Is Antimicrobial Resistance The Next Health Crisis?

We’ve seen how quickly a global health catastrophe can turn our lives upside down in recent years. While the science of vaccines has protected many people against severe illness and death, the long-term consequences of the pandemic, or when COVID-19 will reach an endemic phase by spreading less and more predictably—are not yet clear.

Meanwhile, scientists have known about antimicrobial resistance (AMR) for decades and have been warning us about this global health issue since 1945.¹ 

In 2019, the World Health Organization (WHO) declared AMR one of the top ten global public health threats. Also included on the watch list are:

  • Air pollution

  • HIV

  • Global influenza pandemic

  • Ebola and other high-threat pathogens

  • Weak primary health care

  • Dengue fever

  • Non-contagious diseases (such as heart disease or cancer)

  • Fragile and vulnerable settings (impacts of war or natural disaster) 

A short history of antibiotics 

In 1928, Sir Alexander Fleming accidentally discovered penicillin at St. Mary’s Hospital in London. As a Professor of Bacteriology, he had a reputation as an excellent researcher, and he’d been looking into staphylococci. His experiments culminated in the isolation of penicillin from mold, which forever changed medicine.

Fleming tried to treat influenza with penicillin before discovering it was ineffective. Pathologist Cecil George Paine, a former student of Fleming, carried out the first successful penicillin treatment, curing eye infections in November 1930. 

Fleming cured his friend (Harry Lambert) of streptococcal meningitis, an infection that would have been fatal without treatment. This seemingly miraculous case study led to greater interest in penicillin. The British War Cabinet set up the Penicillin Committee in 1943, leading to mass penicillin production for Allied use during WWII. 

In 1945, Fleming, Howard Florey, and Ernst Chain received the Nobel Peace Prize. They had all played a part in discovering penicillin and its incredible powers. 

However, even back then, Fleming’s Nobel Lecture warned of antibiotic resistance: “The time may come when penicillin can be bought by anyone in the shops. Then there is the danger that the ignorant man may easily underdose himself and by exposing his microbes to non-lethal quantities of the drug make them resistant,” said Fleming.²

Availability of antibiotics increased life expectancy

The period between the 1950s–1970s has been described by some as the ‘golden era’ of antibiotic discovery. By 1970, there was a noticeable rise in life expectancy, owing to fewer dangerous bacterial infections. 

In 1913, European life expectancy was 46.8 years. By 1970, it increased to 70.4 years. In 2019, life expectancy in Europe reached 81.3 years.³ ⁴ ⁵

Since then, the scientific development of new antimicrobial agents has been on the decline.⁴ Now, non-communicable diseases, such as cancer and cardiovascular issues, are among the biggest threats to public health. 

What is antimicrobial resistance?

Antibiotics can cure bacterial infections by killing the bacteria or slowing its growth. However, antibiotic medicines are ineffective against viruses, such as cold and flu.

The misuse of antibiotics for everyday “bugs” renders them useless, and many multidrug-resistant (MDR) disease cases are appearing.⁶

Antimicrobial Resistance (AMR) happens when bacteria, viruses, fungi, and parasites evolve and no longer respond to antibiotics. Bacterial infections become increasingly tough or impossible to treat.

Even though penicillin hadn’t been in use for very long, strains of Staphylococcus aureus developed a strong resistance to it by 1942. Today, some European countries see as many as 50% antibiotic-resistant strains.⁷

Antimicrobial resistance causes one in five deaths in children under five

According to the first comprehensive assessment of the global burden of AMR, young children are especially at risk. One in five deaths due to AMR occurred in children under the age of five—often from once treatable infections.⁸

The World Health Organization (WHO) describes that a child’s developing immune system is not equipped for dealing with drug-resistant microbes and is especially vulnerable to AMR. WHO emphasizes that health workers and caregivers must “guard against AMR by avoiding mis- or over-use of antimicrobials.”⁹

Estimating the global burden of antimicrobial resistance

According to a study published in The Lancet in January 2022, at least 1.27 million deaths per year are because by AMR, making it a leading cause of death globally (even higher than HIV/AIDs or malaria).¹⁰

In 2014, the UK Prime Minister commissioned the Review on Antimicrobial Resistance, published in 2016.¹¹ The review estimates that as many as 10 million people could die from AMR (annually) by 2050.

