Antimicrobial Resistance (AMR)

-Dr. Rohit Kumar

MBBS Intern

Government Medical College, Jammu

Introduction

According to WHO, one of the top 10 global public health threats of our lives is Antimicrobial Resistance (AMR) making it an urgent concern to address. Antimicrobial resistance happens when existing microbes evolve or modify themselves in such a way that they no longer can be controlled by existing antimicrobial drugs thereby increasing their survival even with the administration of a variety of drugs, hence termed ‘superbugs’. Often interchangeably written both antimicrobial and antibiotic resistance are slightly different where the former means resistance against bacteria, viruses, fungi, or parasites whereas later refers to resistance but solely to bacteria.

Microbes like bacteria, viruses, fungi, and parasites, if changes overtime and drugs already working against them if no longer be able to control infections because of their altered form, it is said that the infectious microbe is no longer ‘sensitive’ to the said drug or can ‘resist’ the drug, hence Anti-microbial Resistance (AMR).

This could mean longer hospitalization & prolonged recovery time, chronic disabilities, the financial burden on healthcare management and the public, and thereafter, relying on extensive or high-risk surgeries and treatment options or even death. Essential hospital services like treating gastroenteritis, upper respiratory infections, traumatic wound care, urinary tract infection, sexually transmitted infections, yeast infections, worm infestations, etc. are considered safe due to the presence of antimicrobials however mishandling of such medicine is the chief reason why the infectious microbes tend to alter themselves, hence escaping the treatment. The introduction of antimicrobials back in its early times has decreased the surgical infection rates from 40% to 2%.

Drug resistance isn’t limited to just hospitalized patients but is affecting healthy individuals, animals, and plants as well. The cause and increasing spread of AMR are multidimensional but the primary reason could be a lack of appropriate knowledge and awareness about the topic which means it’s harder to effectively prevent and control the resistance from happening even with the already existing policies, guidelines, and legislature support. Due to our relentless mishandling, misuse, overuse, or underuse of available antimicrobials AMR is spread worldwide. Each year AMR is responsible for an estimated $20 billion in added healthcare financial costs, with about $35 billion in added costs for lost economical productivity due to additional days spent in hospital care. The consequence of it all is the price national economics and its health organizations must shoulder and the loss of productivity of hospital personnel and its resources.

History

The first antimicrobial (not antibiotic) agent in the world was Salvarsan, used against syphilis. Penicillin was the very first antibiotic to be discovered in 1928 which was not therapeutically used until the 1940s. Soon after using it in the same decade an enzyme, Penicillinase was found in certain bacterial strains which countered the action of Penicillin making those strains resistant to the medication. To counter this resistance, in the 1950s penicillinase-stable Methicillin was introduced against these newer strains which soon too became ineffective to emerging bacterial stains like Methicillin-resistant S. aureus (MRSA).

During the 1950s, there was a huge influx of newer antibiotics like aminoglycosides, chloramphenicol, tetracycline, and macrolide. As of now, most of these drugs have one or many bacterial species or strains that can dodge the action of the medication like the resistance of S. pneumoniae to penicillin, H. influenzae to ampicillin, or P. aeruginosa to the most of these antibiotics.

Tuberculosis which is affecting one-third of the world population is another example of AMR. Nowadays a cocktail of drugs is used to treat TB solely due to its nature to develop resistance to already employed drugs like streptomycin and isoniazid. There is a swift rise in the cases of M. tuberculosis variety with absolute resistance to main first-line medications i.e., extensively drug-resistant (XDR) strains.

Malarial parasite is also developing resistance to main treatment option like Artemisinin. Antiretroviral drugs against HIV are also facing resistance to the virus. In the African subcontinent, more than 50% of newborns with HIV are already resistant to the first-line treatment medications.

Fungal species like Candida auris are drug-resistant which adds up to already existing toxicity seen with antifungals like fluconazole, voriconazole, and amphotericin B.

Evolution of AMR

It usually occurs as a result of misuse, and overuse of antimicrobials which leads to genetic changes because of microbes adapting to the presence of the drug. Resistant organisms then spread from person to person, to food, and animals, and disseminate in the environment. Hygiene plays a pivotal role as the driver of AMR, like the genetically varied organisms when spreads through lack of access to clean water, sanitation, and hygiene (WASH) which then contaminates food leading to a chain of infection to humans and animals. Also, lack of access to appropriate medications for a specific microbe, poor control of infections, and preventive efforts do contribute to resistance. Education, knowledge, and awareness of the general population about appropriate antimicrobial medication use play a vital role in ceasing the spread when added with proper laws at disposal. At times healthcare professionals prescribe inaccurate treatment be it the wrong antimicrobial drug or inappropriate dosing and duration of treatment that too contribute to AMR.

Prevention and Control

It is a multisectoral health crisis to urgently deal with not only for human health’s sake but because other forms of life are it aquatic, or terrestrial too are at the stake of getting harmed. A coordinated approach between health research and legislature could help fill the gaps between innovative solutions and policy implementation and recourses needed. Research involving clinical and public health projects on local and higher levels focusing on introducing newer antimicrobial drugs developing innovative diagnostic methods, and newer vaccines could help leap forward. Globally, nations need to access the baseline AMR to ensure progress starting from setting and accessing the goals to reduce the harmful impact and implementing a coordinated action plan for funding to ensure improvement. Promoting and spreading the word for responsible use of medications with the help of policymakers and healthcare professionals to empower everyone’s sense of responsible antimicrobial use.

Individuals’ Role

Healthcare staff should be vigilant when prescribing antimicrobials for their dose, class of bug to be eliminated, and length of treatment. At times Broad-spectrum antimicrobial is given that works against a range of microbes but it leads to unrequired exposure increasing chances of AMR. Resistant bugs are communicable and can spread through close contact and poor hand hygiene among patients and hospital workers making it vital to not overlook basic hand sanitization practices. Hospital workers should screen at-risk patients for developing sepsis or prolonged hospital stays, stay informed on current and local outbreaks of superbugs, and immediate reporting to concerned hospital bodies to limit the spread.

Moreover, agricultural and farm practices of excessive and unnecessary use of antimicrobials lead to more resistance of plants and the gut bacteria of farm animals which inevitably pass on to humans through poor hygiene, food, and meat. Hence it is significant to have healthy livestock practices and habits. Drug-resistant Gonorrhea is becoming hard to treat with conventional antibiotics making it essential to have safe sexual practices or better to follow preventive measures against STIs like barrier contraceptives.

On the patient level, it is crucial to discuss symptoms to get the right medicine and to precisely follow the prescription or to get vaccinated as recommended. It is commonly observed that cold and flu being treated with antibiotics (kills bacteria, not viruses) contributes to AMR. Always consult a healthcare worker for an accurate diagnosis and follow the full regimen as advised. The tuberculosis treatment course should be closely monitored for its entire duration to avoid retreatment and the likelihood of developing multidrug-resistant TB.