Antimicrobial Resistance in the Context of One Health

By: Garrett Coleman

Since the early 2000s, there have been six pandemics throughout the globe: SARS (2002), Swine Flu (2009), MERS (2012), Ebola (2013), Zika (2015), and COVID-19 (2019) ⁽¹⁾. These pandemics generated massive advances in research to better understand, manage, and prevent these diseases. However, possibly the greatest plague has yet to be solved. In 2019, there were more than 2.8 million cases of antimicrobial resistance in the United States., resulting in ~35,000 deaths ⁽²⁾. Subsequently, the WHO has identified antimicrobial resistance as a Top 10 Global Public Health Threat Facing Humanity ⁽³⁾.

Antibiotics were first discovered in 1928, but it wasn’t until the 1940s that they were widely applied in healthcare. As antibiotic treatment became more prevalent, antimicrobial resistance (AMR) emerged. After the discovery of AMR, pharmaceutical companies raced to create stronger antimicrobials while balancing subsequently more significant side effects. However, this “race” to discover novel drugs against resistant bacteria appears to have markedly slowed, with the last novel class of antibiotics (lipopeptides) produced in 1987. Pharmaceutical companies have reduced efforts to discover and develop new antimicrobials because it is not economically feasible to allocate resources to develop a drug that is only used acutely. Without effective treatments for microbial infections, healthcare outcomes for even the simplest diseases could regress.

The greatest misuse of antimicrobials occurs in the outpatient setting and in the agricultural sector. An estimated 80-90% of the volume of human antibiotic use occurs in the outpatient setting ^{(4 – 5)}. Dr. David Reynoso is an infectious disease physician and the Director of Antimicrobial Stewardship Program at UTMB and believes our goal must be to preserve effective treatment with the antibiotics available. This can be done by limiting unnecessary antibiotic use and creating standardized guidelines for providers regarding appropriate indications for antibiotic use. Dr. Reynoso and colleagues have implemented these strategies through institutional guidelines at UTMB as part of the Antimicrobial Stewardship Program. While he has been able to successfully combat “over-prescription” at a local inpatient level; he acknowledges that implementing this at outpatient clinics, long-term care facilities, or at the national level will be difficult.

Solving AMR in healthcare addresses only half of the problem. The overuse of antibiotics in the agricultural sector has a “trickle-down” effect that is passed on to consumers ⁽⁶⁾. For example, farm animals infected with ESBL- producing E. coli confer resistance to certain beta-lactamase antibiotics. Certain occupations such as farm workers and individuals in the meat-packing industry can encounter this microbe. While healthy individuals may not develop an infection, they can still act as carriers and spread the microbe by touching surfaces or through direct contact. Ultimately, the elderly and immunocompromised may develop an infection with subsequent hospitalization, introducing the pathogen into the healthcare system.

Dr. Reynoso believes that ultimately AMR must be combatted through judicious use of antibiotics. To preserve our limited antimicrobial resource, the most effective approach would combine education and training with regulations and policy that enforce evidence-based antibiotic utilization. A solution to antimicrobial resistance must address the underlying issues within our healthcare system as well as the agricultural sector utilizing a One Health based approach.

References:

1. Bhadoria, Pooja, Gupta, Gaurisha, Agarwal, Anubha. Viral Pandemics in the Past Two Decades: An Overview. Journal of Family Medicine and Primary Care: August 27, 2021 - Volume 10 - Issue 8 - p 2745-2750
doi: 10.4103/jfmpc.jfmpc_2071_20

2. Centers for Disease Control and Prevention. (2022, October 5). About antibiotic resistance. Centers for Disease Control and Preventionfrom https://www.cdc.gov/drugresistance/about.html

3. World Health Organization. (n.d.). Antibiotic resistance. World Health Organization. https://www.who.int/news-room/fact-sheets/detail/antibiotic-resistance

4. Public Health England. English Surveillance Programme for Antimicrobial Utilisation and Resistance (ESPAUR): report 2014 [Internet]. London, England: Public Health England; 2014. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/362374/ESPAUR_Report_2014__3_.pdf

5. Public Health Agency of Sweden, National Veterinary Institute. Consumption of antibiotics and occurrence of antibiotic resistance in Sweden [Internet]. Swedres-Svarm 2014. Solna and Uppsala, Sweden: Public Health Agency of Sweden, National Veterinary Institute; 2015. Report No.: ISSN 1650–6332.

6. Manyi-Loh C, Mamphweli S, Meyer E, Okoh A. Antibiotic Use in Agriculture and Its Consequential Resistance in Environmental Sources: Potential Public Health Implications. Molecules. 2018 Mar 30;23(4):795. doi: 10.3390/molecules23040795. PMID: 29601469; PMCID: PMC6017557.