The battle against antibiotic resistance needs to go global, with sweeping changes to the way the medications are developed, financed, and used, according to an international group of infectious disease specialists.
Writing online in The Lancet Infectious Diseases, Otto Cars, MD, of Uppsala University in Sweden, and colleagues argue that the time has come for worldwide, coordinated action to preserve antibiotic effectiveness.
Effective antibiotics are “indispensable in all health systems,” Cars and colleagues wrote, but their value is threatened by rising rates of drug resistance among pathogens.
Absent a global strategy to tackle resistance, they argue, “within just a few years, we might be faced with dire setbacks, medically, socially, and economically.”
“The causes of antibiotic resistance are complex and include human behavior at many levels of society,” Cars said in a statement. “The consequences affect everybody in the world.”
The report of the 26 experts is “very authoritative,” commented Henry Chambers, MD, of the University of California San Francisco and a spokesman for the Infectious Diseases Society of America (IDSA).
“If you wanted to learn 95% of the arguments and what they’re based on,” he told MedPage Today, “you could read this document and know a lot at the end.”
The IDSA has been vocal about the issue of antibiotic resistance, warning repeatedly that thepipeline of new drugs is running dry and calling for efforts to find new ones.
But the issue is more complicated than that, Cars and colleagues argued. In essence, antibiotic resistance is Darwinian evolution in action, but with the pressure of natural selection on pathogens replaced by human pressure.
That pressure takes various forms — overuse and inappropriate use of antibiotics in healthcare settings, in poor communities, on farms and feedlots, and in the streets of the Third World.
“Antibiotic resistance is a complex ecological problem which doesn’t just affect people, but is also intimately connected with agriculture and the environment,” Cars said.
Cars and colleagues noted that more antibiotics are used in animals than in humans by a factor of about four — mostly for nontherapeutic reasons, such as to improve growth. And there is increasing evidence that resistance that develops in animals can make itself felt in human pathogens.
The problem is complicated by economic and social barriers to rational use of drugs — in some places, for instance, hospitals derive much of their revenue from medication sales.
The major drivers of resistance, they argued, include such things as “self-medication, noncompliance, misinformation, and advertising pressures” combined with ignorance, lack of education, and lack of access to healthcare.
Poverty “compounds the problems, because patients do not have access to clean water and hygiene and are at an increased risk of acquiring infections,” Cars and colleagues wrote.
Discovering new drugs — one proposed solution and the heart of the IDSA’s 10x’20 initiative — is equally complex, they noted.
Among other things, the value of new antibiotics to their developers largely depends on them being widely used — but wide use is the very thing that fuels the development of resistance.
“This is not a desirable situation for new antibiotics,” according to Cars and colleagues, who argued that it will be important to find some way to break the link between revenue and use.
And, they noted, in the past few decades the infrastructure for antibiotic development, both in industry and academia, has decayed, so that few if any new drugs are under development.
Summing up, they wrote: “the world is left with a decreasing stock of effective antibiotics, an inadequate pipeline of new classes and analogues, a broken antibiotic market, a paucity of antibiotic discovery infrastructure in academia, and insufficient infrastructure in industry.”
“Antibiotic discovery has stalled but we do not know how to restart the engine.”
In any case, simply finding new drugs is probably not a complete solution, IDSA’s Chambers noted. “I’m not sure we can drug our way out of the problem,” he said, if only because resistance will inevitably arise to any new medication.
Indeed, Cars and colleagues called for a range of new approaches including, among other things:
- Strict monitoring of antibiotic use, including bans on over-the-counter sales unless such prohibitions would “cause an unacceptable access problem.”
- Getting rid of financial incentives to prescribers and dispensers that lead to irrational use.
- Regular revision of standard treatment guidelines into “clear, simple, updated, evidence-based, locally relevant, and accessible documents.”
- Motivational measures, including pay-for-performance policies, audit-feedback mechanisms on antibiotic prescribing rates, and public disclosure of antibiotic prescribing rates of healthcare facilities.
- “Well designed and contextualized” public educational campaigns to cut patients’ perceived need for antibiotics.
- Better implementation of basic hygienic routines in all hospitals and healthcare settings.
- Re-assessment and improvement of infection control interventions.
- Development of new rapid diagnostic tests that will reduce pressure to use antibiotics empirically.
Some of that is already under way. India, for instance, long the home of widespread over-the-counter sales of antibiotics, has begun to curtail the practice.
On the awareness front, the CDC’s ‘Get Smart About Antibiotics Week’ begins Monday, which is also European Antibiotic Awareness Day.
More action, the authors pointed out, will need to be coordinated both nationally and internationally, but there is so far little sign of it, especially at the political level.