WHO Global antibiotic resistance report – experts respond

Overnight, the World Health Organization (WHO) has released its first global report on antimicrobial resistance, including resistance to antibiotic drugs. 

Screen Shot 2014-05-01 at 7.49.02 AMThe report, which also includes information on resistance to medicines for treating other infections such as HIV, malaria, tuberculosis and influenza, provides the most comprehensive picture of drug resistance to date, incorporating data from 114 countries.

The report reveals that antibiotic resistance is no longer a prediction for the future — it is happening right now in every region of the world, and has the potential to affect anyone, of any age, in any country.

Without urgent, coordinated action by many stakeholders, the world is heading for a post-antibiotic era, in which common infections and minor injuries which have been treatable for decades can once again kill.

Key findings from the report:

  • Resistance to the treatment of last resort for life-threatening infections caused by a common intestinal bacteria, Klebsiella pneumoniae — carbapenem antibiotics — has spread to all regions of the world. K. pneumoniae is a major cause of hospital-acquired infections such as pneumonia, bloodstream infections, infections in newborns and intensive-care unit patients. In some countries, because of resistance, carbapenem antibiotics would not work in more than half of people treated for K. pneumoniae infections
  • Resistance to one of the most widely used antibacterial medicines for the treatment of urinary tract infections caused by E. coli — fluoroquinolones — is very widespread. In the 1980s, when these drugs were first introduced, resistance was virtually zero. Today, there are countries in many parts of the world where this treatment is now ineffective in more than half of patients.
  • Treatment failure to the last resort of treatment for gonorrhoea — third generation cephalosporins — has been confirmed in Austria, Australia, Canada, France, Japan, Norway, South Africa, Slovenia, Sweden and the United Kingdom. More than 1 million people are infected with gonorrhoea around the world every day.
  • Antibiotic resistance causes people to be sick for longer and increases the risk of death. For example, people with MRSA (methicillin-resistant Staphylococcus aureus) are estimated to be 64% more likely to die than people with a non-resistant form of the infection. Resistance also increases the cost of health care with lengthier stays in hospital and more intensive care required.

A full copy of the report is available on the WHO website, along with an updated fact sheet on microbial resistance and an infographic.

The Science Media Centre rounded up the following expert comments:

Professor Kurt Krause, Director of Webster Centre for Infectious Diseases, University of Otago, comments:

“It’s clear that the development and worldwide spread of multi-drug resistant bacterial pathogens is becoming the most urgent crisis in infectious diseases.  It threatens to move us into the post-antibiotic era and to change the way we practice medicine. While NZ has been fortunate to avoid the high levels of resistance seen in the most affected areas, it is important that ongoing surveillance continues for these organisms and that clear infection control policies and plans are in place. After all, even the most resistant of organisms are potentially only a plane trip away.

It’s now a very important time to keep the following action points in mind:

1. We must husband our remaining antibiotics by using them wisely.
2. We must work to eliminate any unneeded environmental exposure to antibiotics as in, for example, animal feed.
3. We need close monitoring for resistant organisms in our clinics and hospitals coupled with modern methods of infection control.
4. We need to incentivise research into the development of new antibiotics as is being carried out in North America and the European Union.

“Together we can overcome this issue, but the time for ignoring it, is long past.”

Dr Deborah Williamson, clinical microbiologist at ESR, comments:

“Antimicrobial resistance is arguably one of the biggest man-made public health threats of modern times, and similar to other settings, New Zealand must confront this challenge. Noteworthy contemporary issues in New Zealand include methicillin-resistant resistant S. aureus(MRSA), the circulation of resistant gram negative bacteria the community setting, and the alarming global reservoir and importation of drug-resistant TB.

“New Zealand is fortunate to have a coordinated programme of antimicrobial resistance surveillance that is based at the Institute of Environmental Science and Research, Wellington, and recently, this programme has been greatly expanded to strengthen the national response to AMR.  It is imperative that, in the face of the threats and realities of antimicrobial resistance, New Zealand builds on existing linkages and infrastructure, and adopts a cohesive, pro-active and multi-regional approach that combines expertise from across the medical, academic, and veterinary sectors.”