The same review estimates that the global cost of antimicrobial drug resistance could cost up to $100 trillion USD. The associated costs include expensive antibiotics, specialized equipment, longer hospital stays, and isolation procedures. In addition, when infections become resistant to first-line treatments (antibiotics) doctors have to switch treatment to second- or third-line drugs, which are often more expensive.

As of 2019, the Centers for Disease Control and Prevention (CDC) reported that in the US, 2.8 million (or more) people a year will get an antibiotic-resistant infection, and 35,000 or more will die from an antibiotic-resistant infection.¹²

 Tuberculosis: the ‘forgotten pandemic’

Antimicrobial resistance to standard tuberculosis drugs will hinder healthcare providers from fighting a spreadable disease that still causes illness in 10 million people and 1.6 million deaths per year.¹³ In 2017, around 600,000 cases were resistant to the antibiotic rifampicin—the most effective first-line drug—and 82% of these people had multidrug-resistant tuberculosis.¹³

In several countries outside North America and Europe, tuberculosis drugs are available without a prescription. People use them for UTIs, STIs, and other non-tuberculosis conditions (with other cures). When these drugs are misused and overused, it weakens their effect against tuberculosis.

What are the factors contributing to antibiotic resistance?

Worldwide, people are both overusing antibiotics and using them inappropriately. 

Here are a few examples:

  • Not taking the full course of antibiotics as prescribed

  • Taking a leftover prescription when there isn’t a bacterial infection

  • Doctors prescribing the wrong type of antibiotic or dosage

  • Doctors prescribing an antibiotic when it was unnecessary

According to the Centers for Disease Control and Prevention (CDC) 50% of antibiotic use is inappropriate.¹⁴

Antibiotic resistance in human medicine

For a variety of reasons, a doctor may mistakenly prescribe antibiotics, even when bacteria isn’t the confirmed cause of illness. 

For example, in one study, 75% of all antibiotic prescriptions given were to treat acute respiratory tract infections (ARTIs)—which are usually viral, not bacterial.¹⁵ According to 2011 survey on healthcare-associated infections in Europe, 35% of hospitalized patients were receiving antibiotics.¹⁶

One study found that 59.3% of all patients received at least one dose of an antimicrobial agent during their hospital stay.¹⁷

In 2014, the CDC developed a new checklist¹⁸ to help improve prescribing practices. 

The recommendations state that if doctors reduced antibiotic prescriptions by 30%, it could lead to 26% fewer cases of deadly diarrhea infections. 

CDC Director Tom Frieden, M.D., M.P.H., notes, “Improving antibiotic prescribing can save today’s patients from deadly infections and protect life-saving antibiotics for tomorrow’s patients. Health care facilities are an important part of the solution to drug resistance and every hospital in the country should have a strong antibiotic stewardship program.”

Methicillin-resistant Staphylococcus aureus is a bacterial infection more commonly known as MRSA. It affects mainly people who are hospitalized.¹⁹ This superbug is becoming resistant to all antibiotic classes. MRSA has evolved this way because of antibiotic overuse. It has a high mortality rate and can cause serious health complications.²⁰

According to the CDC, US healthcare providers prescribed 266.1 million courses of antibiotics (over five prescriptions for every six people) in 2014.¹⁴ The 2020 prescription report indicates that healthcare providers wrote 201.9 million antibiotic prescriptions (613 antibiotic prescriptions per 1000 persons). The most commonly prescribed class of antibiotics were penicillins (23%) and macrolides—such as ​​erythromycin and clarithromycin (22%). 

The most frequently prescribed antibiotic agents were azithromycin and amoxicillin.

Self-medication

Self-medication (self-diagnosing and treating without a doctor’s prescription) is a significant factor for AMR. In addition, in some countries, the misuse of antibiotics correlates with the ease of obtaining antimicrobial drugs without a prescription.

A 2011 systematic review of antimicrobial use worldwide found that South Europe reported a higher prevalence of self-medication with antibiotics (19%) in comparison with northern Europe (3%) and central Europe (6%).²¹ It is estimated that at least 36% of antimicrobial use in China is non-prescribed. 

