by microbiology Doctor-dr
Antimicrobial resistance
- Antimicrobial resistance (AMR) is a worldwide danger to human health and development. To attain the Sustainable Development Goals, urgent multi-sectoral action is required (SDGs).
- AMR has been named as one of the top ten worldwide public health hazards facing humanity by the World Health Organization.
- Drug-resistant infections are mostly caused by the misuse and overuse of antimicrobials.
- The spread of microorganisms is aided by a lack of clean water and sanitation, as well as inadequate infection prevention and control. Some germs are resistant to antibiotic treatment.
- The economic burden of AMR is enormous. Longer hospital stays, the need for more expensive drugs, and financial hardships for those affected are all consequences of extended sickness.
- The efficacy of modern medicine in treating infections, notably during major surgery and cancer chemotherapy, would be jeopardised without effective antimicrobials.
- Antimicrobials are substances that kill bacteria.
- Antibiotics, antivirals, antifungals, and antiparasitics are antimicrobial drugs that are used to prevent and treat infections in humans, animals, and plants.
What is the definition of antimicrobial resistance?
Antimicrobial resistance (AMR) develops when bacteria, viruses, fungi, and parasites evolve over time and lose their ability to respond to antibiotics, making infections more difficult to treat and raising the risk of disease transmission, severe illness, and death.
Antibiotics and other antimicrobial medications become ineffective as a result of drug resistance, and illnesses become more difficult or impossible to treat.
Why is antimicrobial resistance such a worldwide issue?
Drug-resistant bacteria that have developed new resistance mechanisms, leading to antimicrobial resistance, continue to pose a danger to our capacity to treat common diseases. The increasing global spread of multi- and pan-resistant bacteria (sometimes known as "superbugs"), which cause diseases that are resistant to existing antimicrobial medications such as antibiotics, is particularly concerning.
The pipeline of novel antimicrobials in clinical trials is depleted. Only six of the 32 antibiotics in clinical development that address the WHO list of priority pathogens were designated as novel by WHO in 2019. Furthermore, a scarcity of high-quality antimicrobials continues to be a key problem. Antibiotic shortages are hurting countries at all stages of development, particularly in the health-care sector.
Antibiotics are becoming increasingly ineffective as antibiotic resistance grows over the world, making infections and death more difficult to treat. New antibacterials are desperately needed to treat carbapenem-resistant gram-negative bacterial infections, which are on the WHO priority pathogen list. However, unless people change the way antibiotics are used now, these new antibiotics will follow in the footsteps of the current antibiotics and become useless.
The cost of AMR to national economies and health systems is high because it reduces patient or caregiver productivity by requiring longer hospital stays and more expensive and intense care.
Without efficient methods for preventing and treating drug-resistant infections, as well as enhanced access to existing and new quality-assured antimicrobials, the number of people who fail to respond to treatment or die from infections will rise. Surgical operations such as caesarean sections and hip replacements, cancer chemotherapy, and organ transplants will become more dangerous.
What factors contribute to antibiotic resistance's emergence and spread?
AMR develops over time, mainly as a result of genetic alterations. People, animals, food, plants, and the environment all have antimicrobial resistant microbes (in water, soil and air). They can transmit from person to person or between humans and animals, as well as through animal-sourced food. The misuse and overuse of antimicrobials, a lack of clean water, sanitation, and hygiene (WASH) for both humans and animals, poor infection and disease prevention and control in health-care facilities and farms, a lack of quality, affordable medicines, vaccines, and diagnostics, a lack of awareness and knowledge, and a lack of legislation enforcement are the main drivers of antimicrobial resistance.
The current condition
Bacterial drug resistance
High rates of resistance against antibiotics often used to treat common bacterial diseases, such as urinary tract infections, sepsis, sexually transmitted infections, and various forms of diarrhoea, have been documented worldwide, indicating that we are running out of effective antibiotics. In countries reporting to the Global Antimicrobial Resistance and Use Surveillance System, for example, resistance to ciprofloxacin, a common antibiotic used to treat urinary tract infections, ranged from 8.4 percent to 92.9 percent for Escherichia coli and from 4.1 percent to 79.4 percent for Klebsiella pneumoniae (GLASS).
Klebsiella pneumoniae is a kind of bacteria found in the intestine that can cause life-threatening infections. K. pneumoniae resistance to last-resort treatment (carbapenem antibiotics) has developed throughout the world. K. pneumoniae is a common source of hospital-acquired illnesses such pneumonia, bloodstream infections, and infections in neonates and patients in intensive care units. Because of resistance, carbapenem medicines are ineffective in more than half of the patients treated for K. pneumoniae infections in various countries.
Resistance to fluoroquinolone antibiotics, which are used to treat urinary tract infections, is common in E. coli.
In many regions of the world, this medication is no longer effective in more than half of the patients.
Colistin is the sole last-resort treatment for carbapenem-resistant Enterobacteriaceae infections that are life-threatening (i.e. E.coli, Klebsiella, etc). Bacteria resistant to colistin have also been found in a number of nations and areas, causing diseases for which no effective antibiotic treatment is now available.
