A new era in the fight against antimicrobial resistance - can we revert the silent tsunami?

Antibiotic resistant bacteria (Photo: Cochrane UK)

This week is World Antimicrobial Awareness Week, marking the fight against the silent and rising global threat of antimicrobial-resistant superbugs. Can patients be part of the solution?

This week is the World Antimicrobial Awareness Week (WAAW) when we turn the world’s attention to the growing problem of drug resistant diseases - caused by bacteria, viruses and other pathogens that have developed resistance to the lifesaving drugs that we use every day. 

Why is this important? Antimicrobial resistance (AMR) is a natural process of pathogens’ adaptation  to the drugs we use to kill them, which should normally have a slow evolution-like pace. Our inappropriate use of common antibiotics, antiviral agents and other drugs on all fronts of human and animal health speedwarps this process. 

The often imperceptible tidal wave of AMR already kills some 700,000 people each year. But it threatens to become a “tsunami”, as World Health Organization Director General Dr Tedros Adhanom recently said. A report last year by a special ad hoc UN group, “No Time To Wait” projected that the world could see up to 10 million deaths annually by 2050. This looming crisis thus has the potential to be as large or even larger than Covid-19 in terms of the death toll and economic costs.

The problem is not new. Alarm bells started ringing as early as 2008, when the European Centre for Disease Prevention and Control issued warnings about the trends. In 2015, the  World Health Organization adopted its first Global Action plan on AMR - and the world observed the first Antimicrobial Awareness Week.  

However, so far the warnings have failed to turn around embedded practices and habits. Although awareness in some health systems is growing, there is widespread overuse of antibiotics and other antimicrobial agents in countries with weak regulatory systems - where people can buy antibiotics and other drugs over the counter without a prescription. 

In addition, drugs that need to be reserved for human use are still wantonly used in industrial livestock production as growth promoters or disease prevention -  further increasing risks that drug-resistant bacteria will emerge. In many countries it is difficult or impossible to even assess how much antibiotics and other antimicrobials are used, where, and on what populations.

Covid-19  has, moreover, spurred increased use of antibiotics - ostensibly to suppress or prevent secondary bacterial infections that people sick with the virus could also get. And this, according to WHO, is exacerbating AMR trends. In the United States, some 70 to 80 per cent of hospitalised Covid-19 patients received antibiotic treatment, according to one report, even though less than 10 per cent actually had secondary bacterial infections.

Pandemic as an opportunity? Against this grim reality, however, the current pandemic may also be serving as something of a wakeup call fostering more action on AMR, among both health care providers -- as well as the patients that my organization, the International Alliance of Patients’ Organizations (IAPO), represents. Having confronted the harsh reality of a deadly virus for which there is no vaccine, medicine or treatment - can we act more assertively to stave off future threats like this that could emerge if more bacteria and viruses become resistant to the existing drugs that we do have?

We have begun to see the world wake up now. 

This July, an AMR Action Fund of nearly $1bn was established by more than 20 leading biopharmaceutical companies, with a mission to bring 2-4 new antibiotics to patients by 2030, and replenish the collapsing antibiotic R&D pipeline. This fund complements other initiatives, like the WHO’s Global Antibiotic Research and Development Partnership, and its added value is in creating market conditions that enable sustainable investment in the antibiotic pipeline.

In August, the Tripartite Coalition of the WHO, the Food and Agriculture Organization (FAO) and the World Organization for Animal Health (OIE) initiated a “One Health” Global Leaders Group on Antimicrobial Resistance, to advocate for urgent action among heads of state, government ministers, private sector and civil society. The  Group, co-chaired by the prime ministers of Bangladesh and of Barbados, will be formally launched at a WHO press conference on Friday.

On Wednesday, Wellcome Trust launched their report “The Global response to AMR: Momentum, successes and critical gaps”, underlining that AMR is not only reversing recent progress in controlling infectious diseases, but is also undermining improvements in healthcare provision in general, threatening to disproportionately more affect the low- and middle-income countries.

