Antimicrobial resistance (AMR) is an expanding problem and according to the World Health Organization (WHO), is on track to become a major barrier to global health. Antimicrobial resistance is defined as resistance of certain microorganisms to antimicrobials originally designed to treat them. The threat is so serious; AMR is on course to reverse modern medicines’ accomplishments leading us to a post antibiotic era where common illnesses could routinely be lethal. In a statement released by the WHO, Dr. Keiji Fukuda states, ‘Effective antibiotics have been one of the pillars allowing us to live longer, live healthier, and benefit from modern medicine. Unless we take significant actions to improve efforts to prevent infections and also change how we produce, prescribe and use antibiotics, the world will lose more and more of these global public health goods and the implications will be devastating'(WHO, 2014 p 1). The Centers for Disease Control and Prevention (CDC) estimate that AMR accounts for roughly 23000 deaths per year in the United States (US) and approximately 25000 per year in Europe (CDC, 2013). AMR to bacteria such as Escherichia coli, Klebsiella pneumoniae, Staphylococcus aureus and Streptococcus pneumoniae have reached alarming levels with 5-6 out of 6 WHO regions reporting >50% resistance to normal treatment options. Streptococcus pneumonia in children < five can be attributed to 826,000 deaths per year (Wang, George, Purych, & Patrick, 2014).
Review of Literature
In an article by Vernet, Mary, Altmann, Doumbo, Morpeth, Bhutta and Klugman, the authors examine the organisms causing the biggest threats. Tuberculosis (TB) and malaria are becoming resistant to antimicrobials with drug resistance found in 10% of TB cases. Severe acute respiratory infections (SARIs) lead to approximately 1.4 million deaths of children <5 years of age. Gram negative bacteria resistant drugs such as carbapenems are increasing. Gaining in numbers is Methicillin-resistance staphylococcus aureus (MRSA) where 38% of all staph aureus infections were resistant. In Asia, AMR accounts for an additional 96000 newborn deaths per year (Vernet et al, 2014). An article found in the International Journal of Students' Research (Deshpande and Joshi, 2011) discusses the rising cost of healthcare spending as a direct result of AMR and the worldwide impact. The increase in global commerce and travel results in an increase in AMR especially when primary drug resistance occurs and practitioners treat with pricier second and third choice drugs. Another alarming trend is the spread of resistant nosocomial infections to the community and an increasing prevalence with more global travel between developing and developed countries (Keown, Warburton, Davies & Darzi, 2014). In an article by Freire-Moran, Aronsson, Manz, Gyssens, So, Monnet and Cars (2011), the authors discuss the prevalence of AMR worldwide and the increased threat due to limited treatment options. Estimates include roughly 25000 deaths per year in Europe due to AMR and mortality from Gram negative blood stream infections was approximately 43% (Freire-Moran et al, 2011)
WHO has identified interventions needed by the global community to curb the growth of AMR. The interventions involve collaboration between global entities such as governments, nongovernment agencies such as WHO and professional groups such as the American Medical Association (WHO, 2001). This collaboration includes improved surveillance of antibiotic use and bacterial culturing programs, monitoring for fake antimicrobials and providing incentives for the creation of new antibiotics. In an article by Uchil, Singh-Kohli, Katekkhaye and Swami (2014), the authors cite the need for programs controlling AMR, control of antibiotic dispensing facilities, requirement of pharmaceutical companies to report antibiotic dispensing and regulating antibiotic dispensing requiring prescriptions. Additional interventions require standardization of infection control practices, surveillance programs for AMR and standardized practices for the handling of culture specimens with faster result times allowing for the narrowing of antibiotic coverage (Uchil et al, 2014).
At risk populations
AMR knows no global boundaries and affects people in all cultures, socioeconomic situations and continents. Despite AMR being global, populations at highest risk for antibiotic resistance are those populations at risk for infections in general; the young, elderly and immune-compromised individuals such as those infected with HIV and tuberculosis, transplants or under treatment for cancer . In a study found in Drug Resistance Updates (Grundmann, Klugman, Walsh, Ramon-Pardo, Sigaupue, Khan'Stelling, 2011), the authors corroborate these at risk populations and further define at risk populations to include people living in developing countries with low gross domestic product (GDP) due to poor access to proper health care and poor sanitation conditions. These populations are put at risk due to the increase of global travel and the transfer of resistant organisms through travel. They further define at risk populations to include people in countries of political conflict, countries post disaster resulting in people living in close, cramped living conditions (Grundmann et al, 2011). In a study by Vernet, et al (2014), at risk populations should also include infants and mothers because of poor prenatal, intra-natal and postnatal care and poor sanitary conditions resulting in as much as 56% of all neonatal deaths in developing countries.
Services, health practices and gaps
Current practices in place to deal with AMR include the interventions listed above such as improved sanitation in developing countries, improved and standardized infection control practices in developing and developed countries. The WHO addresses all of these interventions along with many of the developing and developed nations. Keown et al (2014) suggest required minimum sanitation standards worldwide. Health practitioners continue to collect cultures identifying organisms to tailor antimicrobials for sensitivity and Deshpande and Joshi (2011) discuss in their article the careful use of antibiotics. Also important is the early detection of microorganisms and many hospitals have result times of at least 24 hours for culture and sensitivities (Deshpande & Joshi, 2011). During the waiting period, broad spectrum antibiotics are used. Gaps in health practices occur worldwide but especially in developing countries such as India and the Sub-Saharan African nations. In an Indian study by Kumar, Adithan, Harish, Sujatha, Roy and Malini (2013), the authors examine the state of AMR in India. Many of the challenges facing India involve limitations on surveillance data; lack of policies and procedures in place, enhanced antibiotics dispensing practices and uncontrolled antibiotic sales. They also lack sanitation and infection control practices and a deficiency in cognizance of AMR nationally. These issues are not unique to India but are a worldwide problem hence the global health crisis of AMR (Kumar et al, 2013). In a study by Mustafa, Wani and Wali, (2013) the authors examine the awareness of AMR by employees of a hospital in India. They concluded that an increase in awareness by all employees but specifically health practitioners regarding the scope of this threat was desperately needed. This study is representative of the lack of global awareness or apathy for this growing problem.