Staphylococcus aureus is a bacteria that is found in our skin flora and is a common source of illness in both the community and health-care institutions. Infections with methicillin-resistant Staphylococcus aureus (MRSA) are 64 percent more likely to cause death than infections with drug-sensitive bacteria.
A new AMR indicator was added to the SDG monitoring framework in 2019. This indicator tracks the number of bloodstream infections caused by two drug-resistant pathogens: methicillin-resistant Staphylococcus aureus (MRSA) and E. coli resistant to third-generation cephalosporins (E. coli) (3GC). In 2019, GLASS received data on MRSA bloodstream infections from 25 nations, territories, and areas, and data on E.coli bloodstream infections from 49 countries. The median rate for methicillin-resistant S. aureus was 12.11 percent (IQR 6.4–26.4), and the rate for E. coli resistant to third-generation cephalosporins was 36.0 percent (IQR 15.2–63.0), however the findings are still not nationally representative.
The management and control of gonorrhoea has been hampered by widespread resistance in extremely diverse strains of N. gonorrhoeae. Sulphonamides, penicillins, tetracyclines, macrolides, fluoroquinolones, and early-generation cephalosporins have all developed resistance quickly. The injectable extended-spectrum cephalosporin (ESC) ceftriaxone is currently the only empiric treatment for gonorrhoea in most countries.
Mycobacterium tuberculosis drug resistance
Antibiotic-resistant Mycobacterium TB strains are putting the global tuberculosis epidemic in jeopardy. According to WHO, over half a million new cases of rifampicin-resistant tuberculosis (RR-TB) were identified globally in 2018, with the vast majority of these cases being multi-drug resistant tuberculosis (MDR-TB), a type of tuberculosis resistant to the two most effective anti-TB medications. Only about a third of the half-million persons who got MDR/RR-TB in 2018 were identified and reported. MDR-TB requires lengthier, less effective, and considerably more expensive treatment regimens than non-resistant TB. Only about 60% of people who are treated for MDR/RR-TB get cured.
MDR-TB/RR-TB was found in 3.4 percent of new TB cases and 18 percent of previously treated patients in 2018, and the advent of resistance to new "last resort" TB medications to treat drug resistant TB constitutes a significant danger.
Viruses that are resistant to drugs
Antiviral medication resistance is becoming more of a problem in immunocompromised patients, because continued viral replication and protracted drug exposure result in the selection of resistant strains. Most antivirals, including antiretroviral (ARV) medications, have gained resistance.
Because of the rise of drug-resistant HIV, all antiretroviral (ARV) medications, even newer classes, are at danger of becoming partially or completely ineffective (HIVDR). HIVDR can develop in patients on antiretroviral therapy, and HIV can potentially infect people who are already drug resistant. In the majority of the tracked countries in Africa, Asia, and Latin America, pretreatment HIVDR (PDR) to non-nucleoside reverse-transcriptase inhibitors (NNRTIs) among individuals starting first-line therapy exceeded 10%. PDR has an extremely high frequency among babies. Over half of newly diagnosed HIV patients in Sub-Saharan Africa have a virus that is resistant to NNRTIs. Following these findings, the World Health Organization's current ARV guidelines now advocate the use of a new medicine, dolutegravir, as the preferred first-line treatment for adults and children. The use of this medicine is especially important in preventing the harmful effects of NNRTI resistance.
Because second- and third-line medications are substantially more expensive than first-line drugs, rising levels of resistance have significant economic repercussions. The World Health Organization's HIV Drug Resistance Programme is tracking the spread and emergence of resistance to older and newer HIV medications all across the world.
Malaria parasites have developed drug resistance.
One of the most serious risks to malaria management is the generation of drug-resistant parasites, which leads to a rise in malaria morbidity and mortality. Most malaria-endemic nations employ artemisinin-based combination treatments (ACTs) as the first-line treatment for uncomplicated P. falciparum malaria. The artemisinin component of ACTs is combined with a partner medication. Between 2001 and 2019, research in Cambodia, Lao People's Democratic Republic, Myanmar, Thailand, and Vietnam confirmed partial resistance to artemisinin and resistance to a number of ACT partner medications in the WHO Western Pacific Region and the WHO South-East Asia Region. This makes choosing the proper treatment more difficult and necessitates constant monitoring.
P. falciparum resistance to sulfadoxine-pyrimethamine resulted to artesunate-sulfadoxine-pyrimethamine failures in some countries in the WHO Eastern Mediterranean Region, prompting a switch to another ACT.
Evidence of the occurrence of mutations linked to partial artemisinin resistance in Rwanda was recently published in Africa. So far, the ACTs that have been tried have proven to be highly effective. However, the rise of artemisinin and ACT partner medication resistance could constitute a major public health threat, jeopardising important malaria control successes.
