Introduction

What is Antimicrobial Resistance?

Antimicrobials are the material that either kills or prevents the growth of pathogenic germs, such as mold, parasite, fungi or bacteria. When these microbes stop responding to antimicrobial medications, it is known as antimicrobial resistance (AMR). Drug resistance raises the risk of disease transmission, severe sickness, disability, and even death by making antibiotics and other antimicrobial medications ineffective and making it harder or impossible to treat infections. AMR, also known as superbugs, doesn’t happen overnight. It is a natural process as a result of infraction’s genetic alterations over time. Human activity, particularly the abuse and overuse of antimicrobials to treat, prevent, or control illnesses in humans, animals, and plants, accelerates its establishment and spread. People at any stage of life, and from any sectors, could be impacted by bacterial resistance to antimicrobials. It is therefore among the most pressing public health issues in the world. In 2019, due to its impact on human health, the World Health Organization (WHO) included antimicrobial resistant as one of the top ten threats to global health. 

Why is antimicrobial resistance a problem?

The global impact of AMR on health, economies, and healthcare systems.

Over 2.8 million antimicrobial-resistant infections happen annually in the United States, As a result, about 35,000 people pass away, as reported by CDC. 2019 Antibiotic Resistance (AR) Threats Report. As per recent global burden of diseases (GBD) study which comprises the data from 1090 to 2021, an estimated 4.71 million fatalities in 2021 were linked to antimicrobial resistant bacteria, with 1.14 million of those deaths being directly caused by AMR. Since 1990, AMR-related mortality has increased by more than 80% for individuals aged 70 and older. Antimicrobial resistant infections are creating a huge problem in achieving Sustainable Development Goals (SDGs) as it was targeted to end the epidemics  of AIDS, Malaria, Tuberculosis and other neglected tropical diseases by 2030.

There are two primary components to the burden of AMR: the economic burden and the health burden. Mortality rates, years of life lost, disability-adjusted life years, and excessive length of hospital stay are common indicators of health burden. Whereas, higher medical expenses, decreased output as a result of disease and death, possible losses in trade and agriculture are the major reasons for the economic burden.(WOAH, 2024)

The Science Behind Antimicrobial Resistance

How does antimicrobial resistance happen?

Antibiotic-resistant bacteria can develop in a number of ways as discussed below.

·      Natural Resistance
Some bacteria are inherently resistant to specific drugs because of their structure, e.g., penicillin cannot kill bacteria without a cell wall because they attacks cell walls (such as Mycoplasma).

·      Acquired Resistance
Bacteria can “learn” to withstand antibiotics that they were previously susceptible to.
This may occur through genetic mutations, and acquired genes resistance genes from other bacteria. For e.g., tuberculosis bacteria developing resistance to rifampicin may result antimicrobial resistant infections.

·      Genetic Changes

Protein production is altered due to changes in bacterial DNA, thereby, modify bacterial components or receptors, this makes the bacterial unrecognizable or unaffected by the antibiotic. E.g., Escherichia coli (E. coli) and Haemophilus influenzae developing resistance to trimethoprim.

·      Horizontal Gene Transfer

In many circumstances, bacteria share resistance genes with other bacteria through Transformation (Uptake of naked DNA from the ambient environment), Transduction (Transfer of DNA via bacteriophages), and Conjugation (Direct transfer of DNA through Cell-to-cell contact.)

Causes of Antimicrobial Resistance

1. Overuse of Antibiotics in Human Medicine

“How Overprescribing Antibiotics is Fueling Resistance?

The unnecessary or excessive use of antibiotics in human medicine is a major driver of resistance. This includes prescribing antibiotics for viral infections (like colds or flu) where they are ineffective. As per CDC, approximately one third of antibiotics prescribed in the US are unnecessary. Furthermore, it has been reported from one study that between 30% and 60% of the antibiotics administered in intensive care units (ICUs) are found to be unnecessary as well as inappropriate (The New York Times). In low- and middle-income countries, due to lack of access to diagnostic facilities antibiotics are often overused.

2. Misuse of Antibiotics in Agriculture

 “The Hidden Danger: Antibiotics in Farming and Food”

Antibiotics are frequently employed in the production of crops and livestock  to increase harvesting and avoid disease. Through this approach it helps to resistant bacteria proliferate through the food chain. Among the total antibiotics used 80% are utilized for animals in US. If animal and plant are exposed to resistant Humans can contract resistant bacteria from animals by direct touch, contaminated food, or water. FDA. (2021). 

3. Poor Infection Prevention and Control

 “How Hospitals Are Becoming Hotspots for Superbugs”

A poor infection prevention and control program increases the risk of hospital-acquired infections, promotes the spread of multidrug-resistant pathogens among healthcare staff, patients, and visitors. Limited resources, outdated policies, and inadequate monitoring may contribute to such scenarios. Increased use of invasive devices, Immunocompromised patients, overcrowding and high patient turnover are other causes of hospitals to be hotspot for superbugs.

4. Lack of New Alternative Antibiotics

 “The Antibiotic Crisis: Why Aren’t We Developing New Drugs?”

