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Antibiotic Resistance Getting Worse Globally, But Fixes Could Be Simple

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 percent of samples of the common bacterium MRSA (drug-resistant staph), in different countries, reflects national policies about antibiotic use.
The percent of samples of the common bacteri MRSA (drug-resistant staph), in different countries, reflects national policies about antibiotic use. Source: CDDEP

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.

Source: CDDEP
Source: CDDEP

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.

Source: CDDEP
Source: CDDEP

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.

Source: CDDEP
Source: CDDEP

“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.”

6 thoughts on “Antibiotic Resistance Getting Worse Globally, But Fixes Could Be Simple

  1. I suspect that we’re on the verge of an entirely new class of treatment that has potential to target genes for pathogenicity and antibiotic resistance directly, while leaving competing bacteria unharmed so as to not create new niches for other pathogens. This kind of research is really exciting:

    We show that Cas9, reprogrammed to target virulence genes, kills virulent, but not avirulent, Staphylococcus aureus. Reprogramming the nuclease to target antibiotic resistance genes destroys staphylococcal plasmids that harbor antibiotic resistance genes and immunizes avirulent staphylococci to prevent the spread of plasmid-borne resistance genes. We also show that CRISPR-Cas9 antimicrobials function in vivo to kill S. aureus in a mouse skin colonization model. This technology creates opportunities to manipulate complex bacterial populations in a sequence-specific manner.

    http://www.nature.com/nbt/journal/v32/n11/full/nbt.3043.html

    Obviously there are logistics to work out regarding delivery, but it seems possible that antibiotic resistance is treatable.

  2. This problem needs to be addressed on multiple fronts. One of the most promising is the use of AMPs (Anti-Microbial Peptides) and the work of Dr. Paul Savage at Brigham Young University. His work has been proven in both the laboratory as well as small and large animal trial to be effective against all gram negative bacteria, including MRSA. He has developed a truly remarkable breakthrough.

  3. If an entirely new class of treatment is discovered, and developed, to the tune of billions of dollars, that’s great — if it in fact happens. Seems like the next great thing is always just around the corner. In the meantime, we already know a cheap, effective way to curb resistance, by reducing selection pressure. In other words, stop the enormous overuse of antibiotics in human medicine (estimated as 50%) and stop the overuse in livestock (which, may be upwards of 70%). Best news is that we can get started on that right now! Less sexy, but less dollars and effective. The CDDEP report underscores that approach

  4. As usual McKenna provides us with one of the best and most succinct summaries of the publications in this field. Would be very interested in a similar report looking only at US, particularly looking at prescribing patterns in different regions. I’ve seen something similar for medicare expenditures per capita, would like to see drug prescriptions per capita, especially stratified by outpatient vs inpatient.

    MM: Thank you!

  5. Are we over medicated? Aren’t we weakening our immune systems with all those antibiotics? In other words our immune system relies on those meds and gets lazy? a vicious cycle no? Makes sense?

    1. I agree that it is a vicious cycle. However, I only think it applies to the developed world. A big problem also is that the antibiotics, when misused against viruses, actually harm the human body.

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