Fungi with drug resistance
Drug-resistant fungal infections are becoming more common, complicating an already tough therapeutic scenario. Many fungal infections have known treatment concerns, such as toxicity, particularly in individuals with concurrent infections (e.g. HIV). Drug-resistant Candida auris, one of the most frequent invasive fungal infections, is already ubiquitous, with fluconazole, amphotericin B, and voriconazole resistance on the rise, as well as growing caspofungin resistance.
As a result, fungal infections are becoming more difficult to treat, treatment failures are becoming more common, hospital stays are becoming longer, and treatment alternatives are becoming considerably more expensive. WHO is doing a global evaluation of fungal infections and will publish a list of public-health-relevant fungal pathogens, as well as an overview of the antifungal development pipeline.
Coordinated action is required.
AMR is a complicated issue that necessitates a multi-sectoral response. In order to achieve better public health outcomes, the One Health approach brings together multiple sectors and stakeholders involved in human, terrestrial and aquatic animal and plant health, food and feed production, and the environment to communicate and collaborate in the design and implementation of programmes, policies, legislation, and research.
More investment and innovation is needed in operational research, as well as in the research and development of new antimicrobial drugs, vaccines, and diagnostic tools, particularly for gram-negative bacteria such carbapenem-resistant Enterobacteriaceae and Acinetobacter baumannii. The Antimicrobial Resistance Multi Partner Trust Fund (AMR MPTF), the Global Antibiotic Research and Development Partnership (GARDP), the Antimicrobial Resistance Action Fund, and other funds and activities could help close a funding shortfall. Sweden, Germany, the United States, and the United Kingdom are among the countries that are testing reimbursement methods. To develop long-term answers, further initiatives are required.
Antimicrobial Resistance Global Action Plan (GAP)
During the 2015 World Health Assembly, governments agreed to the framework outlined in the Global Action Plan1 (GAP) 2015 on AMR, as well as the development and execution of multisectoral national action plans. It was later endorsed by the United Nations' Food and Agriculture Organization (FAO) and the World Organisation for Animal Health's Governing Bodies (OIE). Countries must guarantee that national action plans are costed and implemented across sectors in order to achieve long-term progress. Prior to the GAP's approval in 2015, global attempts to limit AMR included the World Health Organization's global strategy for antimicrobial resistance containment, which was developed in 2001 and provides a framework of actions to prevent the emergence and spread of AMR.
Antimicrobial Resistance Tripartite Joint Secretariat
The political declaration from the United Nations High Level Meeting on AMR, which was signed by Heads of State at the United Nations General Assembly in New York in September 2016, reaffirmed a strong focus on a broad, coordinated approach that includes all sectors of health, including human, animal, plant, and environmental health. In a 'One Health' approach, WHO is collaborating with FAO and OIE to promote best practises for reducing AMR levels and slowing its progression.
Following the UN High-Level Meeting on Antimicrobial Resistance in 2016, the Secretary-General of the United Nations established the Interagency Coordination Group on Antimicrobial Resistance (IACG). To establish a plan to combat antimicrobial resistance, the IACG gathered together UN partners, international organisations, and individuals with experience in human, animal, and plant health, as well as food, animal feed, trade, development, and the environment. In April 2019, the UN Secretary-General received the Interagency Coordination Group on AMR's report, "No Time to Wait: Securing the Future from Drug-Resistant Infections." Its suggestions are currently being implemented.
To promote multi-stakeholder engagement in AMR, a tripartite joint secretariat (FAO, OIE, and WHO) has been established and is hosted by WHO. The Global Leaders Group on AMR, which began work in November 2020, the Independent Panel on Evidence for Action against AMR, and the Multi-Stakeholder Partnership Platform, all of which are in the process of being constituted, are among the primary governance mechanisms agreed upon.
Week of Antimicrobial Awareness (WAAW)
World Antibiotic Awareness Week was previously known as WAAW. It has been known as World Antimicrobial Awareness Week since 2020. This reflects WAAW's expanded definition of antimicrobials, which now includes antibiotics, antifungals, antiparasitics, and antivirals. WAAW, which has been held every year since 2015, is a global campaign aimed at raising antimicrobial resistance awareness and encouraging best practises among the general public, health workers, and policymakers in order to reduce the development and spread of drug-resistant illnesses. The WAAW dates for the future have been set by the Tripartite Executive Committee to be November 18 to 24. For the past five years, the overarching motto has been "Antibiotics: Handle with Care." In 2020, this was modified to "Antimicrobials: Use Caution."
The Global Antimicrobial Resistance and Use Surveillance System is a global surveillance system for antimicrobial resistance and use (GLASS)
In 2015, the World Health Organization (WHO) launched the Global Antimicrobial Resistance and Use Surveillance System (GLASS) to continue bridging knowledge gaps and inform actions at all levels. GLASS was designed to gradually combine data from AMR surveillance in humans, antimicrobial medicine surveillance, AMR in the food chain, and AMR in the environment. GLASS establishes a standardised approach for countries, territories, and areas to collect, analyse, interpret, and share data, as well as monitors the status of existing and new national surveillance systems, with a focus on representativeness and data quality. Some WHO regions have developed surveillance networks to assist nations with technical assistance and GLASS enrollment.
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