Due to limited investment and research in the field of development of the pipeline for the new antibiotics has dried up. This lack of innovation has kept us vulnerable to the MDR pathogens. In the past fifty years, just two new classes of antibiotics have been developed. Because antibiotic research is not very profitable, pharmaceutical corporations choose to avoid it. Only 32 medicines are now under clinical testing, and few of them target the most serious resistant pathogens WHO (WHO, 2024).

5. Global Travel and Trade

 “How Travel and Trade Are Spreading Superbugs Worldwide”

Rapid travel and movement make the world a smaller village, which makes it easier for antimicrobial-resistant diseases to spread across national boundaries. AMR is a worldwide problem rather than a regional one because resistant bacteria travel easily, just like people and goods do. Because of this interdependence, an outbreak confined to one area can easily spread to other parts of the world, highlighting the necessity of international cooperation in infection control and antibiotic stewardship.

6. Public Misuse and Lack of Awareness

 “Why Self-Medication is Making Antibiotics Useless”

Over-the-counter medicine, also referred as self-medication, incomplete courses of antibiotics, and lack of public awareness about proper antibiotic use contribute significantly to AMR. Because of ignorance about the danger of self-medication along with higher healthcare costs people are increasingly relying on self-medication (Ventola, 2015)

Global Efforts to Combat AMR

WHO Global Action Plan on AMR

The World Health Organization created the Global Action Plan (GAP) on AMR In order to improve antibiotic stewardship, enhance research on novel antimicrobials, and strengthen surveillance. This action plan has recommended that all the countries create National Action Plans (NAPs) aligning with the goals of the global action plan on AMR.

One Health Approach

One health approach is the unified efforts of the international organizations like WHO, FAO (Food and Agriculture Organization), and OIE (World Organization for Animal Health) to address AMR across sectors as it impacts people, animals, and the environment. Understanding the fact that AMR is caused by the careless and excessive use of antibiotics not only among humans but also in a variety of other interconnected fields, such as cattle husbandry, and agriculture.

Global Antimicrobial Resistance and Use Surveillance System (GLASS)

Global Antimicrobial Resistance and Use Surveillance System (GLASS) was established by WHO in 2015 to standardize AMR surveillance across the globe. This strategy promotes epidemiological approach apart from laboratory based and clinical based evidence on antibiotic use, and conduct research on patterns of resistance. This approach acknowledges the connection across sectors and advocates for a One Health approach. It improves efforts to prevent drug-resistant infections and fight AMR by facilitating international data sharing (WHO, 2015).

Incentives for New Antibiotics and Alternative Therapies

To combat this global issue global initiative offers incentives for the development of novel antibiotics and other treatment. GARDP, BARDA, and WHO are the agencies who fund incentives in research for innovative treatments, such as phage therapy, antimicrobial peptides, and microbiome-based solutions. Pharmaceutical companies are encouraged to invest in antibiotic discovery through public-private collaborations, legislative incentives, and financial support. Addressing the growing threat of AMR requires increasing financing and research (Brogan et. al., 2013). Market entry rewards, push incentives, pull incentives, public-private partnerships are some of the legislative and financial incentives introduced to encourage pharmaceutical companies to invest in antibiotic research.

WHO’s AWaRe (Access, Watch, and Reserve) classification approach

WHO’s AWaRe (Access, Watch, and Reserve) classification is a crucial tactic in the fight against AMR. This approach classified the antibiotics into three groups to mitigate the possible risk of AMR through appropriate use of important antibiotics.

• Access group: First-line antibiotics with a lesser potential for resistance are included in the Access Group, guaranteeing availability for common illnesses.
• Watch Group: It contains antibiotics that are more likely to develop resistance; they are prescribed for certain infections under close observation.
• Reserve Group: Last-resort antibiotics are only used to treat severe, multidrug-resistant diseases in order to maintain their efficacy.

The AWaRe approach protects the efficacy of currently available antibiotics, enhances treatment results, and lowers resistance by encouraging rational antibiotic usage.

Role of Healthcare Professionals

• Antibiotic Stewardship: Make sure that antibiotics are used with right dose and duration. Only prescribe antibiotics when absolutely required.
• Infection prevention and control: Prevent and control infections by adhering to stringent infection prevention guidelines such as aseptic procedures and hand sanitization.
• Patient education: Educate patients on the dangers of misuse of antibiotics and the significance of drug compliance.
• Monitoring and Reporting: Proper monitoring and immediate reporting of AMR resistance to public health authorities.
• Interprofessional Collaboration: Collaborate with microbiologists, pharmacists, and legislators for AMR management activities. Maintain up-to-date knowledge of new resistance trends and its’ management through continuing medical education.

Conclusion

Antimicrobial resistance is major global health concern that threatens public health, economy, and contemporary medicine. Antibiotic overuse, misuse, and self-medication are making diseases more difficult to cure by spreading resistant microorganisms. To combat AMR we need to invest in antibiotics stewardship, have collaborative global efforts. Similarly, surveillance, infection control, and public awareness must be strengthened to lessen this global threat.