Expert Speak Health Express
Published on Apr 06, 2023

Policies and tailored interventions need to be adopted to mitigate the growing global threat of antimicrobial resistance

Combatting Antimicrobial Resistance (AMR) in uncertain systems

Antimicrobial resistance (AMR) is a growing global threat to public health, with estimates suggesting that by 2050, it could result in 10 million deaths per year and a cumulative economic cost of up to US$ 100 trillion. One of the key drivers of AMR is the overuse and misuse of antibiotics, which can lead to the emergence of resistant strains of bacteria. This issue is especially prevalent in developing countries, where antibiotics are often available over the counter without a prescription. The inappropriate use of antibiotics in vulnerable populations, particularly children, exacerbates this issue.

Here are some identified key challenges in combating AMR at global and national levels:

  • Inappropriate use of antibiotics in children: Antibiotics are among the most commonly prescribed medications for children, despite the fact that many infections are caused by viruses and do not require antibiotics. Overprescribing and inappropriate use of antibiotics can lead to the development of antibiotic-resistant bacteria. A recent study found that up to 41 percent of antibiotics prescribed to children in outpatient settings were unnecessary or inappropriate.

  • Gap in development of new antibiotics: The development of new antibiotics has slowed down over the past few decades, and there are few new antibiotics in the pipeline. This makes it difficult to combat new strains of antibiotic-resistant bacteria.

  • Poor antibiotic stewardship: Antibiotic stewardship refers to the responsible use of antibiotics to preserve their effectiveness. It is, therefore, imperative for healthcare providers to prioritise antibiotic stewardship in their clinical practice to ensure the continued effectiveness of these life-saving medications.

Therefore, a crucial priority in the fight against AMR is developing age-appropriate antibiotics that are both effective and safe for children. In response to this need,  certain research and development priorities were put forth by World Health Organisation (WHO) at the global and national levels:

Strengthening surveillance systems for tracking antimicrobial use and resistance in both humans and animals, thus, promoting responsible use of antimicrobials in both humans and animals.

At the global level, three key priorities for research and development of age-appropriate antibiotics were outlined. Firstly, strengthening surveillance systems for tracking antimicrobial use and resistance in both humans and animals, thus, promoting responsible use of antimicrobials in both humans and animals. Secondly, there is a need to increase the understanding of the pharmacokinetics and pharmacodynamics of antibiotics amongst children, making it important to have age-appropriate dosing and administration strategies. The development of new antibiotics that are specifically designed for children is also an important area of research. This can help to ensure that antibiotics are both effective and safe for use in this population. Finally, there is a need to increase the availability of existing antibiotics in formulations that are suitable for children. Many antibiotics that are commonly used in adults are not available in formulations that are appropriate for children, making it difficult to provide effective treatment.

At the national level, there are several aspects where action is needed to improve the availability and use of age-appropriate antibiotics. Firstly, there is a need to improve the regulation of antibiotic use amongst children, including the promotion of appropriate prescribing practices and the restriction of over-the-counter sales. Secondly, there is a need to improve the quality and safety of antibiotics that are meant for children. Finally, there is a need to improve the availability and accessibility of age-appropriate antibiotics in low- and middle-income countries. This can be achieved through a range of measures, including improving supply chains, reducing prices, and promoting local production of antibiotics.

Collaboration between academia, industry, and government can bring together their unique strengths and resources to facilitate the development of age-appropriate antibiotics. For instance, the Drugs for Neglected Diseases initiative (DNDi) has worked with partners to develop a new antibiotic, fexinidazole, which is now being used to treat children with T.b. gambiense also known as sleeping sickness in Africa. Another example is the Innovative Medicines Initiative (IMI), which is a public-private partnership that works to accelerate the development of new drugs and vaccines. They funded several projects aimed at developing new antibiotics for children, including the DRIVE-AB project, which focused on developing innovative models for antibiotic development.

