Antimicrobial Resistance Collaborators, “Global burden of bacterial antimicrobial resistance in 2019: a systematic analysis”, The Lancet, January 19, 2022, https://doi.org/10.1016/S0140-6736(21)02724-0.
After two years of relentless conversations about one pathogen that has ruled over the world causing over 52 lakh deaths in this period, The Lancet recently woke the world up to six other deadly pathogens (individually, or in combination with certain drugs) wrecking havoc in 2019, as a result of antimicrobial resistance (AMR). A late January 2022 publication in the peer-reviewed journal estimated that 4.95 million deaths were associated with bacterial anti microbial resistance in 2019. Bacterial antimicrobial resistance occurs when changes in bacteria causes the drugs used to treat the infection to become less effective.
Arguably the first such comprehensive study on AMR globally, the paper authored by Antimicrobial Resistance Collaborators states that AMR is a leading cause of death around the world, with the highest number of deaths occurring in low-resource settings. “Understanding the burden of AMR and the leading pathogen-drug combinations contributing to it is crucial to making informed and location specific policy decisions, particularly about infection prevention and control programmes, access to essential antibiotics, and research and development of new vaccines and antibiotics,” the authors have recommended.
Research on a massive scale
The study is an analysis of the burden of AMR, producing estimates for 204 countries and territories, 23 bacterial pathogens, and 88 drug-pathogen combinations in 2019. They obtained data from multiple data sources — including from published studies (microbiology data, in patient data, data on multiple causes of death, and pharmaceutical sales data), and directly from the collaborators on the Global Research on Antimicrobial Resistance project, members of the Global Burden of Diseases, Injuries and Risk Factors collaborator network. Additionally, they computed two counter factual scenarios — one where all drug resistant infections are replaced by susceptible infections, and secondly, a scenario where all drug resistant infections are replaced with no infections. The deaths and burden of AMR were estimated in these two scenarios, and served as a measure to inform the development of potential intervention strategies.
The six leading pathogens for deaths associated with resistance included E. coli, S. aureus, K. pneumoniae, S. pneumoniae, A. baumannii and Pseudomonas aeruginosa. They accounted for 73.4 % of the deaths attributable to AMR, and have been identified as priority pathogens by WHO.
While the study was done in 2019, it is possible that the intervening epidemic has worsened the situation in terms of pushing AMR levels further. Dr. V. Ramasubramanian, Senior consultant, Dept of Infectious Diseases, Apollo Hospitals, Chennai, explains that during the COVID-19 pandemic, the use of antibiotics went up. The tendency was also to use antibiotics for patients on a ventilator with fever. Secondly, due to the large number of patients during the peaking waves, lack of appropriate infection control (as will be done in the case of patients with resistant bacteria) was rendered impossible. He points out that antibiotics are the only batch of drugs, used in one person, that can impact the rest of the community. When the gut biome is modified and excreted, it can lead to contamination of lands and water sources, thus spreading resistant bacteria further in the community.
“We have always known that the burden of AMR in the world was huge. If action was not taken it was not because of the lack of data,” says Abdul Ghafur, infectious diseases expert, Apollo Hospitals, and architect of the Chennai Declaration. “It is because at the global level, we lost momentum.” India had framed its AMR policy in 2017, but only three States have initiated a state plan of action. According to official sources, 11 States are still working on a state plan of action.
Action plan to control AMR
“We should apply the principles of COVID control to AMR control. By whom was the most effective strategies against COVID deployed? By the public. If you look at global strategy, the public have been consistently kept out of the picture. We should involve the public, carpet bomb them with information and announce an AMR action plan that will involve them in control. Another major strategy would be to ensure hygiene and sanitation in all places. In a study that we conducted among healthy volunteers, 14 % of them were carrying colistin-resistant bacteria in the gut, that had a food source, they did not contract it in a hospital, Dr. Ghafur said.
AMR, reasons Dr. Ramasubramanian, is a classic case of ‘tragedy of the commons’ where a perfect solution is elusive. “You have got to use antibiotics, they are life saving. But there are so many factors that impact on such use such as using the right drugs, following the right quantity/schedule, over the counter issue of antibiotics, exposure to antibiotics used in certain sectors in farming and poultry as well as the lack of clear guidelines to follow (by the medical community) and incentives by the pharma industry to write out prescriptions for antibiotics …”. The authors of the paper also make a strong case for improving sanitation across the world, as part of an intervention strategy to prevent infections. Along with implementing hospital based prevention programmes, community based programmes that will improve hygiene, water and sanitation is essential. This is particularly important in low and middle income countries where the burden of AMR is highest and a clean water and sanitation network difficult to come by.
They have also suggested that preventing infections through vaccinations will automatically reduce the need for antibiotics. Currently, vaccines are available only for one of the six leading pathogens (S pneumoniae) but vaccine programmes are reportedly on for some others as well.
The way forward
Reducing exposure to antibiotics that are used in the farming sector and poultry industry is also key. In this context, Dr. Ghafur points out that India’s move to ban colistin usage in the poultry industry will go a long way in reducing the AMR burden in the country.
Antibiotic stewardship, or minimising the use of antibiotics unless absolutely necessary, remains at the core of the fight against AMR. It is in this aspect that Dr. Ghafur indicates the strong involvement of the community.
It is the hope of all collaborators, who continue to fight the big war with bacterial antimicrobial resistance, before, and through pandemics, that this new data provides the urgency and fresh momentum for global action to counter the single biggest burden that poses a major threat to human health.