Antimicrobial resistance pandemic potentially looms in shadow of Covid

Covid may have grabbed the headlines but there is another pandemic getting progressively worse in its shadows caused by antimicrobial resistance (AMR); the bugs increasingly resistant to most antibiotics.

In January 2022, the Lancet published analysis estimating 1.27 million people died worldwide during 2019 from infections caused by bacteria resistant to antibiotics – in the largest study of the issue to date. Previous estimates were challenged due to unreliable data and difficulty in attributing burden to AMR specifically.

The Lancet figure is more than the annual death toll from malaria or Aids. Poorer countries are worst-affected but AMR threatens everyone’s health and brings vast additional costs even in the most advanced healthcare systems – including Ireland’s.

It underlines the need for urgent investment in new drugs and using current ones more wisely as overuse of antibiotics for trivial infections means they are becoming less effective against serious infections. People are dying from common, previously treatable infections because the bacteria that cause them have become resistant to treatment.

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Most AMR deaths are caused by lower respiratory infections, such as pneumonia, and bloodstream infections leading to sepsis. MRSA (methicillin-resistant Staphylococcus aureus) was particularly deadly, it found, while E.coli was also linked to high levels of drug resistance. Young children are at most risk, with about one in five deaths linked to AMR among the under-fives.

The UK Health Security Agency (UKHSA) chief medical adviser Dr Susan Hopkins warned in late 2021 of a “hidden pandemic” with the risk coming out of Covid-19 it would lead to another crisis, as serious AMR infections were set to rise again without responsible prescribing.

Needless deaths

The toll on patients and their families is largely invisible but is reflected in prolonged bacterial infections that extend hospital stays and cause needless deaths. Patients with longer hospitals stays are more likely to have resistant pathogens than those with shorter stays.

Drug-resistant infections are predicted to result in an estimated 10 million lives per year by 2050 while the economic cost of lost global production caused by AMR will amount to $100 trillion between now and then.

This goes far beyond difficult-to-treat hospital infections. The problem is that the sheer volume of antimicrobials being used in humans, animals and in other situations is leading to big increases in the rate of development of resistance.

“Antibiotics transform and extend lives. We need antibiotics that work for people and animals. They prevent suffering, premature death and economic loss,” Prof Martin Cormican of NUI Galway told a recent Veterinary Ireland conference.

Antibiotic resistance, however, is making it progressively more difficult and more costly to prevent and treat infection in a scenario where, in people and in animals, we are using more or less the same set of antibiotics. “We need to make what we have last,” said Cormican.

“We know what will work to slow or stop antibiotic resistance. We will use less antibiotics in all sectors if we prevent infection with hygiene, sanitation and vaccination. We will use less antibiotics if we get better at diagnosis of infections that antibiotics don’t work for. When we need antibiotics, we can use them better.”

The world is so connected by travel and trade that no sector and no country can hold back this tide on its own, he noted.

Rivers of superbugs

Regular genomic testing, tracking the genetic fingerprint of microbes and antibiotic residues, in human sewage is increasingly being used to get a more accurate global picture of AMR.

UK rivers near livestock farms are awash with superbugs and antibiotic residues, the Bureau of Investigative Journalism reported in November. It found evidence of drug-resistance in waterways near poultry and pig farms and in cattle farm waste, highlighting risks from slurry leaks contaminating rivers.

Dr Ramanan Laxminarayan from the Centre for Disease Dynamics, Economics and Policy in Washington DC has called for key data gaps to be filled and for global spending on AMR to match levels seen for other diseases.

“Spending needs to be directed to preventing infections in the first place, making sure existing antibiotics are used appropriately and judiciously, and to bringing new antibiotics to market,” he said in response to the Lancet findings.

Much of the world faced the challenge of poor access to affordable, effective antibiotics – and that needed to be taken seriously by political and health leaders everywhere, Dr Laxminarayan added.

Only 17 countries – including Ireland – have a funded and monitored national action plan to tackle the growing problem of AMR, according to the latest World Health Organisation data. It points to widespread gaps in efforts to tackle a spiralling health crisis estimated to be associated with five million infections annually.

Ireland is taking a “one health” approach to AMR; co-ordinated action across the human health, animal health and environment sectors, and including numerous stakeholders and agencies. This aligns with the approach recommended by the WHO and the European Commission. It recognises “health and wellbeing of people is connected to the health and welfare of animals, biodiversity, and the environment”.