Mitigating Global Disparities in the Fight Against Antimicrobial Resistance

Marie-Françoise Gros, MD, MBA

Marie-Françoise Gros has a degree in medicine and an MBA. She began her career as a medical doctor and later joined the in vitro diagnostics industry. After a role in strategic marketing, she became VP Global Medical Affairs at bioMérieux . Marie-Françoise coordinates the AMR initiatives for bioMérieux, working closely with R&D, innovation, and marketing to help define future products, develop internal awareness about AMR. She manages the partnership with Antwerp University: The Global Point Prevalence Survey of Antimicrobial use and Resistance. She also oversees the scientific and medical coordination of COVID-19, providing insights to Marketing and R&D.

Antibiotics are considered one of humankind’s greatest achievements. Beginning with the discovery of penicillin in 1928, antibiotics have been used to save countless lives. But what happens when the antibiotics we depend on are no longer effective? Imagine a scenario where routine surgeries and minor infections can frequently become life-threatening, and the cost of treatment increases substantially. The reality is that some people are already experiencing these effects, with some groups and regions more at risk than others.

Antimicrobial resistance (AMR) is a natural process whereby microbes, including bacteria, fungi, and viruses, evolve to be able to fight or evade the action of drugs designed to eradicate them. Currently, across the globe, approximately 700,000 individuals lose their lives each year because of drug-resistant infections. AMR is one of the most urgent global health threats that humanity faces today.

In The Review on Antimicrobial Resistance, David Cameron, former UK prime minister, was quoted saying, “If we fail to act, we are looking at an almost unthinkable scenario where antibiotics no longer work and we are cast back into the dark ages of medicine.”

How does antimicrobial overuse and misuse lead to resistance?

AMR is driven by the replication and spread of microbes exposed to antimicrobial drugs and the mechanisms the microbes have evolved against those compounds. This naturally occurring process is accelerated when antimicrobials are frequently present in the environment or in the microbes’ hosts. The largest contributing factors to increasing AMR are the misuse and overuse of antimicrobials, particularly antibiotics, in health care and agricultural settings.

In health care, the U.S. Centers for Disease Control and Prevention (CDC) estimates that doctors in the US unnecessarily prescribe 47 million courses of antibiotics each year, and in many other countries around the world, it is possible to get antimicrobial drugs without a prescription.

The unnecessary use of antibiotics in the agricultural industry, particularly in livestock, is also a major issue. In the US, large quantities of antibiotics that are medically important for humans have been sold for use in animals for production purposes rather than therapeutic purposes. A 2019 U.S. FDA report showed that domestic sales and distribution of medically important antimicrobials approved for use in food producing animals increased by 3 percent between 2018 and 2019.

What is the impact of antimicrobial resistance on low- and middle-income countries?

Although AMR is a global health concern, there are countries and regions that are disproportionately affected. “Low- and middle-income countries bear a greater burden of infectious disease and with limited resources will be most adversely affected by AMR,” states the Technical Brief on Water, Sanitation, Hygiene (WASH) and Wastewater Management to Prevent Infections and Reduce the Spread of Antimicrobial Resistance (AMR). Many low- and middle-income countries (LMICs) lack the infrastructure to adequately prevent and treat infections on a large scale. The lack of organized care, sanitation, hygiene, and clean water contributes to the risk of infection.

The seriousness of AMR cannot be overstated. “Antimicrobial resistance has been described as a hidden pandemic and it’s important that we do not come out of COVID-19 and enter into another crisis,” Dr. Susan Hopkins, the chief medical advisor at the UK Health Security Agency (UKHSA), said in November 2021 press release from UKHSA.

In LMICs, a lack of resources tends to be one of the biggest issues when it comes to implementing an antimicrobial stewardship program (ASP). Often, developing countries do not have enough technology or skilled workers to provide accurate and timely microbiology results to determine a patient’s best treatment path. Simultaneously, in LMICs there is the combined challenge of lab capacity, education, access to antimicrobials, poor hygiene, lack of resources, and over-the-counter antimicrobial sales.

When this is the case, the priority must be to set up the most critical lab resources and equipment to properly operate at a minimum. Here are several steps that clinical lab managers can take to support antimicrobial stewardship in LMICs:

Develop a plan: An ASP must be developed and agreed upon first. Then, the program must be implemented outside of the lab and eventually built into the lab setting.
Determine needs: While you are setting up your ASP, determine what resources are needed and what indicators are needed to support your lab’s plan.
Educate and train: To have a successful plan, education and training of hospital staff, lab professionals, clinicians, and nurses is critical. This is a multidisciplinary effort and must be accounted for in every ASP.
Lean on diagnostics: Lab managers must rely on diagnostics as the most important step to help determine appropriate uses of antibiotics for patients. Lab managers have significant value in effective stewardship and frontline impact by using diagnostics to support clinicians in evidence-based decision making.
Maximize data output: Maximize data usage with surveillance; having strong data and analytics will support tracking resistance in the lab. Using diagnostic data can also support better patient outcomes. Consider an IT solution for your lab as part of your ASP to maximize data output.