Foreseeing where the world may be headed, efforts were made by India and South Africa in October 2020 for waiving patents at the World Trade Organisation (WTO), but the global agency acted too late and did too little.

By using the, Communities in Action: Pathways to Health Equity Framework, we can address the issue of AMR by engaging communities and implementing interventions that are tailored to their specific needs. This can help promote health equity and reduce the burden of AMR on vulnerable populations. Here are some ways to implement this framework: (i) Raise awareness; (ii) Promote appropriate use of antibiotics; (iii) Encourage community engagement; (iv) Promote infection prevention and control; (v) Support research and development; (vi) Foster multi-sectoral collaboration and partnerships.

Role of G20 and IBSA:

The G20 and IBSA (India, Brazil, and South Africa) can play a significant role in combating AMR. These multilateral groupings  can help ensure that we have effective antibiotics to treat infections in all age groups by increasing funding, encouraging private sector investment, promoting responsible use, strengthening surveillance and monitoring, fostering international collaboration, and developing and implementing policies. For instance, India has been taking several steps to combat antimicrobial resistance (AMR) in recent years. The country has developed a National Action Plan on AMR, which outlines strategies to increase awareness, improve infection control, and promote the responsible use of antibiotics. India has also established a National Programme on AMR Containment i.e., establishing a laboratory-based AMR surveillance system in the country to generate quality data on antimicrobial resistance to monitor the spread of resistant bacteria and track their prevalence. In addition, the government has launched a campaign to encourage healthcare professionals to prescribe antibiotics only when necessary and to follow proper treatment guidelines. India has also implemented regulations to control the sale and distribution of antibiotics, including restricting over-the-counter sales of antibiotics without a prescription. Brazil and South Africa have also made strides in addressing AMR. Both countries have developed their National Action Plans on AMR, emphasising surveillance, infection prevention and control, and education of healthcare professionals and the public on appropriate antibiotic use.

A pandemic-prepared future means when an outbreak occurs, clinical trials should follow a standard master protocol and the results of every clinical trial should become available in one database so that every country can access them and take appropriate decisions.

Antimicrobial Stewardship Programmes, implemented in Australian hospitals, are another essential component of the fight against AMR. These programmes aim to improve the appropriate use of antibiotics and reduce the development and spread of resistant bacteria. They involve various strategies, such as education and training, surveillance, and audit and feedback, to promote responsible use of antibiotics and preserve their effectiveness. Initiatives led by WHO such as the Quadripartite agreement on AMR, signed by the Food and Agriculture Organization of the United Nations (FAO), the World Organisation for Animal Health (WOAH), the UN Environment Programme (UNEP) and the WHO, is an example of a coordinated approach to tackling AMR at the global level. Through this agreement, the organisations are working together to promote responsible use of antimicrobials in animal agriculture, strengthen surveillance systems for tracking AMR, and support research and development of new antimicrobials. Coordination among various sectors in G20 countries can develop a comprehensive, collaborative approach (develop best practices, sharing resources, and expertise) to combat AMR. A coordinated effort to invest in new technologies and innovative strategies, such as rapid diagnostics and alternative treatments like phage therapy, can further bolster the global fight against AMR. This will not only benefit their populations but also contribute to global health security and ensure the continued effectiveness of antibiotics for future generations.

In conclusion, AMR is a complex problem that involves the interaction of multiple factors. A systems thinking approach acknowledges the interconnectedness of these factors and the need for a multisectoral and multidisciplinary response. It also includes one-health approach, responsible use of antibiotics in healthcare settings, and stewardship programmes. Therefore, improving prescribing practices, increasing awareness among healthcare providers and the general public about the risks of AMR, surveillance and monitoring of AMR and supporting research and development of new antibiotics as well as recognising that the health of humans, animals, and the environment is interconnected. By implementing these strategies, we can work towards a future where antibiotics remain effective in the treatment of bacterial infections and can be used to form policies and develop tailored interventions to mitigate AMR.

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