A 2019 randomized, cross-sectional study of participants in Sudan found that 100% of participants practiced self-medication, citing the cost of visiting a doctor as the top reason.²²

Other complicating factors that can arise with self-medication include substandard quality and inappropriate dosage or type. A 2009 survey on the use and understanding of antibiotics revealed a concerning trend. 20% of participants admitted they had taken antibiotics to treat flu-like symptoms, and 14% said they had taken antibiotics to treat a common cold.²³

A different study showed that 38% of respondents did not know that antibiotics do not work against most coughs or colds.²⁴

Antibiotics in agriculture and food-producing animals

Using antibiotics on livestock or crops is controversial and certain drugs have been banned in recent years.

Food-producing animals

Farmers may give their livestock antibiotics to prevent illness, encourage growth, or treat illness. In some countries, approximately 80% of medically necessary antibiotics are used in animals, primarily to promote growth.²⁵

Though some types of antibiotics on US farms have fallen (after peaking in 2015), the use of other antimicrobials (which are medically significant) has risen. 

Dr. Matt Ferreira, US veterinarian, and public health expert, elaborated, “Better data collection is still needed. For example, we are still seeing sales and distribution data as opposed to actual usage amounts…there is still a great deal of work to be done.”²⁶

Agriculture

Bacterial diseases severely impact crop yields. For example, streptomycin is the main antibiotic used to prevent a disease called fire blight, which affects apple and pear trees. 

Still, antibiotic use is contentious. The main concern is that such antibiotics might increase antibiotic-resistant bacteria in plants, which could be transferred to clinically-relevant bacteria.  

However, a direct link between sprays on plants and antibiotic resistance in clinical bacteria has not been demonstrated.²⁷

The environment and the spread of resistance

Soil

Most antibiotics originate from soil microorganisms resistant to antibiotics, which means that soil is essentially a cache of antibiotic-resistant genes. Additionally, water that’s contaminated with fecal organisms and organic fertilizers used on food crops may spread drug-resistant bacteria in the soil.

Wastewater and treatment plants

Wastewater is used water from homes, commercial operations, and agriculture. Antibiotic-resistant bacteria and genes are detectable in wastewater samples. 

Moreover, conditions in wastewater treatment plants are suitable for resistant bacteria growth—several studies have reported high concentrations of antimicrobial (mainly tetracycline and sulfonamide) resistant bacteria and genes in treatment plants.²⁸

A 2020 systematic review found that predictors of antibiotic resistance occured in hospital wastewater at higher rates than in community sources in over 80% of the studies reviewed.²⁹

Antibiotics can no longer treat common infections

Research indicates that a rising number of pathogens are resistant to more than one antimicrobial drug.²⁹ As a result, some common infections are extremely difficult or nearly impossible to treat. 

For example, pneumonia was once highly treatable after introducing penicillin, but now it more commonly requires second-and third-line antibiotics. 

Cystitis is a common bacterial infection in women, and it was once easily treatable as well. However, now it tends to require more complex antibiotic treatments that create added costs for both the patient and the health care system.

Innovation alone is not enough to combat AMR

The rapid global spread of multi-resistant bacteria (also known as ‘superbugs’) is alarming and contributes to multi-resistant infections— infections that doctors can’t easily treat. 

In 2019, the WHO identified 32 antibiotics in clinical development that address priority pathogens (antibiotic-resistant bacteria). While science has made remarkable strides, innovation alone is not moving fast enough to counter antimicrobial resistance.  

Between 1980 to 2000, 63 new antibiotics received approval for clinical use. From 2000 to 2018, 15 additional antibiotics received approval.

Out of the seven of the deadliest, drug-resistant bacteria, vaccines are only available for two ( Streptococcus pneumonia and Mycobacterium tuberculosis).​ 

Five steps  to mitigate antibiotic resistance

Wash your hands

80% of infectious diseases transfer through touch. Regular hand-washing helps fight germs and combat illness. According to the World Bank, increasing hygiene is the most cost-effective health action to reduce disease.³⁰

Know the symptoms

Learn the early symptoms of an infection. Not all infections need antibiotics. If you think you have an infection and it’s not getting better or getting worse, talk to a healthcare professional.

Use antibiotics properly

Antibiotics only work against bacteria. Unfortunately, viruses cause many infections which antibiotics cannot treat. Examples include respiratory illnesses such as a cough, stuffy nose, bronchitis, or the flu. 

Excessive or improper use of antibiotics causes side effects and reduces their long-term effectiveness.³¹ Listen to your doctor if they tell you that antibiotics aren’t appropriate for your illness. 

