Antimicrobial resistance is a critical global health threat, affecting the human, animal, and environmental health sectors. Although many countries have national action plans to combat this growing and deadly problem, their implementation in low- and middle-income countries has been stalled by the lack of evidence from robust data to quantify and surface the problem for policy makers.
In countries around the world, doctors are being left powerless to treat common infections such as Streptococcus pneumoniae, Staphylococcus aureus, and others that are often acquired in the very hospitals they work at. Yet clinicians have lacked the data needed to encourage government ministers to invest more in interventions that can control antimicrobial resistance (AMR), such as infection prevention and control, or better diagnostics.
A paper published Wednesday in The Lancet shows that AMR was the direct cause of at least 1.27 million deaths in 2019 — more than many widely recognized causes of death, such as malaria and HIV/AIDs.
Antimicrobial resistance occurs when microbes evolve in ways that make them impervious to existing treatments, making infections harder to treat and often resulting in deaths that would previously have been preventable. The paper is a sharp warning that AMR is already putting extra pressure on frontline health care workers and an urgent response is needed to control this threat.
Antimicrobial resistance has been a growing threat for decades, but the peer-reviewed paper in The Lancet offers evidence showing its true global impact. Using data from 204 countries, the research estimates the burden of AMR for 23 types of bacteria and 88 so-called bug-drug combinations: a patient’s infection with a specific bacterium, and that person’s subsequent treatment with an antimicrobial drug.
Deaths due to antimicrobial resistance are due to infections in the lower respiratory tract, the bloodstream, the abdomen, and elsewhere, infections that spiraled out of control because the microbes causing them were resistant to the antibiotics on hand. Shockingly, 1 in 5 of these deaths occurred in children under the age of five.
The paper shows that both low- and high-income countries are facing significant rates of antimicrobial resistance, with the highest burden in sub-Saharan Africa at 27.3 deaths per 100,000. This is despite lower levels of antibiotic consumption, indicating that in lower- and middle-income countries, policy responses must go beyond stewardship measures to limit the use of antibiotics and include efforts to improve access to all types of antibiotics.
The study was conducted by the Institute for Health Metrics and Evaluation at the University of Washington in partnership with the University of Oxford, and was funded by the UK Department of Health and Social Care, the Bill and Melinda Gates Foundation, and Wellcome, the organization I work for.
The researchers identified seven types of bacteria that each led to more than 80,000 deaths attributable to antimicrobial resistance: Staphylococcus aureus, Escherichia coli, Klebsiella pneumoniae, Streptococcus pneumoniae, Acinetobacter baumannii, Mycobacterium tuberculosis, and Pseudomonas aeruginosa. Although all seven of these have been identified as priority pathogens by the World Health Organization (WHO), only two have been a focus of major global health intervention programs — Streptococcus pneumoniae, primarily through pneumococcal vaccination, and Mycobacterium tuberculosis.
By providing greater insight into the main drug-bug combinations in each region, as well as estimating disability adjusted life years (DALYs) lost and hospitalizations, my hope is that this new information can support more targeted action from policymakers at national, regional, and international levels. Unchecked, antimicrobial resistance has the potential to reverse the achievements made toward the WHO’s Sustainable Development Goals and decades of progress in global health.
AMR presents a clear economic threat that is already limiting doctors’ ability to safely carry out essential medical practices such as surgery, childbirth, and cancer treatment, since infection is a risk with each of them.
The world must now move from awareness to urgent action and use the new data to make informed decisions about policy development for mitigating antimicrobial resistance and accelerating measures under AMR national action plans, whose progress has often been hampered by a lack of prioritization and shortage of long-term financing.
The good news is that we already know what needs to be done, particularly as Covid-19 has demonstrated the power of international collaboration between governments and the research and development community, as well as the importance of global commitment to infection control measures. The WHO’s global action plan on antimicrobial resistance has been endorsed by 194 member states to mitigate the impact of AMR. Policy action should urgently focus on:
- taking greater action to monitor and control infections, within individual hospitals and at the national level
- accelerating the ability to prevent and control infections by expanding access to vaccines, clean water and sanitation, and funding research for high-priority bacteria, such as Klebsiella pneumoniae and Escherichia coli
- optimizing the use of antibiotics unrelated to treating human disease, such as in food and animal production and taking a One Health approach to recognizing the interconnections between human and animal health
- minimizing the use of antibiotics and other antimicrobials where they are not necessary and acting according to the WHO’s global action plan and its AWaRE guidelines
- increasing funding at every stage of the development pipeline for new antimicrobials targeting priority pathogens, from basic research to securing access through innovative market solutions
The Lancet paper presents an important step in the journey to tackling antimicrobial resistance and has been presented to leaders at the G7, with plans to share the findings with further stakeholders globally.
Historically, the lack of data on AMR in many low- and middle-income countries has been a barrier to decision-making and prioritization. Alongside the regional data currently available in the new paper, country-level data will also be available in the future and can be used to tailor local initiatives such as the revision of treatment guidelines, infection prevention and control initiatives, and antimicrobial stewardship. Geospatial maps will also enable comparison of trends over time and country comparisons.
As funders of the research, Wellcome, the UK Department of Health and Social Care, and the Bill and Melinda Gates Foundation are fully committed to supporting effective use of the data to inform action on AMR. Solid data, such as that provided by The Lancet paper on annual deaths due to antimicrobial resistance, are important to have. But they don’t mean much unless policymakers and the health community put them to use and take urgent action to avoid further preventable deaths.
Janet Midega is the senior research manager in the Wellcome Trust’s Drug Resistant Infections Programme and a senior public health fellow in the New Voices Fellowship at the Aspen Institute in Washington D.C.