Dr Siouxsie Wiles, microbiologist, University of Auckland comments:

“Alongside vaccines, antibiotics are arguably one of the most important discoveries in medical history. In antibiotics, humans are exploiting the weapons produced as part of an arms race that has existed between microbes for millennia. The first antibiotic was used to treat people in 1937 and not long after that we became aware of the other side of the microbial arms race – that microbes can become resistant to these wonder drugs. Resistance to penicillin was known before the antibiotic even came into use. Latest estimates put the number of potential antibiotic resistance genes that exist at more than 20,000. But it doesn’t end there, microbes have crafty ways in which they can share resistance genes between themselves, and this has exacerbated the problem.

“The fact that antibiotics have been is use for over 80 years, and it is only now that the WHO have produce their first global report on the state of antibiotic resistance, just shows how we underestimated the impact antibiotic resistance would have. Their report highlights what microbiologists have been shouting for a while now, that a world without antibiotics is a scary place, and we are likely to be living in that world in as little as ten years.

“It is clear that we need novel ways to tackle infectious microbes and the WHO placed ‘fostering research and developing new tools’ as a way that policymakers and industry can help. It is a worry that infectious diseases were specifically excluded from the three health-related National Science Challenges announced by the government last year.  In a country with increasing rates of infectious diseases, if tackling these aren’t a national challenge, then I don’t know what is.”

Dr Mark Thomas, Associate Professor in Infectious Diseases, Faculty of Medical and Health Sciences, University of Auckland, comments:

“Excessive antimicrobial use in New Zealand makes a significant contribution to the spread of antibiotic resistant bacteria in our community. The level of antibiotic use within New Zealand is relatively high compared with many other developed countries, and has been rising steadily in recent years. Antibiotic resistance in bacteria that commonly cause disease in people has increased in New Zealand in recent years and is a steadily increasing problem for the treatment of infection in many patients. Furthermore, while infections due to bacteria that are resistant to all available antibiotics are presently very rare in New Zealand, occasionally such cases do occur. We need to take effective steps to reduce the level of consumption antimicrobials in New Zealand, and maintain the effectiveness of these medicines for the future.”

Professor John Fraser, Dean, Faculty of Medical and Health Sciences, University of Auckland, comments:

“The WHO report reveals the antibiotic resistance as a truly global issue.  We are fortunate in New Zealand to benefit from a high quality surveillance system but in reality this only slows rather than protects us from the emerging antibiotic resistance. Indeed there is clear evidence that certain practices is this country have rapidly led to our own NZ specific resistant strains, so we are part of the problem and should as much as possible take steps to increase vigilance and to reduce those practices that promote antibiotic selection.”

Associate Professor Dr Anthony Poole, Lecturer in Genetics, University of Canterbury, comments:

“The major kinds of antibiotics have been identified from a handful of microbial sources. Our global focus on pathogens means we have heavily studied these microbes, but we tend to neglect the enormous diversity of microbial life – stuff that’s not an immediate threat to our health or food supply. An untapped source of novel antibiotics almost certainly resides in the genomes of poorly-studied species, so to build up our armory of antibiotics, and our capacity to keep pathogens at bay, we need to embrace the study of the other 99% of microbial diversity. We still know very little about microbial diversity in NZ, and this report should thus be a wake-up call for us as a nation to think more broadly about investing in basic research to understand our hidden microbial treasures.”

Dr Sally Gaw, Director of Environmental Science, Senior Lecturer in Environmental Chemistry, University of Canterbury, comments:

“The use of household products containing antimicrobial agents such as triclosan and triclorban may also contribute to the development of antibiotic resistant bacteria. These antimicrobial agents can be found in soaps, deodorants, toothpaste, kitchenware, sportswear and children’s toys.  These chemicals are released into the environment via discharges from sewage treatment plants.  There is growing evidence that widespread domestic use of antimicrobial compounds is contributing to the development of antibiotic resistance in bacteria in the environment.  Soaps containing triclosan have been shown to be no more effective at controlling illness in peoples’ homes than ordinary soap. The domestic use of antimicrobial agents needs to be reassessed to ensure that these products do not reduce the effectiveness of medical treatment. Our obsession with killing germs may actually be putting people’s lives at risk.”

The UK Science Media Centre gathered the following comments from UK-based experts:

Dr Jeremy Farrar, Director of the Wellcome Trust, said:

“We welcome the WHO report which highlights AMR as a pressing global issue. However, we believe there is too much focus on more surveillance and this is a missed opportunity.  While surveillance is important and certainly needs to be improved it does not solve the problem. Committed and coordinated action is required across international governments and stakeholders to address the critical gaps in challenging the AMR threat.