This AMR week will also see a flurry of activities across WHO regions, under the theme “Unite to prevent antimicrobial resistance”. And in the spirit of “One Health, stakeholders across diverse sectors are linking together on this common interest. 

This is reflected in a joint call for more action  issued Wednesday by IAPO along with the International Hospital Federation, the International Society for Quality in Health Care, and the International Federation of Pharmaceutical Manufacturers and Associations. 

The statement calls for the development of more innovative partnerships of healthcare providers, patients and the business sector to tackle the growing AMR threat while improving healthcare safety and quality worldwide.  It aims to raise awareness of AMR, promote antibiotic stewardship and call upon policymakers to create the appropriate conditions to attract investments in R&D to ensure that a sufficient pipeline of antibiotics will remain available to treat both common and rare infections.

Empowering patients to Fight AMR in A Global AMR Patient Alliance. Paternalistic approaches to healthcare have largely left patients on the sidelines in the battle against AMR. This, despite the abundant evidence showing that patients bear a big part of the responsibility for what is happening right now. 

Driven by Einstein’s postulate that we cannot do the same thing, and expect a different result, IAPO along with patient organisations from different regions and countries has developed A Global Patient Consensus Statement and a Call to Action, that aims to convene civil society groups representing patients, carers and advocates in a global AMR Patient Alliance, to be launched in the first week of December. The AMR Patient Alliance will be a place where patients can exchange views, be educated, and acquire knowledge and resources that we need to raise awareness about the importance of sustaining the efficacy of antibiotics - for as long as possible, for as many patients as possible. 

Among patients today, there are widespread practices of self-treatment with antibiotics. Patients also put pressures on providers to prescribe such medications - even when their health care provider may not think they are needed. And, there remains a widespread public perception of antibiotics as ‘a wonder drug’; evidence shows that if patients can get access to antibiotics without a prescription, they will do so. Oftentimes, patients may only follow a partial antibiotic course or use antibiotic leftovers inappropriately - if no direct harm is perceived.  But these behaviours also stimulate drug resistance. All of this needs to change. 

It is always politically sensitive to mention that patients have some responsibility. But, no amounts of funding to develop new drugs or curb AMR now will work, if people at the grassroots continue to abuse their life-saving potential. The magnitude of people’s power is so great...and it can be destructive or productive.

That is why, at IAPO we have joined the AMR fight in order to convert this challenge into an opportunity, by building awareness and empowering patients to take responsibility - so as to preserve their right to use antibiotics and antimicrobials over the long term.  

We all have a role to play. The problem of antibiotic overuse or misuse is not restricted to certain countries or regions, although the drivers may vary by country.  According to Professor Hanan Balkhy, assistant director general for antimicrobial resistance at the WHO, categories of antibiotics that are only used very selectively when all else has failed, on hospitalized patients in intensive care - can often be obtained by outpatients or over-the-counter in low- and middle-income countries. 

And even when drugs to people are being rationed more carefully, an out-sized footprint for antibiotic use in livestock exists in countries ranging from the USA to Spain, Italy and Chile. This exacerbates risks that these drugs may one day soon, become ineffective in human populations. 

Finally, only about one third of all countries are actually tracking their antibiotic use systematically, according to WHO, with significant discrepancy across regions - from 85% of European countries to none in South East Asia. In some countries, notably  the USA, animal use is systematically reported at the national level - but not so for human use. 

The problem is not a simple one - solutions are complex and interrelated. We knew that progress would be slow and the current pandemic has set up new challenges. The ‘infodemic” of fake news and unconfirmed facts has also seen conflicting messages about the effectiveness of antibiotics on viruses – undermining one of the key principles of rational and appropriate antibiotic use. 

Appropriate antibiotic use is everybody’s business – not only of governments and healthcare providers, but of patients and industry as well. The old ones we have to preserve, as the new antibiotics discovery pipeline has run dry in the past decade. Our generations have enjoyed the 20th century discovery of antibiotics; yet, we need to treat them not as an inheritance from the past, but as borrowed from the future generations. If we want to live in and leave a better, safer world.