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Combating Antimicrobial Resistance

The issue of antimicrobial resistance (AMR) superbugs, wherein pathogens such as bacteria, viruses, and fungi develop ways to resist different drug treatments, is rapidly becoming an issue on the international stage. In 2016, the United Nations General Assembly met to discuss the issue of AMR and the G20 meeting included AMR in its closing communique, placing strong emphasis on the need to both develop new drugs and implement policies that limit overzealous drug use. These meetings reveal the concern that many actors have over AMR’s threat to pubic health, economic growth, and social stability.

 

Unfortunately, the issue of AMR is starting to become a reality at the domestic level. On August 2016, the Washoe County Health District in Nevada received a patient who was resistant to all fourteen drug lines available to the district’s acute care hospital. The patient was in her seventies and had recently returned from an extended visit to India, a country known for drug resistant strains of bacteria. She died in early September despite attempts at recovery.

 

Further testing by the CDC showed that the woman would have likely died even if she had been in a better-equipped hospital; her strain of superbug bacteria could fend off all twenty-six available classes of antibiotic in the US. The bacteria was a strain of carbapenem-resistant enterobacteriaceae (CRE), named after a class of antibiotics called carbapenems that are supposed to be the last line of defense for antibiotics when other classes fall. The woman, who successfully recovered from a bone infection in her femur and hip while in India, was likely exposed to CRE and had those strains transfer carbapenem resistance genes to nearby bacteria.

 

Many professionals in the health community, including policymakers and epidemiologists, see this development as a red flag. The patient in Nevada was quarantined after tests showed resistance, limiting the possibility of exposure to other patients. However, experts claim that she’s a symptom of a much larger trend due the rapidity of AMR and the spread of globalization. That is, as populations migrate and intermingle, people are often exposed to different bacteria, increasing the potential for a drug resistance gene to spread and for one superbug to develop resistance to multiple classes of antibiotics.

 

For example, consider colistin, another antibiotic of last resort. The drug fell out of favor in developed countries due to the risk of severe kidney damage, and was eventually picked up by the agricultural industry. Farms often use colistin because low doses of antibiotics can promote growth. Unfortunately, frequent exposure to an antibiotic helps develop genes that are resistant to the drug; over time, bacteria that have colistin-resistant mutations start to spread due to natural selection. In the case of colistin, that gene was mcr-1.

 

Chinese scientists discovered mcr-1 in pig farms, on meat in supermarkets, and even in hospitals, showing evidence of a horizontal transfer of the mcr-1 gene from animals to humans. The team published a 2015 report in The Lancet that prompted a series of international investigations, which revealed that mcr-1 had already spread to other countries, such as Denmark, Germany, Vietnam, and the United States. Critically, the convergence of the mcr-1 gene with other resistant genes into one superbug is a real possibility.

 

Importantly, international actors have paid attention to the concerns voiced by the health profession over AMR. The inclusion of AMR in important forums such as the UN and the G20 shows that advocacy is working. It is another question, however, whether the policies and promises generated by these meetings will work to effectively stop AMR.

 

Pushing for more research and development in the pharmaceutical industry is, arguably, a doable task. Certainly, the future demand for more last-line classes of antibiotics is a great incentive for pharmaceutical companies. However, it is much more difficult to change the habits of other actors. Travellers like the patient in Nevada and farmers like the ones in China are only marginally affected by the AMR epidemic. They only face the consequences of these bacteria at the crisis point, and even then, the parties affected comprise only a small segment of their population. Combatting AMR requires public education over the risks, a health intervention that will likely blend into other education initiatives for other dire issues. Although some actors are optimistic about combatting AMR, most are simply wondering when the next red flag will appear.