Stakeholders can be divided into groups including policy creators and government officials, manufacturing and the academic community, agricultural representatives, health care professionals and the public including patients (Keown,et al, 2014). The role government and officials of health organizations such as the WHO and CDC play involve raising and maintaining awareness of this global threat. They create legislation and standards for the pharmaceutical, agriculture, food and medical industries. Industry such as the medical, research and pharmaceutical companies and academic institutions aid in the creation and promotion of new antimicrobials, research techniques and medical advances for controlling AMR. The agricultural industry assists in controlling AMR by regulating the use of antibiotics as growth aids in the food industry. Health care professionals are the first line of defense in the fight against AMR. Doctors and other prescribing health care professionals are accountable for responsible prescribing of antibiotics, infection control practices, surveillance of infections and patient teaching regarding the proper usage of antibiotics. Other health care professionals such as pharmacists and nurses assist physicians in patient teaching and pharmacists specifically are the primaries for patient teaching regarding the effective and responsible use of antibiotics. Finally, patients and the public play an integral part in the fight. They are responsible for appropriate antibiotic use including completing antibiotic courses, avoiding self-medication and infection control within their homes and workplaces (Keown et al, 2014).
Comparison of United States versus India and developing countries
In the US, AMR is addressed at each healthcare facility and with each practitioner. The CDC addresses the issue of AMR through their surveillance and awareness programs. Awareness of the global threat of AMR is lacking in the US and worldwide despite the work of the CDC and WHO. Most citizens are not aware of the pressing issue of AMR and how important stewardship of antibiotics is to the health of the world. While the US may be advanced in its infection control practices and its use of antibiotics, these issues still exist and AMR is seen daily in the US with microorganisms such as carbapenem resistant enterococcus (CRE), MRSA and klebsiella pneumonia. Due to global travel and the spread of AMR through this travel, the US remains open to increasing numbers of AMR. The developing countries such as India struggle with issues of infection control, sanitation, the availability of antibiotics and financial constraints. Added to the financial constraints of treating these infections is the lack of qualified practitioners and healthcare available to the citizens of these developing countries.
Programs and gaps
International organizations such as the WHO and the Food and Agriculture Organization of the United Nations (FAO) have established programs to create awareness. The FAO takes a 'one health' and 'food chain' approach because antimicrobials are widely used in agriculture and livestock production. They promote responsible antibiotic use and efficient, healthy livestock and agriculture practices (FAO, nd). WHO creates awareness through World Health Day in 2011 by focusing on AMR (WHO, nd). In 2013, the World Innovation Summit for Health developed programs to increase consciousness, promote responsible antimicrobial use, improving sanitary conditions worldwide, improved surveillance of AMR and antimicrobial dispensing and encouraging exploration of new antimicrobials (Keown et al, 2014). A program established by National Endowment for Science, Technology and the Arts called the Longitude Prize offers a financial award to individuals finding solutions to scientific challenges. The hope is that scientists will tackle AMR in hopes of winning this coveted prize. A program by Innovative Medicines Initiatives offers monies specifically for the development and production of new antibiotics (Keown et al, 2014). The CDC and the European Center for Disease Prevention and Control (ECDC) both acknowledge AMR and produce literature regarding this threat but major awareness and response programs are lacking. Gaps exist in all aspects of this threat ranging from awareness and surveillance to research and development.
The European Commission (EC) has addressed policy issues with regards to AMR by enacting the European Community Strategy against antimicrobial resistance in 2001. Coupled with the Commission's 2011 renewal of these policies, it addressed the requirements by all members to reinforce surveillance practices, promote responsible antibiotic use, promote responsible use by the animal industry, proper infection control practices and national awareness programs (EC, 2015). The Infectious Diseases Society of America (IDSA, nd) has instituted policies similar to the EC encouraging appropriate antibiotic use. The US through the CDC has made recommendations regarding antimicrobial resistance but no formal, legal policies are in place (CDC, 2015). The FDA has issued several mandates regarding antimicrobial resistance and coordinates through the National Antimicrobial Resistance Monitoring System (NARMS) the surveillance of resistance specifically found in food (FDA, 2015). While there are many programs and organizations addressing this issue, there are no legal or monetary ramifications for not following the guidelines and in that respect policy is weak.
Recommendations for curtailing AMR include a multi-tier approach involving governments and other legislative agencies, manufacturing such as pharmaceutical companies, health practitioners and the public. A public awareness program complete with media coverage should begin along with surveillance programs to regulate the dispensing of antibiotics and bacterial culture programs. Governments should collaborate and institute policies and procedures for regulation and surveillance of antibiotic dispensing. Health practitioners should be educated on the responsible dispensing of antimicrobials, use of cultures to determine appropriate antibiotic coverage and all parties would be held accountable for these behaviors.
The late Elinor Ostrom likened AMR to climate change 'in the sense that both phenomena involve non-renewable global resources, both are caused by human activity and are intrinsically linked to our behaviour. The problem can only be addressed through international cooperation' (Cars, Hedin & Heddini, 2011, p 1). We have a responsibility to ourselves and future generations to treat this issue with the importance and gravity it deserves.
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