The absence of adequate regulatory controls, treatment guidelines, and patient awareness has led to a huge global surge in antibiotic resistance. The problem is compounded by a desperate shortage of new drugs to treat multi-drug resistant bacterial infections, says a team of 26 medical professionals, including two from India

Bangalore: Leading medical researchers have called for a total overhaul of the global healthcare system. The entire structure of health-care delivery for effective antibiotics – from research and development, to distribution and rational use – needs to be re-engineered to address the looming global threat of antibiotic resistance, a global team of 26 scientists asserted in a report in The Lancet Infectious Diseases journal on Sunday.

The report presents a comprehensive global overview of the growing problem of antibiotic resistance, its major causes and consequences, and identifies key areas in which action is urgently needed. The findings were published ahead of European Antibiotic Awareness Day, and the US Centers for Disease Control and Prevention (CDC) ‘Get Smart About Antibiotics Week’ on Monday. The team included Prof Ramanan Laxminarayan of the Public Health Foundation of India and Dr Chand Wattal of the department of clinical microbiology, Sir Ganga Ram Hospital.

Lead author Professor Otto Cars, of Uppsala University in Sweden, said, "The causes of antibiotic resistance are complex and include human behaviour at many levels of society; the consequences affect everybody in the world. Within just a few years, we might be faced with unimaginable setbacks, medically, socially, and economically, unless real and unprecedented global coordinated actions to improve surveillance and transform the way antibiotics are regulated and developed are taken immediately."

The problem is more at the political level, since the decisions have to be taken there. "Only now has the awareness and urgency of the problem of antibiotic resistance reached a level that a new sustainable global system to counteract these problems can be built," said Cars. "Addressing these problems will require nothing less than a fundamental shift in how antibiotics are developed, financed, and prescribed."

The problem itself is not new. Even before penicillin was introduced, resistant strains of bacteria had been detected. The selection pressure caused by the use of millions of tonnes of antibiotics over the past 75 years since antibiotics were introduced has made almost all disease-causing bacteria resistant to antibiotics commonly used to treat them.

There have been initiatives to tackle the malaise, but the researchers noted that these programmes need time and patience to be set up and need to be backed by visionary governments with adequate funding. "A stepwise approach to a national strategy according to a contextualised and prioritised road map might be the best way forward for most settings," they said In this context, a special mention was made of the 'Channai Declaration' that was issued last year by Indian professional societies. They put together an implementable road map for resistance containment in the country that pushed for central coordination and implementation support from the government.

Comprehensive research itself is an issue. The professionals called for availability of clear information on the health and economic burden of antibiotic resistance so as to make this complex problem tangible to policymakers. "A global surveillance system for antibiotic resistance, including outbreak reporting and an early warning system to detect new resistance mechanisms and their global spread, is still lacking, despite the obvious need of such a system and several proposals for potential models, they wrote.

At the end of the day, it would have to be the governments' call. "The ultimate responsibility for the provision of equitable and affordable access to effective antibiotics for those in need lies with national governments. The consequences of antibiotic resistance reach far beyond the human health sector and thus no one governmental ministry or agency can be held solely responsible," they warned.

It's now up to governments to pick up the gauntlet.

• Antimicrobial resistance (AMR) is resistance of a microorganism to an antimicrobial medicine to which it was originally sensitive.
• Resistant organisms (they include bacteria, fungi, viruses and some parasites) are able to withstand attack by antimicrobial medicines, such as antibiotics, antifungals, antivirals, and antimalarials, so that standard treatments become ineffective and infections persist increasing risk of spread to others.
• The evolution of resistant strains is a natural phenomenon that happens when microorganisms are exposed to antimicrobial drugs, and resistant traits can be exchanged between certain types of bacteria.
• The misuse of antimicrobial medicines accelerates this natural phenomenon. Poor infection control practices encourages the spread of AMR.

AMR kills: Infections caused by resistant microorganisms often fail to respond to the standard treatment, resulting in prolonged illness and greater risk of death. The death rate for patients with serious infections treated in hospitals is about twice that in patients with infections caused by non-resistant bacteria.

AMR hampers disease control: AMR reduces the effectiveness of treatment, thus patients remain infectious for a longer time, increasing the risk of spreading resistant microorganisms to others.

Pre-antibiotic era: Many infectious diseases risk becoming untreatable and uncontrollable, which could derail the progress made towards reaching the targets of the health-related United Nations Millennium Development Goals set for 2015.

Cost of health care: When infections become resistant to first-line medicines, more expensive therapies must be used. The longer duration of illness and treatment, often in hospitals, increases health-care costs and the economic burden to families and societies.

AMR jeopardises health-care gains: The achievements of modern medicine are put at risk by AMR. Without effective antimicrobials for care and prevention of infections, the success of treatments such as organ transplantation, cancer chemotherapy and major surgery would be compromised.

AMR threatens health security, and damages trade and economies: The growth of global trade and travel allows resistant microorganisms to be spread rapidly to distant countries and continents through humans and food.

The development of AMR is a natural phenomenon. However, certain human actions actually accelerate the emergence and spread of AMR. Underlying factors that accelerate the emergence and spread of AMR include:

• lack of a comprehensive and coordinated response;
• weak or absent antimicrobial resistance surveillance and monitoring systems;
• inadequate systems to ensure quality and uninterrupted supply of medicines;
• inappropriate use of antimicrobial medicines, including in animal husbandry;
• poor infection prevention and control practices;
• insufficient diagnostic, prevention and therapeutic tools.