One silver lining of the COVID-19 pandemic might be found in the fight against drug-resistant infections, which are on course to cause millions of deaths in the next decades as many common conditions such as pneumonia and urinary tract infections become resistant to antibiotics.
The pandemic has underscored the importance of hand hygiene, driving a fast behavioural shift that might help reduce the spread of all infections. “During [the COVID-19 pandemic], I’ve been amazed and it's been impressive to see how hand hygiene and other measures to prevent infection have become widespread,” said Carmem Pessoa-Silva, who leads WHO's Global Antimicrobial Resistance Surveillance System (GLASS). “I do hope this will be a permanent, positive gain from all this suffering.”
However, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections might also fuel the inappropriate use of antibiotics in health-care settings. Hence, WHO has released guidance on the clinical management of COVID-19, which recommends not to provide antibiotic therapy or prophylaxis in patients with mild or moderate disease unless there is a clinical indication to do so. “We believe this clear guidance on the use of antibiotics in the COVID-19 pandemic will both help countries tackle COVID-19 effectively and prevent the emergence and transmission of antimicrobial resistance (AMR) in the context of the pandemic”, said Hanan Balkhy, assistant director-general for antimicrobial resistance at WHO, in a news release to mark the publication of the third GLASS report. Launched in 2015, the focus of GLASS is the surveillance of AMR in the set of human bacterial pathogens of greatest global concern. To do so, it encourages countries to report AMR data, and it will progressively incorporate information from other surveillance systems, such as monitoring of antimicrobial consumption and emerging resistance.
The 2020 GLASS report aggregated data from more than 64 000 surveillance sites, reporting information on AMR for over 2 million patients in 66 countries, territories, and areas—a remarkable increase from the 729 surveillance sites across 22 countries that contributed data for the 2018 report. The data revealed high prevalence of resistance to antimicrobials often used against common infections, highlighting the global decrease in effective options available for their treatment.
The stark consequences of AMR were highlighted in a 2019 report of the UN Interagency Coordination Group on Antimicrobial Resistance, which estimated that drug-resistant infections could cause 10 million deaths each year globally by 2050, if no action is taken. The document also reported that currently at least 700 000 people die each year from drug-resistant infections, including 230 000 people who die from multidrug-resistant tuberculosis.
Pessoa-Silva emphasised that AMR is a global concern. “Many people were expecting to find AMR only in high-income countries but [the 2020 GLASS] report shows only one-third is there and the other two-thirds in low[-income] and medium-income countries”, she said. “The international community has a role in making investment in countries including infrastructure that is needed to tackle AMR”, she added, explaining that “the focus [of GLASS] is not only on getting more data but also on increasing country capacity to generate, interpret, and use the data in their national action plans, particularly supporting the most vulnerable”.
Many countries lack laboratory capacity and antimicrobial stewardship programmes. Furthermore, unchecked and unregulated use of antibiotics in many regions is likely to drive the emergence and spread of AMR and should be tracked.
Global per-capita antibiotic consumption has been estimated to have increased by 39% in 2000–15, and that of Watch antibiotics—antibiotics that WHO recommends only for specific indications because of their increased AMR potential, under the AWaRe classification—has been reported to have increased by 91%, over the same period of time, with the increases being greatest in low-income and middle-income countries. Ramanan Laxminarayan, co-author of the Articles reporting these estimates and director of the Center for Disease Dynamics, Economics & Policy, which helps to compile the Drug Resistance Index on the use of antibiotics, said “Globally, south and southeast Asia are of concern, from Vietnam and China to India and Pakistan”, but adds that “every country has AMR hotspots in the same way [as] they have coronavirus hotspots”.
Global AMR surveillance should extend to all countries, including those that are afflicted by conflict or political instabilities. Nada Malou, microbiology advisor at Médecins Sans Frontières, thinks that to this end, GLASS should include data compiled by non-governmental organisations. “In some countries where there is no AMR surveillance, such as Yemen, MSF is sitting on years of data but is not allowed to share it. Lots of organisations have data from regions where not even the WHO has a presence,” she said. “War-wounded [countries] are not included in GLASS but we have found a high rate of AMR in Yemen, Syria, Gaza and Iraq. We have tried to open a discussion about this with WHO because this has a huge impact.”
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