The Role of Public Health in Addressing Antimicrobial Resistance

Introduction:

Antimicrobial resistance is one of the top ten public health threats globally. Antimicrobial abuse or misuse is the main factor causing antimicrobial resistance due to the development of drug-resistant pathogens. Improper sanitation measures and lack of clean water availability result in the rapid spread of infection, and the pathogens involved can develop drug resistance. The healthcare costs concerning antimicrobial resistance are soaring and have become a major economic burden. Due to the prolonged hospital stays caused by disabilities and chronic illness, hospital-acquired infections are common, and the majority of them develop antimicrobial resistance. Recent advances in medicine are incomplete without effective and appropriate antimicrobials that are necessary to treat various infections during prolonged hospital stays, post-operative healing periods, during and before surgeries, and even during cancer chemotherapy.

What Are Antimicrobials?

Antimicrobials are the medications used to treat and prevent infections concerning humans, animals, and plants as well. They include antibiotics, antivirals, antifungals, and antiparasitics to act against viral, fungal, and parasitic infections, respectively.

What Is Antimicrobial Resistance (AMR)?

Antimicrobial Resistance (AMR) refers to the resistance offered by bacteria, viruses, fungi, and parasites due to the changes occurring in their genetic material over a period of time, making the antimicrobials ineffective in preventing the spread and eradicating the infection completely from the host body leading to severe illness and sometimes even death.

What Causes Antimicrobial Resistance?

• Antimicrobial resistance (AMR) usually occurs over a period of time, mainly due to the genetic changes in the pathogens.

• Antimicrobial-resistant pathogens are present in humans, animals, food, plants, and environmental agents like water, soil, and air.

• These organisms can be transmitted between humans or between human and animal populations, and even from food or animal origin.

Factors leading to antimicrobial resistance include:

1. Antimicrobial abuse or overuse.

2. Failure to implement (WASH) programs, which include clean water, sanitation, and hygiene among human and animal populations.

3. Failure of health care facilities and farms to implement infection control and disease prevention measures.

4. Lack of availability of affordable and quality medicines, vaccines, and diagnostic facilities.

5. Lack of awareness about antimicrobial resistance.

6. Failure to bring strict rules and regulations concerning the usage and availability of the antimicrobials.

How Effective Are the Antimicrobial Interventions in Treating Various Infections in the Current Clinical Scenario?

Antimicrobial treatments indicated for eliminating various infections have proved to be less effective due to an increase in resistance development against them.

Drug Resistance Involving Antibiotics:

• Bacterial infections like urinary tract infections, sepsis, sexually transmitted infections, and certain types of diarrhea have developed heavy antibiotic resistance to the antibiotics that were used frequently against these infections, thus demanding newer and more effective antibiotics to treat them.

• Resistance in Klebsiella pneumoniae, which is a common intestinal bacteria causing potentially life-threatening complications, has developed against Carbapenem antibiotics in many countries which is given as a last resort of treatment for hospital-acquired infections like pneumonia, blood infections, infections involving newborns, and intensive-care unit patients.

• Now, Colistin is being given as the last resort of treatment against Carbapenem-resistant Enterobacteriaceae (E.coli, Klebsiella, etc.).

• Also, resistance has developed against Colistin in many countries, and the medical fraternity is falling short of effective antibiotics in this regard.

• The Staphylococcus aureus,being a part of normal skin flora, leads to community-based and clinical infections due to its antibiotic-resistance traits.

• Due to the development of resistance against Methicillin, which is used to treat Staphylococcus aureus infection, many people have lost their lives.

• Many antibiotics like Sulphonamides, Penicillins, Tetracyclines, Macrolides, Fluoroquinolones, and early-generation cephalosporins have developed resistance.

• In the case of gonorrhea infections, the extended-spectrum Cephalosporin (ESC), Ceftriaxone has been considered an empiric therapy against gonococcal infections.

Drug Resistance Involving Antivirals:

• Many antiretroviral (ARV) drugs, including old and new, are becoming fully or partially ineffective due to the emergence of drug-resistant HIV (HIVDR).

• According to the latest WHO (World Health Organization) ARV guidelines, a new drug called Dolutegravir has been considered as the drug of choice for treating HIV infection among adults and children.

• Dolutegravir is also indicated in cases of resistance to NNRTIs (non-nucleoside reverse transcriptase inhibitors).

Drug Resistance Involving Antifungals:

• The prevalence rates of drug-resistant fungal infections have increased in recent years, making the antifungal intervention more complex and difficult.

• Most of the antifungal drugs pose toxicity issues and make the treatment options more complex.

• The drug-resistant Candida auris causes invasive fungal infections and is now increasing its resistance against Fluconazole, Amphotericin B, and Voriconazole.

• The emerging drug-resistant antifungal infections and drug toxicities have led to failure of treatments, prolonged hospital stays, and unaffordable treatment regimens.

What Is the Role of Public Health in Addressing Emerging Antimicrobial Resistance?

Surveillance:

• The surveillance department should devise and implement plans to eliminate antimicrobial surveillance.

• Check for the drug susceptibility data for surveillance.

• Antimicrobial drug usage is to be monitored.

• Implementing rules and regulations to govern the usage of antimicrobials in treating human infections, agriculture, and veterinary medicine.

Prevention and Control:

• Conducting public health education programs to create awareness about appropriate antimicrobial usage.

• Collaborative partnerships in conducting various training programs to train clinicians about correct antibiotic prescriptions.

• Evaluating the effectiveness of current and novel infection-control measures, including cost-effectiveness in health sectors and other extended-care platforms.

• Revising and implementing the rules proposed by the FDA for governing the effectiveness of newer antimicrobials used in veterinary medicine and agriculture.

Research:

• Conduct studies and research on antimicrobial resistance issues, which are of public health concern, to come up with newer treatment regimens to fight against antimicrobial resistance.

• Following precise, affordable, and reliable methods in testing, developing, and evaluating the rapid diagnostic methods to deal with antimicrobial resistance.

• Conducting research for developing new vaccines and utilizing them in human and veterinary medicine.

Product Development:

• Identifying and prioritizing various public health needs, which include newer drugs, targeted spectrum antibiotics, point-of-care diagnostics, vaccines, anti-infective medical devices, and disinfectants.

• Sponsoring and promoting the programs that educate about the development and appropriate use of antibiotics to treat human and veterinary infections.

Conclusion:

Amidst various rules and regulations implemented globally, it is the responsibility of each and every country to act and address the antimicrobial resistance challenge with the policies accustomed to the regional and local environments. Antimicrobial resistance is a global issue that needs the collaborative efforts of both human and veterinary health fraternities to tackle the problem. Public health organizations as a whole are an integral part in combating the pathogens that have developed resistance against the antimicrobials by conducting various surveillance, prevention, and control programs and encouraging research activities to fight the drug-resistant microorganisms with newer drugs and thus creating awareness among the public regarding appropriate use of antibiotics to prevent antimicrobial resistance.