Antimicrobial resistance crisis: A long time coming

20170106100000, Tristan Manalac

By 2050, at least according to the estimate of a December 2014 Review by a British team led by Jim O’Neill and commissioned by the UK Prime Minister, the annual deaths will reach a staggering 10 million people.

This figure dwarfs the deaths attributable to other top public health enemies. Cholera, for example, is expected to take between 100,000 to 120,000 lives annually by 2050. For measles, this value reaches an approximately similar count at 130,000 deaths annually.

Even big names can’t even come close. Indeed, road and traffic accidents are estimated to cause around 1.2 million deaths annually by 2050 while diarrheal diseases are expected to kill 1.4 million yearly. Also by 2050, around 1.5 million are expected to succumb to Diabetes annually.

As it turns out, what will be responsible for such a large number of yearly deaths is a phenomenon that scientists, pharmacists, and clinicians call antimicrobial resistance.

Cancer, arguably the most infamous and most fearsome disease of today, is estimated to rack up 8.2 million annual deaths by 2050. This is, without a doubt, a monstrous value, but it is still 1.8 million lives away from the 10 million of antimicrobial resistance.

This is a deeply troubling fact that deserves more emphasis: according to estimates, by 2050, antimicrobial resistance will kill more people than cancer.

Unlike most of those compared to it, however, antimicrobial resistance isn’t a disease per se. It is, instead, a phenomenon wherein microorganisms, mostly bacteria and mostly disease-causing, become resilient and immune to common drugs used against them.

An important and troubling consequence of antimicrobial resistance is that disease treatment and intervention, in some settings,becomes increasingly difficult and expensive. Sometimes, treatment can even become impossible.

Microorganisms, as a result of being exposed to antimicrobial agents, naturally develop resistance. Left to its own devices, this process moves at a glacial pace. The misuse and overuse of antimicrobials – something humans are guilty of –accelerates this.

Nevertheless, antimicrobial resistance still creeps up on us at a pace slow enough that the general public, for the most part, does not notice it.

Recently, however, the threat of having pan-resistant strains of disease-causing microorganisms – those that are resistant to the entire arsenal of drugs available to medicine –just became much more urgent.

Just last May 2016, a Pennsylvanian woman was reported to be infected by a rare Escherichia coli strain that contains the mcr-1 gene. Incidentally, this gene confers resistance to colistin, an antibiotic commonly used as a last-ditch attempt against hardy infections.

Last August 2016, a man in New Jersey was found to be infected by an E. coli strain containing both the mcr-1 and blaNDM-5 genes. This makes it resistant to colistin and carbapenems, a class of drugs also used as a last-ditch attempt.

Fortunately, in both cases, the E. coli still weren’t pan-resistant; that is, the infections were still treatable using other antimicrobial agents. However, both mcr-1 and blaNDM-5 are contained in the extra-chromosomal plasmids; thus,transfer from one strain to another is relatively easy.

What this means, essentially, is that at least in the United States, the stage is all set for all the necessary genetic elements to converge into one omni-resistant strain. If nothing is done, this will be a global inevitability and the only thing that will stand in its way is time.

A history of malpractice

Antimicrobial resistance is not a new concept. In fact, there have been warnings about it as early as 1954. In the first joint meeting of the Royal Society of Medicine on the use and abuse of antibiotics, Dr. J. D. N. Nabarro is documented to have said:

“From the point of view of the population as a whole, the widespread and unnecessary use of antibiotics is most undesirable because it encourages the emergence of resistant strains. […] It appears, therefore, that the emergence of resistant strains is closely related to the extent to which an antibiotic is used.

“The only way to minimize this change in the bacterial population is to cut down as far as possible the amount of antibiotic used and to reserve it for cases in which it is really needed. If we fail to do this, if we continue  to prescribe antibiotics for minor ailments, we may well produce a situation in which all the patients but none of the organisms are sensitive to them.“

Even earlier, Alexander Fleming, most famously known for accidentally, if not serendipitously, discovering penicillin, already warned us about antimicrobial resistance during his acceptance of the 1945 Nobel Prize.

Testing for antimicrobial resistance

Testing for antimicrobial resistance

That antimicrobial resistance has been known for quite some time now should come as no surprise. It is, after all, rooted in evolution: the antibiotics act as a selective pressure on bacterial populations, killing those susceptible to it and leaving those resistant to it alive. Over time, when only those that are immune to the drugs dominate the population, antibiotics will cease to be effective.

It is, in a way, a micro-scale survival of the fittest.

Over the years, humans have been guilty of various malpractices that have exacerbated the situation. The sheer overuse of antibiotics, for example, increases the selective pressure on bacterial populations, thus speeding up the domination of resistant bacteria. That some antibiotics are largely deregulated in some countries only compounds this problem.

Similarly, incorrectly prescribing drugs, aside from not having beneficial therapeutic effects, can also accelerate the rate at which microorganisms develop resistance. The prescription of antibiotics for viral illnesses, like the flu, for example, can help move resistance along.

Antibiotics are also used to make livestock healthier and improve growth, thus increase yields. This, subsequently, also creates a population of antibiotic-resistant bacteria in livestock. When these are ingested by humans, the bacteria are also transferred and can eventually result in infections and diseases.

Educate and engage

“In the new Pharmacy Law,” Krishelle Obispo writes in an e-mail to MIMS, “one of the flaws in the industry that would likely contribute to AMR has been addressed, which is the distribution of antibiotics samples; it is now prohibited in the newly enacted law.”

Krishelle is a Pharmacist who works for Sandoz Philippines Corporation, a multinational pharmaceutical company. According to her, the Philippine pharmaceutical industry, for the most part, is responding very positively to the initiatives to slow down antimicrobial resistance.

That is, companies, especially multinationals, are very compliant with the new Pharmacy Law and other relevant policies, and participative with initiatives that were established during the recently-concluded Philippine Antibiotic Awareness Week 2016.

There is, of course, room for improvement. First, Krishelle offers, is that companies can do better at reinforcing the campaign against antimicrobial resistance internally.

“Incorporating education on AMR in trainings or company meetings or communications to associates vis-a-vis strong implementation of the no prescription, no dispensing policy… would affect their behavior towards antibiotics in their operational functions and in their external interactions,” she explains.

Conversely, expanding the reach of the campaign to other fields, those that are beyond the immediate circles of influence of these companies, will strengthen it because consumers will be properly educated and engaged.

“Integration of practices across fields would greatly affect the behavior of our consumers as they would consistently be reminded of the proper use of antibiotics, as well as the repercussions when not properly taken,” she concludes. MIMS

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