The AMR Dilemma: Part 2 – The impact

Finding the missing pieces to the puzzle of antimicrobial resistance

Although accurate statistics are difficult to tabulate, over two million people in North America become infected with bacteria resistant to antibiotics annually. At least 23,000 people die as a direct result of these infections. Virtually, all significant bacterial infections in the world are becoming resistant to the antibiotic treatment of choice. Health authorities in North America estimate nearly one million acute-care patients acquire an infection while in hospitals. More than 70 per cent of bacteria acquired in a hospital setting are resistant to at least one of the antibiotics commonly used to treat them. Approximately 90,000 people die every year from nosocomial (hospital-acquired) infections.

Bacteria are everywhere — in drinking water, food, soil, plants, animals, and humans. Although most bacteria do not harm us, and some are even useful, many are capable of causing severe infections. The ability of antibacterials to stop infection depends on killing or halting the growth of harmful bacteria, but some resist the effects of drugs, multiply and spread. Although resistant bacteria have been around a long time, the scenario today is different from even just 10 years ago. The number of bacteria resistant to many different antibiotics has increased, in many cases, tenfold or more. Many new drugs that have been approved are confronting resistance soon after introduction.

In North America, approximately 250,000 people require hospital care for Clostridium difficile (C. difficile) infections every year. Antibiotic use is a major contributing factor leading to C. difficile infection. Between 15,000 and 20,000 people die each year from acquired C. difficile infections, many of which are preventable. Common, resistant infections contracted while in hospital threaten the ability to implement advanced medical procedures.

It’s estimated antibiotic resistance costs the U.S. economy $20 billion to $35 billion a year, including as many as eight million extra patient days spent in the hospital and another $35 billion in indirect costs including lost productivity. Bacterial diseases, now resistant to all antimicrobials and considered untreatable, cause two million illnesses and 23,000 deaths annually. Unfortunately, the investment to combat AMR isn’t commensurate with the threat. In the U.S., for instance, 2014 federal spending on antibiotic resistance was approximately $450 million in direct funding ($1.40 per American per year). Very little has been published about current overall medical costs of antibiotic resistance to the Canadian health-care system. Rough estimates put it at around $200 million per year. New investment, private and public, are necessary to create change.

Antibiotics are among the most commonly prescribed drugs in human medicine. The use of antibiotics is the single most important factor leading to antibiotic resistance around the world. It’s estimated, up to 50 per cent of all the antibiotics prescribed for people are not needed, or are not optimally effective as prescribed.

Antibiotics are also commonly used in food animals to prevent, control, and treat disease, and promote growth. Regulatory and industry groups have wrestled with the fact that the use of antibiotics for promoting growth is not necessary, and the practice should be phased out, especially for classes of antibiotics deemed important in humans.

Direct comparison of drug volumes used in people and animals is difficult. Evidence suggests approximately 70 per cent of the total volume (in tonnes) of antimicrobials produced are used in food-producing animals (including poultry). Many of the antibacterial drugs used in animals have no application in humans, an example being the ionophores used extensively in poultry and cattle for prevention of disease.

Another concern to some health experts is the escalating use of antibacterial soaps, detergents, lotions, and other household items. Some health authorities feel antibacterial products should be reserved for the hospital setting, for sick people coming home from the hospital, and for those with compromised immune systems.

Missing pieces of the puzzle

The ability to measure success is often missing. The scientific community must address difficulties faced tracing the origins and spread of resistant microbes — more fundamentally, the transmission and spread of specific resistance genes in microbial communities.

Millions of dollars continue to pour into research on antimicrobial resistance without a clear way of integrating research priorities between teams of scientists. Meaningful surveillance systems are frequently missing and there seems to be no clear way of evaluating research findings and applying the knowledge in a way we collectively understand what’s happening. Perhaps it reflects a gap in our understanding of AMR’s complexity, but more often than not it’s the reluctance of research institutions to egress from academic and bureaucratic silos and work together in becoming problem solvers.

In searching for missing pieces, the importance antibiotics continue to play in livestock production and the supply of safe and wholesome food cannot be omitted. Diversity of the livestock industry is vast. Today, prudent antimicrobial use is a significant part of producing food more efficiently and safely. The maxim being: safe and wholesome food comes from healthy animals.

Antimicrobials become important tools in assisting the veterinary profession and agriculture industry deliver appropriate standards of care for livestock and poultry. The industry is slowly coming to grips with antimicrobial applications that take precedence over improvement in production practices that would lessen the need for antimicrobials. A prime example being less stressful ways of introducing weaned calves to the marketplace, including better vaccination and preconditioning programs. Finding better ways of weaning calves and use of quality vaccines in preconditioning programs as an alternate to broad-spectrum antimicrobials to treat and prevent bovine respiratory disease will become part of the industry’s commitment to responsible stewardship. If the effort is not genuine, or not visible and understood by consumers, and if not properly communicated the default is agriculture’s misrepresentation of prudent antibiotic use. The full extent to which antibiotic resistance in animal agriculture contributes to human infection is not known. While risks to human health posed by agricultural use of antibiotics are a matter of serious concern, supposition and fortune-telling are unproductive — from all perspectives. Clear, concise, scientifically accurate debate must prevail.

Progress, I believe, will require careful consideration regarding an appropriate home to manage and provide direction on the entire subject of antimicrobial resistance. It may not be a government agency. Governments at all levels appear unable to fund AMR research without the continuous and unpredictable burps of fiscal restraint. The nature of government makes it difficult to set priorities across tiers of jurisdictions — then, the inability to effectively communicate within the sphere of political fatuity. Is it time to establish a virtual, for profit, community run by a board of directors with administrative, financial, scientific and communication skills armed with the ability to establish laboratories, set research priorities, hire and manage people and manage surveillance programs? Government, livestock industries, veterinary and human medical institutions, the pharmaceutical industries and public organizations become paying clients. Accurate yet clearly understood scientific information and sound communication capabilities would be products offered for sale. The virtual community could be located within an academic setting or spread across existing facilities and managed centrally.

A number of organizations in the haphazard pursuit of answers related to AMR has identified a number of valid key outcomes. They encompass: international co-operation, long-term investment and leadership, surveillance and response capacity, stewardship in human health care and animal agriculture, commercial development, new antibiotics and fundamental research. A number of groups has identified the limitations of estimating the burden of disease associated with AMR a critical gap.

Other missing pieces in the pursuit of understanding AMR include:

  • Limited national, state, and federal capacity to detect and respond to urgent and emerging antibiotic-resistance threats.
  • Lack of systematic international surveillance related 
to antibiotic resistance.
  • Systematic collection of data on antibiotic use 
in human health care and in agriculture.
  • Universally applied programs to improve antibiotic 
prescribing practices.
  • Lack of access to advanced molecular detection technologies 
to identify genetic causes of AMR.

About the author

Columnist

Dr. Ron Clarke prepares this column on behalf of the Western Canadian Association of Bovine Practitioners. Suggestions for future articles can be sent to Canadian Cattlemen ([email protected]) or WCABP ([email protected]).

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