Combatting antimicrobial resistance with stewardship

Antimicrobial resistance (AMR) is one of the top threats to global health, alongside climate change and non-communicable diseases. Preventing its further spread requires antimicrobial stewardship, which aims to promote appropriate use of antimicrobials to ensure they remain effective.

The challenge of antimicrobial resistance

Over 100 years ago, the development of antimicrobials (such as antibiotics and antivirals) that could effectively treat life-threatening infections radically changed the face of modern medicine. Today, antimicrobials help to fight many common infections such as pneumonia, tuberculosis, and urinary tract infections. They also enable life-saving procedures such as cancer treatments and invasive surgery.

However, the growing spread of resistance to antimicrobials means there are fewer medicines that can effectively treat infections, increasing the risk of mortality and morbidity. Although resistance to antimicrobials can occur naturally over time, it can be exacerbated by the excessive or inappropriate use of antimicrobials such as antibiotics.

Antibiotic-resistant infections can be incredibly costly for patients and healthcare systems because treatment and care are often complex and require lengthy hospital stays. For patients who contract drug-resistant infections, the outlook is potentially dire. Patients are at risk of severe illness, becoming immunocompromised, and experiencing serious complications, all of which could be potentially life-threatening. Moreover, patients may need multiple rounds of treatment, which can be physically and emotionally taxing. Some antibiotics can also be highly toxic, with side effects such as kidney damage and cardiac events, adding to treatment complexity and disease burden.

AMR disproportionately affects low- and middle-income countries (LMICs), with over 70% of all deaths due to bacterial AMR occurring in sub-Saharan Africa, South Asia, and Southeast Asia. Sub-Saharan Africa has the highest death rate due to bacterial AMR. In resource-constrained settings, patients suffering from drug-resistant infections face worse outcomes as diagnostic tools and targeted treatments are unavailable. This particularly threatens progress made on some of the biggest causes of mortality in LMICs such as HIV, tuberculosis, and malaria. AMR surveillance is also often weak in such settings, making it difficult to ascertain the extent of resistance.

In LMICs, lack of access to effective antibiotics, inadequate infection prevention and control, poor hygiene and water sanitation, and the misuse of antibiotics to treat viral infections contribute to the high AMR burden. For instance, diarrhoea caused by unclean water consumption can increase antibiotic use, which can in turn increase the spread of resistance.

Antimicrobial stewardship as a response

Antimicrobial stewardship is a “coherent set of integrated actions which promote the responsible and appropriate use of antimicrobials to help improve patient outcomes across the continuum of care.” It is a strategic response, adopted by health systems across the globe, to the clear association between increased antimicrobial use and the emergence of resistance.

The Global Action Plan on AMR emphasises the importance of stewardship. It was endorsed by the World Health Assembly in 2015 to guide national and international efforts to combat AMR. Antimicrobial stewardship aims to optimise the use of antimicrobials in an effort to ensure that antimicrobials remain effective for patients who need them. Additionally, the WHO has created practical guidance for countries to develop Antimicrobial Stewardship Programmes (ASPs), which are cost-effective interventions that help to ensure the judicious use of antimicrobials through evidence-based guidelines. Studies have shown that following antimicrobial stewardship guidelines in hospitals can reduce the risk of infection-related deaths by up to 35%.

Stewardship also requires working across sectors. Antimicrobial resistance can spread through increased use of antibiotics in the agriculture industry, which necessitates a “one health” approach to global health that recognises the interdependence of human, animal, and environmental health. The one health approach is integral to effective stewardship actions at national and international levels, as well as raising awareness of AMR for all stakeholders, including individuals, healthcare professionals, businesses, and national and global policymakers.

Implementing stewardship actions, such as training healthcare professionals on appropriate prescribing practices and developing and maintaining surveillance systems for drug resistance, can be resource-intensive. To enhance stewardship programmes, there is a great need for structural and resource support for healthcare systems in LMICs, many of which have human, structural, and financial constraints.

Access to antibiotics

While stewardship is an important component of combatting resistance, insufficient supply of effective antibiotics may undermine antimicrobial stewardship practices in combatting AMR, especially in LMICs. Limited access to effective antibiotics makes it difficult to successfully treat bacterial infections in LMICs, often forcing healthcare workers to use whatever antibiotics they have in stock, thereby increasing resistance. It has long been recognised that having a good rotation of effective antimicrobials in healthcare facilities is essential for successfully treating infections and slowing the spread of antimicrobial resistance. These issues highlight the urgent need for new antimicrobials to be developed.

Concerningly, the development of new antimicrobials has slowed over time. Only a handful of new antibiotics have been approved since 1998. Additionally, antibiotics often take much longer to reach LMICs, sometimes taking decades to arrive. With fewer options for antibiotics globally, and delayed access to new antibiotics in LMICs, millions of patients will be left without treatment options for life-threatening infections. In particular, “last resort” antibiotics (which are used once all other treatments have failed) are quickly losing their effectiveness, leaving many patients at high risk of mortality and morbidity.

Addressing this important challenge requires global action. It is crucial that we incentivise the development of new effective antimicrobials while ensuring the considered use of current antimicrobials through stewardship. It is particularly imperative in LMICs where the burden of AMR is high.

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Note: The UN General Assembly is convening a High-Level Meeting on antimicrobial resistance in September 2024, where numerous organisations and individuals will be in attendance to address the global challenge of AMR.

Our approach to antimicrobial resistance