Collaborate to stop antimicrobial resistance—for the sake of the planet

Abstract

Antimicrobial resistance is one of the top ten global health threats facing us according to WHO, and threatens to undo more than 100 years of progress in medicine—currently, the UN estimates that around 700 000 people die annually from resistant infections. And the emergence and spread of resistance in all pathogen types is rising fast. For example, for Escherichia coli, resistance rates as high as 92·9% against ciprofloxacin and 36·0% against third-generation cephalosporins have been reported. Around 500 000 cases of rifampicin-resistant tuberculosis were identified in 2018, and more than 50% of infants in sub-Saharan Africa newly diagnosed with HIV have a virus that is resistant to non-nucleoside reverse-transcriptase inhibitors. Clearly, swift action needs to be taken to halt and reverse this trend, and it is crucial that research in the area of antimicrobial resistance is catalysed into policy and practice. A panel chaired by WHO in July, 2021, discussed the need for more collaborative efforts between researchers and policy makers and to narrow the gap between research and policy. The drivers of resistance are myriad, ranging from causes resulting from poverty such as poor sanitation and inadequate infection control and access to health care, to overuse and misuse of antimicrobials that increase the selection for resistance (either acquired resistance through mutations in the DNA of pathogens or gain of resistance genes through horizontal gene transfer). For example, the COVID-19 pandemic led to excessive use of antibacterial disinfectants, which could lead to more antimicrobial-resistant infections in the future. The complexity of resistance highlights why collaborations, together with adequate funding of research and political will are important. Part of the problem might be that antimicrobial resistance is narrowly viewed as a purely human and animal health threat, rather than the far-reaching and more insidious threat to the environment and planetary health. The overuse of antibiotics in medicine, and of both antibiotics and pesticides in agriculture, for example, can leach antimicrobial residues and resistant bacteria into sewage systems, water, and soil, helping to directly or indirectly select for antibiotic resistance and the development of antimicrobial-resistant infections in humans and animals. Jason Burnham (Division of Infectious Diseases, Washington University School of Medicine, St Louis, MO, USA) commented “Antimicrobial resistance in the environment can increase selective genetic pressure on bacteria, against which they are well suited to evolve, leading to increases in antimicrobial resistance in the environment that can spread to animals and human beings in a destructive cycle”, emphasising how more locally sustainable agriculture that uses fewer pesticides and antibiotics is needed. Additionally, the UN have highlighted how both antimicrobial resistance and pandemics are partly driven by climate change and pollution; increases in antibiotic resistance are associated with increases in local temperatures, which have risen due to climate change. One study showed that every 1°C increase in temperature correlated to increases in resistance of 1·02 times for meticillin-resistant Staphylococcus aureus, 1·03 times for carbapenem‑resistant Klebsiella pneumoniae, and 1·01 times for multiresistant E coli. Decreasing the use and misuse of antimicrobials is one of the key actions to reducing resistance, and effective communication from researchers and policymakers to all individuals, including clinicians, farmers, food manufacturers, and patients, is important. Multiple stakeholders and sectors should work together to implement effective research programmes and legislation. Additionally, adequate funding of research to develop new antimicrobials is crucial to overcome the inevitable resistance to existing drugs: groups such as the AMR Action Fund who aim to develop two to four new antibiotics by 2030 through investment and provision of resources and expertise are paving the way. But framing resistance as a wider planetary health issue and including environmental groups in collaborations with scientists and clinicians might also be helpful to bring pressure on policy makers and governments to make the right policy changes. Socioeconomic factors should also be considered, since resistance levels vary not only between countries but also between populations, and lower national incomes might be linked with circumstances that increase the spread of resistance, such as poor hygiene and sanitation. Burnham highlighted how the correct policy changes will only be possible through reducing wealth inequalities and fairer elections, commenting “the gaps between groups and policy makers is important. The problem is electing policy makers who have agendas consistent with a sustainable way of human living, which relies on fair elections. We need more partnerships [between] governments and scientists, and we need to have partnerships with politicians [who] are elected that represent the will of the people.”