Antimicrobial Resistance: A Call to Action
By Amesh A. Adalja, MD, FACP, FACEP, December 6, 2013
Antibiotic resistance is a longstanding problem increasingly recognized to be a global crisis. Also increasingly recognized is the need for global commitment to a comprehensive and integrated plan of action. Responding to the crisis of antimicrobial resistance rising at an alarming rate among bacteria and the scarcity of new antimicrobials, The Lancet Infectious Diseases Commission has just published “Antibiotic resistance—the need for global solutions.” This 9-part document, authored by a group of infectious disease experts from around the world, makes a strong case for addressing the problem of antimicrobial resistance now, before it escalates into a global public health emergency.
The Commission begins with a global survey of antibiotic resistance epidemiology, highlights of which include the following:
- In the United States, antibiotic-resistant bacterial infections cause an estimated 2 million illnesses and 23,000 deaths each year. The numbers are similar in Europe.
- In 2012, close to 5% of US hospitals reported at least 1 healthcare-associated infection caused by carbapenem-resistant Enterobacteriaceae (CRE). The rates in many other parts of the world are much higher. CRE infections are fatal in 30% to 50% of cases, and the bacteria are resistant to nearly all (and in some rare cases, all) licensed antibiotics. Alarmingly, this form of resistance can be transmitted by plasmids between species. One form of CRE (NDM-1) has been found in drinking water in India.
- The death rate of MRSA bacteremias is 2.7 times higher than that of methicillin-sensitive Staphylococcus aureus bacteremias. While the incidence of healthcare-acquired MRSA infections has stabilized in high income countries, it continues to rise in much of the rest of the world, and the incidence of community-acquired MRSA is rising everywhere.
- Much of modern medicine—including organ transplantation, chemotherapy, neonatal care, and routine surgery—depends on the availability of effective antibiotics. If resistance renders antibiotics obsolete, up to 40% of patients having total hip replacements, for example, would suffer postoperative infections, with potential case fatality rates of 30%.
The Commission then turns to a discussion of approaches to solving this problem: hospital antimicrobial stewardship programs; judicious use of antimicrobials in the community; and improved infection control, education, and diagnostics. The authors emphasize the problem of diagnostic uncertainty, which they identify as a driver of irrational use and over-use of antibiotics. Also discussed is antimicrobial use in animals.
An important section, titled “Beyond antibiotics—alternative strategies for prevention and treatment,” emphasizes that the benefits of traditional methods of drug discovery will be limited in the 21st century. The authors argue for augmentation, including antibiotic adjuvants that target resistance mechanisms, virulence factors that target molecules, monoclonal antibodies, vaccines, immune modulators, and the “age-old phage treatment.”
The Commission concludes with a call for specific actions that should be taken now, namely: measuring the global extent of the problem, practicing rational infection control and antimicrobial use, developing and using rapid diagnostics more broadly, employing alternative treatment options, and developing coordinated strategies and governance.
This is an extensive and rich document that we cannot do justice to with a summary in this format. But the Commission’s report warrants attention and consideration, and we encourage all to read the document in full.
Laxminarayan R, Duse A, Wattal C, et al. Antibiotic resistance—the need for global solutions. The Lancet Infectious Diseases 2013;1057-1098. http://www.thelancet.com/journals/laninf/article/PIIS1473-3099(13)70318-9/abstract. Accessed December 4, 2013.