that secondary bacterial infections occur at a low frequency, even in severe cases of viral infections. Meaning there is a need for more careful and targeted antimicrobial therapy rather than widespread and indiscriminate use of antibiotics.

I would not place my bets on a new antibiotic to treat an infectious disease. The one thing that can save us from the public health crisis and next pandemic--antimicrobial resistance--is the judicious and appropriate use of available antimicrobials.

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