This article was originally published in Public Health Trends Newsletter.
Background
Antimicrobial resistance is a significant threat to public health. Various organizations and individuals have raised the alarm against this threat, which may take us back to the pre-antibiotic era, nullifying modern medical science gains. The silent pandemic AMR, like the ongoing pandemic COVID19, profoundly impacts global health and socioeconomic parameters. Yet it gets comparatively very little attention from politicians, policymakers and the general public.
The issue in perspective
AMR is now one of the top 10 global public health issues. Drug-resistant bacteria, or superbugs, present a serious and worsening threat to human health. Millions of people in Indian hospitals and worldwide acquire serious infections caused by antibiotic-resistant bacteria each year, and some of them die as a result. We routinely encounter patients with infections that do not respond to available antimicrobials, and when new drugs come to market, bacteria can quickly develop resistance to them.
To avoid further aggravation of the AMR problem becoming a crisis, we have to fundamentally change our approach. Our journey over the last seven years with GAP has given us insight that this inherently complex issue can not be contained with the conventional approach. We need out-of-box thinking, we need to put practical tools into the hands of those who are dealing with Antimicrobials rather than preaching till hoarseness of our voice. The pandemic provides AMR stakeholders with an unprecedented opportunity to find synergy and support for emerging diseases, including drug-resistant infections.
The 2022 World Health Assembly theme is Health for peace, peace for health. Strengthening preparedness for and response to health emergencies is a key theme of the Health Assembly. The AMR stakeholders should fully utilize this occasion to build better plans and, more importantly, precise actions to deal with this health emergency.
The way ahead
Already a complex challenge, AMR needs to be addressed in a changing healthcare landscape post-COVID scenario. Unfortunately, COVID has exacerbated the issue by taking away that little attention and resources allocated to AMR containment.
While addressing AMR, most of the discussion revolves and the majority of research is done defining and finding more scientific proof and validation for AMR as an issue. In our opinion, very little is done to address big components in AMR containment plans. In most AMR containment plans no alternatives are provided to shun or limit empirical prescription in the human and veterinary sectors. The same is true for environmental sectors, and the rhetoric calls for improving the practices and reducing the effluent without viable alternative options in place.
To ensure AMR containment, we need multi-pronged alternative approaches: a) Awareness and education beyond the key stakeholders thru simplified, jargon-free communication b) Alternative near real-time diagnostics to avoid or improve the accuracy of empirical antibiotic prescription, and c) Alternative therapeutics to Antibiotics to improve AMS etc. When we look at the AMR Global Action Plan adopted by the World Health Assembly in May 2015, which outlines five objectives and global AMR funding to contain the further escalation of resistance, it is evident the focus is not much on the above critical components.
Accessed https://dashboard.globalamrhub.org/reports/investments/overview on 20th June 2022
As seen from the above dashboard lion’s share of investments are channelled into developing new antimicrobials. Other aspects like developing near-real-time diagnostics, alternatives to antimicrobial therapy, vaccines and efficient & economical options to treat pharmaceutical effluents are finding minuscule funding.
Barking at the wrong tree!!
The problem is frequently blamed on insufficient access to antibiotics, but such debates only derail finding alternate solutions and inadequate attention to better use of existing antibiotics. There is also a pressure of opinion from various quarters to improve the antibiotics pipeline (all the top AMR stakeholder organizations and individuals speak about it) rather than effectively finding alternative tools to combat resistance. Though there is a need for newer, more effective antimicrobials, they are not a panacea, and the strategy to rely on them may not be sustainable for multiple reasons.
On the other side, if you look at the five GAP AMR objectives (Ref: https://www.who.int/publications-detail-redirect/9789241509763) we will find a vague reference to some of the crucial aspects like alternative tools and mechanisms.
At the same time, the Comprehensive Review of the WHO Global Action Plan on Antimicrobial Resistance (ref: https://cdn.who.int/media/docs/default-source/documents/about-us/evaluation/gap-amr-final-report-v2.pdf?sfvrsn=1db7e8b0_1&download=true) of September 2021 to gauge progress towards outcomes, objectives and goals indicates that the desirable results off the mark.
The GAP guideline underscores the need for a practical “one health” approach involving coordination among numerous international sectors and actors, including human and veterinary medicine, agriculture, finance, the environment, and well-informed consumers but the challenge facing GAP AMR implementation is that there does not appear to be a shared understanding of what the desired outcomes are or what success might look like. The GAP per se does not use the term ‘outcome’. The plan’s goal is described in quite general terms as “to ensure, for as long as possible, continuity of successful treatment and prevention of infectious diseases with effective and safe medicines that are quality-assured, used responsibly, and accessible to all who need them”.
Let’s talk about specifically objective of awareness which we call one of the quadrant pillars. This “hypothesizes that if the general public, school students and relevant professionals are more aware of AMR and understand it, certain changes would occur” but practically no serious work is done in this direction.
Alternative solutions for effective GAP, NAP and SAP implementation
Keeping all the above in mind, we propose considering a simple quadrant of actions in addition to the five stated GAP objectives to overcome the GAP, NAP and SAP implementation challenges and contain AMR.
Reference: IFCAI internal model
Awareness campaigns at Higher Education Institutions (HEI): We at Infection Control Academy of India, in collaboration with USR Consortium, ReACT Asia Pacific, UKIBC and others, developed a project called Smart Antibiotic Use Campus (SABUC), intending to sensitize and convert 120,000 students, faculty and staff as “AMR containment Champions” at 12 consortium partner universities. Once the pilot is complete, this project can be expanded to all HEI across the globe.
Alternative diagnostics: the role of diagnostics is crucial to use antimicrobials wisely. Accurate and quick diagnosis is the bedrock for the effective treatment of infections. Conventional diagnostics/ Clinical investigations require culture and AST, long report wait time, Lack of adequate scientific basis for the prescription of empirical antibiotic therapy, Expensive etc. These factors delay the onset of treatment, reduce the treatment options, increase the chances of over and/ or inaccurate prescription for antibiotics and potentially lead to clinical complications. Near real-time diagnostics based on newer technologies, including digital technologies like Artificial Intelligence (AI), Machine Learning (ML) etc, can revolutionize the diagnostic process making antibiotic treatment accurate and timely.
Alternative therapeutics: It is known that we aggravate the AMR potential every time we use an antimicrobial product. Hence complete reliance on antimicrobials for the treatment of infections is not a sustainable option. We need to promote and incentivize the development of alternative therapies to treat infectious diseases while renewing the efficacy of older antimicrobials and investing in newer generations of antimicrobials. Some of the examples could be bacteriophages and microbiome-based treatments.
Alternative effluent, sewer, and other waste treatment: currently available effluent treatment is expensive and not sustainable. Especially for antimicrobials manufacturing plants, the current technologies are not affordable. We need to promote and incentivize the development of alternative effluent treatment technologies with low capital expenditure and sustainable bio-based components for filtration, remediation etc.
We hope the above alternative solutions will break the status quo and bring godspeed to the Global Action Plan for the containment of antimicrobials resistance.
There is a need for time-bound actions, and we have no luxury of procrastinating anymore.
Authored by: Professor Ranga Reddy Burri, President – Infection Control Academy of India, Honorary Professor – University of Hyderabad and Public Health Foundation of India
Reviewed by: Professor TV Rao, Former Professor of Microbiology TMC Kollam Kerala and Advocate for equitable access to education