Antimicrobial resistance (AMR) is on the rise, and projections for how rates will grow from here are not promising.
A study published in The Lancet in September 2024 sounded the alarm on how antimicrobial resistance is becoming even more of a problem worldwide and projected how much of an impact it will have all the way through 2050. The authors looked at data across 204 countries and territories from 1990 to 2021 and eventually ended up collecting 520 million individual records or isolates.
In 2021 alone, the authors estimated 4.71 million deaths were associated with bacterial AMR and 1.14 million were directly attributable. Those numbers are expected to rise precipitously according to the researchers’ calculations; they estimate about 8.22 million deaths associated with AMR and 1.91 million attributed to it in 2050. Providing some optimism is the notion that nearly 92 million deaths could be averted between 2025 and 2050 through “better care of severe infections and improved access to antibiotics.” An additional complicating wrinkle is that rates of deaths associated with AMR rose particularly quickly in adults over age 70, which represents a concerning trend only made more frightening by the rapidly aging world population.1
Another study, available to view on the NIH website’s PubMed Central, aimed to categorize some broad spectrum facts about antibiotic resistance specifically and the drivers of its rise in prevalence. The researchers laid out that the transmission and acquisition of AMR occurs “primarily via the human-human interface both within and outside of healthcare facilities. Humans, animals, water, and the environment are found to be reservoirs, and antimicrobial-resistance genes can be transmitted between and within these reservoirs.”
They also explain several specific factors that make antimicrobial resistance happen in the first place. Among these factors include the misuse and overuse of antibiotics; an increase in gross domestic product around the globe, leading to an elevation in global antibiotic use; inappropriate prescribing patterns; a lack of new novel antibiotics to counteract existing antibiotic resistance; the use of antibiotics in agriculture; easy travel routes facilitating more human movement; and knowledge gaps among healthcare workers and members of the public.2
Healthcare Purchasing News spoke with Rodney Rohde, PhD, MS, SM(ASCP)CM, SVCM, MBCM, FACSc, Regents’ Professor at Texas State University System, on the rise of antimicrobial resistance and what clinicians can do to play a part in reducing the burden as well as general trends concerning AMR in general.
What causes antibiotics to be prescribed in situations that don’t necessarily call for them?
A: There are many reasons for this issue and sometimes it is a complex set of variables. Some of the most common reasons are an uncertain diagnosis. This can be really difficult if a patient is in danger from something like sepsis and it is life threatening. In these cases, time may not be available to wait for a laboratory confirmation via culture and antibiotic susceptibility testing or even a rapid test. In these cases, a broad-spectrum antibiotic may be utilized as a "cover our bases" for sepsis or other dangerous conditions. Patient pressure/expectations are always an issue, and we all need to be able to "educate" our patients about why antibiotics should not just be handed out. Physician fatigue, lack of patient education, limited diagnostic tools, and perception of risk can also play into this issue.
How can clinicians ensure antibiotics are not being over-prescribed?
A: The quick answer is education surrounding adherence to antibiotic (or other antimicrobial drugs) stewardship principles and practices. “How to” elements are now available for clinicians via CDC and other entities for creating an Antibiotic Stewardship Program [ASP] to implement guidelines. Clinicians and others can also advocate for better diagnostic tools for a more accurate diagnosis and treatment plan. ASP teams should be collaborating with the medical laboratory, the ID pharmacist, and others on the ASP team to optimize prescription practices: selection of best antibiotic, correct dose/duration, delayed prescribing for conditions that might resolve without antibiotics, and optimized delivery (oral versus IV).
ASP teams should be working with clinicians to enhance education and expertise to create "positive peer pressure" to not prescribe unnecessarily. They should also be working to build better tracking and reporting systems for prescribing to provide feedback. Lastly, ASP teams and all involved should work to engage patients in education and expectations for the use of antimicrobials, including the global issue of AMR.
What specific concerns exist around antimicrobial resistance right now?
A: There are so many concerns on AMR. The ongoing and increasing difficulty in treating infections due to "superbugs" has led to reduced effectiveness of existing drugs. This has led to more threats and concerns while performing typical surgeries, transplants, and other procedures. The rise of specific resistant (including pan-resistant) pathogens like MRSA, CRE, TB, fungi (like Candida auris), malaria, and many others is an ongoing threat for all treatment.
The drivers of AMR are many and it's a global concern that must be addressed via "One Health" frameworks. Misuse, overuse, inappropriate use (like agriculture), lack of regulation in some countries coupled with globalization making travel of pathogens "easy" now are all examples of factors contributing to AMR.
How do you see the topic of antimicrobial resistance changing over the next 10 or so years?
A: In my professional opinion, AMR is going to continue to become an even more urgent and pressing global problem in the next decade and even beyond. It will take a tremendous amount of effort, education, and global willingness to work on the issues stated.
What steps can be taken by clinicians in the fight against rising antimicrobial resistance?
A: Clinicians, infection preventionists, pharmacy, nursing, patients, and many in the healthcare arena must work together to optimize antimicrobial prescribing practices. This is currently supported by research. For example, clinical "nudging" and the use of accurate antibiograms has been adopted by many who are in ASP teams. The enhancement of infection prevention and control measures can reduce the risk of infections and thus reduce the use of antimicrobial measures (hand hygiene, vaccination, isolation precautions, proper sterilization and disinfection of surfaces, for example). Education, collaboration, and advocacy are critical to building an environment that helps reduce pressure to use antibiotics or other antimicrobials without proper reasoning.
What will have to happen as resistance grows?
A: As AMR grows, we can expect any number of infections to become increasingly more difficult or impossible to treat. It may become more expensive to treat them, which could impact a patient's ability to even address infections. This will in turn put a greater strain on healthcare systems with economic and healthcare equity consequences. Longer hospital stays with increased costs, higher morbidity and mortality, and reduced productivity which may lead to higher poverty are all possible outcomes. AMR could very likely be the #1 killer, outpacing things like cancer, in the coming decades which will be a threat to global health security. Simple infections like strep throat or a "staph" skin infection may become things we can't take for granted any longer.
Have you observed anything encouraging or troubling with regards to antibiotic prescription lately?
A: If you look at the literature and reporting, there is increased awareness and action by many global health organizations and governments. CDC and WHO have invested significant funding for infrastructure like surveillance tools, diagnostic tools, and education materials. In some settings, we have seen some declining AMR rates such as long-term care pharmacies coupled with improved prescription adherence practices. ASP teams are increasing in healthcare systems, and more clinicians are collaborating with these teams to tackle specific resistant infections like MRSA bloodstream infections and surgical-site infections in the U.S. The Global Antimicrobial Resistance and Use Surveillance System [GLASS] and others have shown the global burden of AMR deaths among the pediatric population under 5 has declined by 50% between 1990 and 2021.
Any final thoughts for our readers?
A: I am a passionate advocate of Science Communication and Health Literacy in the framework of a One Health approach. We must all work to educate our population about AMR being a significant global threat. We need more support for antimicrobial research and development, better and more accurate diagnostic testing and tools for all nations, stronger surveillance systems, and overall promotion and funding support for the experts and professionals needed to combat this global trend.
Matt MacKenzie | Associate Editor
Matt is Associate Editor for Healthcare Purchasing News.
