The state of knowledge about antibiotic resistance gets a powerful update today with a new report from the think tank known as CDDEP—the Center for Disease Dynamics, Economics and Policy—and what it has to say, about the rise in resistance around the world, is disturbing.
The report, called The State of The World’s Antibiotics 2015, brings together data from sources that have never been aggregated before: public surveillance programs and private laboratory networks from most regions of the world. The data paints a dismaying picture of antibiotic use and resistance rising in areas where international attention and policy haven’t yet focused: the developing economies where the drugs are easily available but national strategies to contain their use don’t exist or are just being launched.
The industrialized world can’t escape criticism though. The data the report harvests makes clear that rising resistance and lack of policy attention to it are critical issues worldwide.
“Antibiotic resistance is now clearly a problem in both the developed world and developing countries,” Ramanan Laxminarayan, a co-author of the report and CDDEP’s founder, told me by phone. “Things are about to get a lot worse before they get better.”
The gap between knowledge and action is vividly displayed in CDDEP’s potent online charting tool, called ResistanceMap, which now contains data on antibiotic use in 69 countries and on antibiotic resistance in 12 bacteria from 39 countries. In its on-demand visualizations you can see, for instance, that in India, the common bacterium E. coli is well on its way to untreatable, while in the United States, resistance to the last-resort class of drugs called carbapenems has risen sharply across just 10 years.
A particular strength of the 80-page report is the clear links it draws between antibiotic resistance and antibiotic use, and between antibiotic use and the event and actions that drive it. It documents, for instance, that 80 percent of antibiotics globally are used outside hospitals, where there is less attention to whether the right drug is being prescribed for the right amount of time. (That is, if the drug even was prescribed: in the developing world, antibiotics might be purchased over the counter without any medical involvement at all.) But the industrialized world comes in for blame as well: Though antibiotic use is rising most rapidly in the emerging BRIC economies (Brazil, Russia, Indian and China), the highest per capita user remains the United States.
Troublingly, that rising consumption worldwide takes in the most precious last-ditch drugs. Carbapenem use rose by 40 percent between 2000 and 2010, and the use of the very last-resort drug class polymixins rose by 13 percent. Sales of those drugs are rising fastest in India, Pakistan and Egypt, and many of those sales are retail, outside countries’ healthcare systems.
The CDDEP report also scrutinizes the use of antibiotics in agriculture worldwide. It finds that campaigns to reduce the use of the drugs in animals that are not sick—that is, for growth promotion and the prevention of disease—are having some effect, but that many more countries are turning to the drugs as their national economies, and spending on meat, both rise.
The report devotes a section to a proposal that is likely to be controversial: It argues that high-profile campaigns to increase production of new antibiotics are missing the point. The answer to misuse and resistance, it says, is not filling the so-called “empty pipeline” of new drugs, but coming up with ways to curb the use of any antibiotics—because without changes in behavior, new drugs will be rendered ineffective as quickly as older ones were.
“I can’t emphasize this enough,” Laxminarayan told me. “We’re making a mistake focusing on the supply of new antibiotics. The private market is already showing it is perfectly capable of coming up with new drugs, though they are expensive. We are not investing the kinds of money we need to to conserve the effectiveness of antibiotics and to change the system of incentives in which we are using them. If we don’t address stewardship, we are doomed to failure.”
In a change from lengthy policy proposals issued, for instance, by the World Health Organization and the Centers for Disease Control and Prevention, the CDDEP report proposes that the resistance and misuse problems it enumerates can be addressed with just six actions, covering the behavior of medicine, agriculture, everyday citizens—and, crucially, political systems. It calls for the creation of national antibiotic-resistance strategies in every country, contending that every country can begin to work on the problem no matter the state of its economy.
“There is this notion that antimicrobial resistance is an evergreen problem, that it is not actionable, that it requires too much of developing countries,” Laxminarayan told me. “I think that’s wrong. The things that will make a difference are very doable, and we should be doing them, right away.”