United Nations High Level Meeting on Antimicrobial Resistance
To better understand the threat of antimicrobial resistance (AMR), we can look at a case of a 50 year old woman, who develops a high fever, a week after major cancer surgery, while she remains in intensive care. Her blood pressure starts to drop as she slides into septic shock. She most likely has a severe bacterial infection; such hospital-acquired infection is commonly resistant to multiple antibiotics. Tests are obtained to diagnose infection, but the results may take days to come back. There is no time to waste to start necessary treatment, including appropriate antibiotics. The required antibiotics are expensive, potentially toxic and have mixed results. AMR means a longer stay in the hospital, more expensive care, and a greater risk of death.
AMR is a problem that may affect us all. It is worldwide in its scope, but particularly targets the poor and the vulnerable. It is a huge cost to the world in terms of health care finances and resources, as well as in lost productivity. AMR was estimated to have caused 700,000 deaths, as a conservative estimate, worldwide in 2012, increasing to over 10 million in 2050; greater than the number of deaths due to cancer. It impacts on a wide array of other treatments where infection is a potential risk. For example, risks of death from cancer chemotherapy or of severe illness after joint surgery, which, may outweigh the potential benefits if antibiotic-resistant infection is likely.
The more antibiotics are used, the more live bacteria are exposed to antibiotics, the greater the likelihood of resistance. When antibiotics are used wisely, to treat serious bacterial infections, they are an asset. When they are used to treat other conditions, they are of no benefit to the recipients and a major risk to the local environment. When they are used for dubious reasons, such as growth promotion in farm animals (70% of antibiotics in the United States are for this use) they are a danger to society.
AMR may impact on any kind of infection, but worldwide attention has focused on big killers: organisms such as malaria, HIV, TB, as well as ‘super-bugs’ like MRSA, Clostridium difficile, and various resistant Gram negative infections, which are commonly organisms in hospital acquired infection. Much of the response has been high level, engaging the world to address the problem. The most comprehensive blueprint for action, however, comes from the Jim O’Neill report in the United Kingdom, which treats AMR worldwide as a health, social and economic issue. Their extensive list of proposals to respond to the problem calls for a variety of measures to prevent infection and reduce unnecessary use of antibiotics. They call for promotion of the development of novel therapies for infection. They recognise the key importance of education of the public, not to expect antibiotics in non-bacterial infection, as well as promotion of human resources in microbiology and clinical infectious disease. Their final recommendation is for a ”global coalition for real action”.
Jim O’Neill reports that the cost of his proposed interventions worldwide is far less than the cost of the infections they would prevent. In other words, he believes that improved understanding, better diagnostics, more use of existing and future vaccines, improved hygiene, and innovative treatments will be cost-saving as well as life-saving.
We got into our difficulties with AMR because antibiotics were so good. They killed bacteria with relatively little toxicity and they saved lives. The advent of AMR undermines the antibiotic miracle. AMR has been years in the making and will take years to remedy. With the G20 meeting and soon the UN, the system has been engaged. We must all put our shoulders to the wheel for the well-being of our children and ourselves. The General Assembly discussions are only a beginning.
Raphael Saginur, MD, FRCPC, FIDSA
ISC Treasurer and Trustee