We live in an era where outbreaks and pandemics have become more and more common. There are estimates that show increasing rates of disease emergence from animal reservoirs, which have also been associated with causes from environmental changes. These findings suggest a high probability of observing pandemics similar to COVID-19—currently estimated at 38%—which is actually expected to double in coming decades.

With the persistent threat of infectious diseases, humans have been forced to act quickly and develop their strongest weapons against them—the antimicrobial drugs. The development of modern antimicrobial drugs, during an era called the “Golden Age” of antimicrobial discovery, actually started way back in the mid-1940s and lasted up to the 1960s. Unfortunately, as medicine and technology developed and adapted through the years, so have the microbes. Scientists knew that the occurrence of bacterial resistance to antibiotics was inevitable; however, most were surprised at how fast it happened given that these wonder drugs were developed less than a century ago.

Antibiotic resistance is now considered as a global public health and developmental threat. The fact that antibiotics are becoming less effective because of resistance spreading in hospitals is affecting all countries. As an infection preventionist, I constantly face in my work numerous hospital deaths that are associated with multi-drug resistant bacterial infections. Scientists now call the antimicrobial resistance (AMR) as the “Silent Pandemic” since it is still unknown to most of the public, and is considered as an underestimated threat. There were 1.27 million deaths attributable to bacterial AMR in 2019. These figures are very alarming, considering that the numbers are growing rapidly. Moreover, the SARS-CoV-2 pandemic has exacerbated the existing global crisis of antimicrobial resistance, as many more have turned to self-medication with antibiotics. This behavior resulted from a number of misconceptions that the public continuously communicates amongst themselves. Many have always considered  antibiotics to be the cure for anything. So, whenever they feel sick it feels right for them to go to the nearest pharmacy and just buy antibiotics, even if they do not necessarily address their case. And, much to my knowledge, many countries still do not have any legislation forbidding this.

AMR does not only possess deadly consequences for humans, but also grave economic repercussions on the world’s economy. This is due to complicating the medical treatments of patients, leading to prolonged hospital stays and increased health-care costs for both the individual and the government. It is estimated that by 2050, ten million lives a year and a cumulative 100 trillion USD of economic output are at risk due to the rise of drug resistant infections, especially if we do not find proactive solutions now to slow down the rise of drug resistance.

Photo credit: Centre for Health Protection, Hong Kong

Fortunately, there have been published strategies to tackle the AMR global threat, among which are two specific strategies that I would like to stress upon here:. 

  1. First is through improving global surveillance of drug resistance and antimicrobial consumption in humans and animals; and 
  2. Second is reducing the unnecessary use of antimicrobials in farming to prevent their dissemination into the environment. 

Industrial farming is especially known for giving antibiotics to animals to prevent possible infections, as well as to increase their productivity—i.e., getting more meat output but with less feed input—by changing the colony of bacteria in the rumen (one of four stomachs in cattle) to produce more of the compounds needed by cattle for growth. This is of major concern to us humans because animal health is closely related to human health, as is environmental health. Whatever these livestock intake, and the bodily changes that happen because of the misuse of antibiotics, also end up affecting us as we consume their meat. This perspective of the interconnectedness of the health of all living beings on earth is called the “One Health Approach”. This recognition of interconnectedness must inspire us to be very aware of what we do now, as it affects more than just the human race. 

This irresponsible  overuse of antibiotics is not limited to livestock alone. Many people have also been using antibiotics for nearly everything—from the slightest cough to the most life-threatening symptoms. These drugs have been regarded by many as the magical treatment. Adding insult to injury, I have personally seen many people in my home country, Egypt, insisting on taking antibiotics unnecessarily as they think it would not do them any harm. This grave misuse of antibiotics thus becomes one of the main reasons why we now have to face the AMR issue at the community setting. Moreover, even amongst healthcare workers in both public and private sectors, millions of antibiotics are being falsely prescribed every year where the proportion of inappropriate antibiotic prescriptions exceeded 50% in some studies carried out in primary care in low-and middle-income countries. The accountability of healthcare workers is of high importance in the conversation of rational antibiotic use since they are responsible for explaining to their patients when and how these should be taken correctly. They must also highlight to patients the proper use of prescriptions and to avoid unnecessary purchasing of unregulated antibiotics online.

Over and above that, we have run out of ammunition of new antibiotics to cope with the continuously developing antimicrobial resistance. The last class of antibiotics discovered was “Daptomycin” in 1986, which was only approved in 2003 by the US Food and Drug Administration (FDA). This highlights the fact that antimicrobial agents found in the market in the last 30 years are associations or improvements of existing molecules; but no new genuine antibiotic drug has been discovered since the 1980s until now i.e., our current pipelines of novel antibiotics is pretty empty.

The discovery of antibiotics was a revolutionary gift, but we unfortunately abused our legacy of antibiotics. This dangerous unconscious behavior has now led us to serious threats, and the menace of possibly losing one of medicine’s most valuable treasures. Global collaboration is strongly recommended to overcome this global health threat. It is a pandemic that knows no boundaries. No part of the world is safe if the threat has not been curbed globally, meaning less accessible countries must not be left to continuously suffer the consequences of AMR. If we do not take a global approach to address this, it will easily spread worldwide and end up affecting the greater population. To emphasize just how big of a threat this is, the World Health Organization has actually declared that AMR is one of the top 10 global public health threats facing humanity to this date. And if we want to prevent this from spiraling into something even more uncontrollable, strict laws and legislations have to be issued and enforced in every country. This is particularly important in low- and middle-income countries where some antibiotics are actually purchasable over the counter or without a doctor’s prescription. In addition, I believe that large pharmaceutical stakeholders also need to continue investing in scientific research and development—to aid scientists working hard to discover new antibiotic drugs that may serve as backup lines to help maintain our valuable medical legacy.  

Photo credit: Africa CDC

It is worth mentioning that efforts to maintain such legacy was recently done through a high-level meeting on antimicrobial resistance held by the Swedish Presidency of the Council of the European Union (EU) in Stockholm, Sweden last 6th-7th March 2023. This meeting focused on the EU’s contribution in curbing AMR at the global level; as well as on ensuring global sustainable access to existing and new antibiotics that are effective treatments for different bacterial infections. The high-level meeting brought together ministers, state secretaries, director-generals, heads of European health authorities, and other high-level participants from international organizations. All of whom came to support and secure the continuous and responsible access to antibiotics, and further strengthen the global action to combat this very rampant health issue. 

To conclude, this global issue is serious but it is still remediable. Many initiatives are actively working on the existing AMR threat that is affecting both state and institutional levels. Many are building strong cases and formulating applicable legislation to contain it. And, even at the level of the general public, more individuals are becoming aware and joining in the cause to increase the noise on what has long been considered a silent pandemic.


Author: Hosam Mahmoud Ali
Edited by: Jasmine Therese Arcilla
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