Experts press for wider scope, evidence in drug resistance battle

Focused attention on antimicrobial resistance, underscored by coordinated global and national awareness campaigns this week, is welcome, but discussions overlook broader questions such as how to preserve access for populations who need them and how to maintain the effectiveness of the drugs, according to a series that launched in The Lancet today.

According to one of the series' five main reports, the global battle against antimicrobial resistance is threatened by a lack of a strong evidence base for control policies, with another finding that more people die each year from a lack of access to the medications than from resistant bacteria infections.

Resistance discussions too narrow

The series, launched at an event today at Imperial College London, also includes several expert commentaries. In an editorial introducing the series, Lancet editors Pamela Das and Richard Horton, MD, wrote that the topic of antimicrobial resistance has come of age and now has the political visibility that it desperately needs.

But they said the series is intended to add important and missing elements from the current debate. "The focus on resistance alone is too narrow. It misunderstands the challenge of antibiotics and fails to take a global perspective on the needs of those for whom antibiotics are indeed such a precious resource," Das and Horton wrote.

The new Global Action Plan on Antimicrobial Resistance is a good blueprint but lacks the technical and financial mechanisms needed for it to progress, they wrote. The World Health Assembly's work on a resolution for the United Nations should include concrete proposals for extending access to those most at risk, especially children with treatable illnesses such as pneumonia and diarrhea. The two added that broadened policies should also integrate animal health and environmental concerns.

The series was coordinated by John-Arne Rottingen, MD, PhD, executive director of Environmental Health and Infectious Disease Control and the Norwegian Institute of Public Health.

Evidence gaps hamper policymaking

In one study, an international team of experts probed the factors that drive and enable access to antimicrobials and what approaches are needed to guide appropriate use.

They recommended national research assessments to better gauge the access people in lower- and middle-income countries have to effective drugs. They also said that a bigger focus on access to vaccines is needed as a main strategy to control antimicrobial resistance.

Meanwhile, another group contended that current policies to reduce antimicrobial resistance are poorly understood, and it's not clear if ones that have been implemented will work or provide good value for the money. They pointed out that policymakers have little reliable guidance for the best options for controlling antibiotic resistance and that coordinated efforts are needed now to evaluate and research the best strategies.

Access, vaccine strategy need addressing

In another paper, an international team led by the Center for Disease Dynamics, Economics, and Policy in Washington, DC, looked at community-acquired pneumonia in children younger than 5 years. They estimated that universal access to antibiotics could cut pneumonia deaths in 101 countries by 75%, preventing 445,000 of 590,000 deaths.

The team also examined the impact of increased use of pneumococcal and Haemophilus influenzae type b (Hib) vaccine in the same age-group, without increased use of antibiotics to treat pneumonia. They found that the strategy could prevent as many as 11.4 million days on antibiotics annually, amounting to a 47% cut in days on antibiotics across 75 countries.

Problem too big for the WHO?

In a report that explored international access to the medications, another group of experts found that current incentives for pharmaceutical companies to develop new antibiotics aren't strong enough, and that a radical overhaul is needed of finance and development mechanisms.

They argued that World Health Organization (WHO) can't tackle the problem on its own, because of interrelated agricultural and veterinary components of the issue. The experts emphasized that a One Health model is needed to spur action and bring meaningful change, and they suggested a new United Nations–level coordinating body or an international treaty to take on the issue and enforce the solutions.

Rottingen said in a Lancet press release e-mailed to journalists that the economic value of new antimicrobial drugs doesn't come about until the old drugs fail. And by then it's too late.

"We need to completely rethink the way that research into antimicrobials is funded, starting by decoupling innovation in drug development from sales," he said. "The funding of these drugs needs to be driven by public health needs, not by profit."

Reducing selection pressure

In a fifth report, a research team took an in-depth look at how bacteria and other pathogens acquire resistance. They reported that removing evolutionary pressure won't necessarily reverse resistance, which has key implications for the global effort against the problem.  Experts warned that resistance could remain for many years, even despite steep reductions in the use of the drugs.

Alison Holmes, MD, MPH, lead author of that report and infectious disease specialist at Imperial College London, said in the Lancet release that the current understanding of how pathogens acquire resistance suggests there is no single solution to the global antimicrobial resistance problem. "We need to tackle this problem synergistically, on multiple fronts, which will require an unprecedented level of international cooperation."

See also:

Nov 18 Lancet editorial on the series

Nov 18 Lancet report on access to appropriate antimicrobial use

Nov 18 Lancet report on evidence base for national and regional policy

Nov 18 Lancet report on health impact of limited antimicrobial access

Nov 18 Lancet report on international cooperation to improve access to antibiotics

Nov 18 Lancet report on mechanisms and drivers of antimicrobial resistance (Holmes)

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