What is the impact of antimicrobial resistance on at-risk patients?

Effective antimicrobials are also especially important for people who are immunocompromised. For many, living with a weakened immune system means a higher chance of illness and infection. Patients with cancer, those living with HIV, and patients who have received organ transplants are examples of groups of immunocompromised people who depend on effective antibiotic treatments and face a threatening challenge in AMR.

According to a 2016 article published in Infectious Disease Clinics of North America, “Rates of infection with multidrug resistant organisms (MDRO) are increasing among immunocompromised persons, as greater numbers of MDRO are observed throughout the population.”

Clinical laboratory professionals can make a significant difference in combating AMR for at-risk patients. Diagnostic tools and rapid tests, for example, can impact the potential of antibiotic therapy.

Diagnostics provide the ability to detect organisms, identify the infection, and measure antibiotic susceptibility before treatment is provided. Specifically, rapid tests can help target an infection and detect MDRO. They can also help avoid the transfer of infection from patient to patient.

Diagnostics support the customization and personalization of a patient’s treatment. When available, sophisticated tools like biomarkers can help clinicians personalize treatments, such as ceasing antibiotic therapy as soon as a patient starts improving.

While it can be more difficult to do so in LMICs, whenever possible, clinical lab professionals in all regions of the world should work with health care workers to provide all patients, and especially at-risk patients, with personalized treatment options. This avoids the “one size fits all” approach that contributes to AMR.

Finally, robust IT solutions are key in lab settings to follow up and analyze data in real time. While having strong IT solutions can be a difficult resource for LMICs to access, they enable health care professionals to easily communicate data findings to all stakeholders.

During education and training, it’s important that all health care professionals involved in a patient’s treatment understand what the data and results mean, how it evolves, and how each player can better impact the results.

Fighting back against antimicrobial resistance

Globally, many organizations, task forces, and governments are working to help combat AMR in both health care and the clinical industry.

Since the inception of the Presidential Advisory Council on Combating Antibiotic Resistant Bacteria (PACCARB) in 2014, the US has made significant progress toward addressing AMR. Many other countries have adopted national action plans to fight AMR and assemble their own ASPs. Evaluating the progress that has been made requires closely examining available indicators and determining which indicators to select and follow.

First, it is key to look at antibiotic cues and prescriptions. Some antibiotics are more effective than they were 5 years ago, for example.

Another cue is whether the volume of antibiotic prescriptions is increasing or decreasing and the quality of antibiotic prescriptions.

Perhaps the most critical cue is to follow resistance rates in hospitals. Checking resistance rates in hospitals can support a successful action plan, but it cannot be done without diagnostics.

Clinical lab managers should follow all selected cues as well, as they play a critical role in any ASP and action plan to combat AMR.

Additionally, the CDC has provided seven core elements of an ASP: hospital leadership commitment, accountability, pharmacy expertise, action, tracking, reporting, and education.

According to the CDC, clinical microbiology laboratory staff can do the following:

Guide the proper use of tests and the flow of results as part of “diagnostic stewardship.”
Help optimize empiric antibiotic prescribing by creating and interpreting a facility cumulative antibiotic resistance report or antibiogram.
1. Laboratory and stewardship personnel can work collaboratively to present data from lab reports in a way that supports optimal empiric antibiotic prescription and is consistent with hospital guidelines.
Guide discussions on the potential implementation of rapid diagnostic tests and new antibacterial susceptibility test interpretive criteria (e.g., antibiotic breakpoints) that might impact antibiotic use.
1. Microbiology labs and stewardship programs can work together to optimize the use of such tests and the communication of results.
Collaborate with stewardship program personnel to develop guidance for clinicians when changes in laboratory testing practices might impact clinical decision making.
Hospitals where microbiology services are contracted to an external organization should ensure that information is available to inform stewardship efforts.

Addressing AMR in countries and in patient communities that are most at risk is critical in the global fight against infectious diseases. This will take a coordinated global effort that includes individuals at a community level and leaders of nations across the world. Together, we can make progress toward combating AMR for all.

Other global organizations and task forces committed to fighting AMR and the misuse of antibiotics include:

Adapted from the bioMérieux Connection blog and updated by Marie-Françoise Gros, MD, MBA, bioMérieux VP global medical affairs.