“This is a complex issue and requires a multifaceted approach addressing fundamental and translational research to understand the emergence and spread of resistant pathogens. The problem demands improved use of existing interventions, accelerated therapeutic development, economic incentives and simplified regulatory approval processes to support the development of point of care diagnostics and drug discovery. A better understanding of  the impact of prescribing and health behaviours is also crucial.

“There has been much discussion on this issue, what is required now is concerted action.” 

Professor Nigel Brown, President of the Society for General Microbiology, comments:

“We welcome this WHO report, which highlights the growing levels of antimicrobial resistance, an issue that is of national and international concern.

“While the report is right to raise the importance of good surveillance data if we are to understand the extent of antimicrobial resistance, more data are not the total solution to the problem, which will ultimately come from scientific research.

“It is vital that microbiologists and other researchers work together to develop new approaches to tackle antimicrobial resistance. These approaches will include new antibiotics, but should also include studies to develop new rapid-diagnostic devices, fundamental research to understand how microbes become resistant to drugs, and how human behaviour influences the spread of resistance.”

Professor Martin Adams, President of the Society for Applied Microbiology (SfAM), comments:

“SfAM welcomes the WHO report on antimicrobial resistance. As the report’s authors acknowledge, the fact that many countries were unable to provide data on all of the microbe-antimicrobial combinations in question is worrying. That said, whilst surveillance is clearly important – we cannot know the extent or location of the problem, or, indeed, the contribution of international travel and trade to the spread of resistance without it – this must not be seen as a solution.

“At the same time as improving surveillance, there must also be a global effort on prevention and control of infections involving drug resistant microbes in humans and animals. This will require development and implementation of new products, policies, and practices; and fundamental research to unpick the mechanisms by which resistance develops and can be passed between microorganisms and from environment to environment. Even if there are new antimicrobial drugs brought to market, we will still face the spectre of resistance unless we can learn how to minimise or slow its development.

“Ideally, as well as surveillance of infection, there would be considerable support for research into the distribution and evolution of the genes that confer resistance. We still know very little about the transfer of resistance genes between the harmless organisms that live on and in us and those microbes that can cause disease. We could also learn more about the geographical spread of resistance by following the unique genetic characteristics of resistant organisms.

“In addition, we must better understand the role of animal rearing in the development and spread of resistance, globally, both in terms of antibiotic use in an agricultural/veterinary context and also as a source of foodborne disease. There has been much talk of the misuse of antibiotics in agriculture as a major source of antimicrobial resistance, but in reality, it is difficult to draw such a conclusion from current data.”

Dr Nicholas Brown, President of British Society for Antimicrobial Chemotherapy (BSAC), and Consultant Microbiologist, Addenbrooke’s Hospital Cambridge comments: 

“BSAC commends the WHO report. We hope that the global work programme under development will provide the framework through which governments worldwide will take responsibility and make funding available to initiate steps to protect the few antibiotics we have that remain effective against resistant bacteria. We also hope that this framework will be the mechanism by which appropriate use of antibiotics across all sectors, people and animals, can be achieved.”

Professor Laura Piddock, BSAC Chair in Public Engagement, Director of Antibiotic Action and Professor of Microbiology, University of Birmingham comments:    

“This report aptly demonstrates why initiatives such as Antibiotic Action (www.antibiotic- action.com) are so important. It adds to a long list of reports published by many in the last ten years about this crisis, what is now needed is action – hopefully this report will provide the impetus. The world needs to respond as it did to the AIDs crisis of the 1980s. To do this, we need to be ambitious to succeed – moves such as a fully funded mandatory global surveillance programme will document the size of the problem and funded public education will help minimise use – but these are just starting points. We still need a better understanding of all aspects of resistance as well as new discovery, research and development of new antibiotics.

“Defeating drug resistance will require political will, commitment from all stakeholders, and considerable financial investment in research, surveillance and stewardship programmes. For many years there has been a reliance on work funded by learned societies and other charities – such as the BSAC resistance surveillance programme (www.resurv.org) which is now in its 15th year – to provide data by which to map antimicrobial resistance and emerging resistance. Such programmes are invaluable but they are also expensive to maintain and, to have global impact, need to be funded from the ‘public purse’ so that their successes and value can be replicated to make the global difference that is needed. As funding from UK government agencies for research on antibiotics has continually dwindled (last year it was only 0.7% of available UK research funding) there needs to be a significant increase in national and global funding to be able to address this public health crisis.”