If you do need antibiotics, it’s important to take the right one, at the right dosage, for the right amount of time. Only take antibiotics when appropriately prescribed. 

Prepare food safely

Antibiotic-resistant bacteria can contaminate food, which is just one of many reasons to prepare food with proper care. The Centers for Disease Control and Prevention (CDC) recommends four simple steps to prepare food safely at home: clean, separate, cook, and chill.

Get vaccinated

Encouraging people to get vaccinations as recommended by their healthcare provider can help reduce AMR including:

  • Infection prevention

  • Decreasing the number of infectious disease cases (reducing antibiotic use)

  • Preventing viral infections (that lead to inappropriate use of antibiotics)

  • Preventing secondary bacterial infections in flu patients (that require antibiotics)

The lowdown

AMR is a pressing, global health concern that won’t be solved by one tactic alone, such as simply creating more new types of antibiotics. Many factors, namely the misuse and overuse of antibiotics in humans and animals, have turned antimicrobial resistance into a significant health threat. It will take a dedicated, multi-prong approach to address it. On an individual level, it is important to wash hands, get vaccinated, take antibiotics only when appropriate for bacterial infections, and use and finish the antibiotics course exactly as instructed by your healthcare professional. The information provided is designed to support, not replace, the relationship that exists between a patient/site visitor and their existing health care professional(s).

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Sources:
  1. Ten threats to global health in 2019 | World Health Organization

  2. Alexander Fleming: Penicillin Nobel lecture (1945)

  3. Life expectancy | Our World in Data

  4. The treasure called antibiotics (2016)

  5. Mortality and life expectancy statistics | Eurostat Statistics Explained

  6. An update on multidrug-resistant tuberculosis | 2019

  7. Antimicrobial resistance: a global multifaceted phenomenon | 2015

  8. An estimated 1.2 million people died in 2019 from antibiotic-resistant bacterial infections | University of Oxford

  9. Children’s immature immune systems threatened by increasing ‘superbugs’ | World Health Organization

  10. Global burden of bacterial antimicrobial resistance in 2019: a systematic analysis (2022)

  11. Antimicrobial resistance: Tackling a crisis for the health and wealth of nations (2014)

  12. Antibiotic resistance threats in the United States (2019)

  13. Non-prescription antimicrobial use worldwide: a systematic review - PMC (2013)

  14. Measuring outpatient antibiotic prescribing | Centers for Disease Control and Prevention

  15. Outpatient antibiotic prescribing in the United States: 2000 to 2010 (2014)

  16. Development of case vignettes for assessment of the inter-rater variability of national validation teams for the point prevalence survey of healthcare-associated infections and antimicrobial use in European acute care hospitals (2019)

  17. Variability in rates of use of antibacterials among 130 US hospitals and risk-adjustment models for interhospital comparison (2008)

  18. Improving antibiotic prescribing in hospitals can make health care safer | Centers for Disease Control and Prevention

  19.  The evolutionary history of methicillin-resistant Staphylococcus aureus (MRSA) - PMC (2002)

  20.  Methicillin resistant staphylococcus aureus - StatPearls (2021)

  21. Non-prescription antimicrobial use worldwide: a systematic review (2011)

  22. Self-medication practice among patients living in Soba-Sudan | Open Access Text

  23. Antimicrobial resistance (2010)

  24. Don't wear me out--the public's knowledge of and attitudes to antibiotic use (2007)

  25. Stop using antibiotics in healthy animals to prevent the spread of antibiotic resistance | World Health Organization

  26. Antibiotic use plummets on US farms after ban on using drugs to make livestock grow faster | The Bureau of Investigative Journalism

  27. Use of antibiotics in plant agriculture (2012)

  28. Antibiotic resistance, antimicrobial residues, and bacterial community composition in urban wastewater (2013)

  29. Comparison of antibiotic-resistant bacteria and antibiotic resistance genes abundance in hospital and community wastewater: A systematic review (2020)

  30. WASH (water, sanitation & hygiene) and COVID-19 | The World Bank

  31. Using medication: Using antibiotics correctly and avoiding resistance (2013)

Victoria is a writer from the UK with a keen interest in health and science. She loves writing about mental health, scientific advancements, and dispelling pseudoscience. When she’s not writing sass-laden articles, she walks her rescue dogs, giggles at anxiety memes, eats chocolate, and absorbs useless knowledge for quiz shows.

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