A new report from the World Health Organization (WHO) shows that an increasing amount of data is being reported on antimicrobial resistance (AMR) and use, and some of the data suggest troubling trends, particularly in low- and middle-income countries (LMICs).
The WHO's fourth Global Antimicrobial Resistance and Use Surveillance System (GLASS) Report includes information on more than 3 million laboratory-confirmed bacterial infections caused by pathogens of concern in 70 countries in 2019. That's more than a sixfold increase in the number of infections reported to GLASS when sites first began reporting AMR surveillance data in 2017.
Although WHO officials caution that the data are limited and more research is required to draw firm conclusions, among the findings are high rates of resistance in common pathogens to first-line antibiotics used to treat urinary tract infections (UTIs) and extremely high resistance to last-resort antibiotics in some healthcare-associated pathogens. The data also show higher rates of resistance in LMICs for the most common causes of bloodstream infections (BSIs).
"The volume of AMR infections is alarming," WHO Assistant Director-General Hanan Balkhy said in a press release. "However, it is encouraging to see that despite the ongoing challenges of COVID-19, more countries are reporting in on AMR….The more information we have, the better placed we are to tackle this increasingly serious health threat."
More countries providing AMR data
GLASS, which was launched in 2015 to help achieve the goals of the WHO's Global Action Plan on AMR, seeks to standardize the collection and sharing of AMR surveillance data across the globe. Establishing country-level surveillance of antibiotic resistance and consumption is seen as crucial to understanding the extent and burden of AMR and to combating the rise and spread of resistant pathogens.
The first GLASS report, published in 2018, included data collected on more than 500,000 infections from 22 countries. Since then, the number of countries enrolled in GLASS has grown from 52 to 109. Of those 109 countries, 107 now provide AMR data, and 17 measure antibiotic consumption. GLASS also monitors the progress in implementation of national surveillance systems and helps countries collect data on key AMR epidemiolog indicators.
For the GLASS report, countries collect and submit AMR data on select pathogens for four types of infection: BSIs caused by Acinetobacter spp., Escherichia coli, Klebsiella pneumoniae, Salmonella spp., Staphylococcus aureus, and Staphylococcus pneumoniae; UTIs caused by E coli and K pneumoniae; gastrointestinal infections caused by Salmonella spp. and Shigella spp.; and genital infections caused by Neisseria gonorrhoeae.
The GLASS data for 2019 show that, in UTIs caused by E coli and K pneumoniae, resistance to the first-line antibiotic co-trimoxazole was 54.4% and 43.1%, respectively, and resistance to ciprofloxacin, a broad-spectrum second option for UTIs, was also found to be consistently high (43.1% for E coli and 36.4% for K pneumoniae). The report notes that the high rate of resistance to ciprofloxacin is consistent with reports that the antibiotic is frequently being overused for UTI treatment.
"This is a crucial issue as fluoroquinolones have an important role in the treatment of more severe infections, such as septicaemia, and therefore resistance to fluoroquinolones can have serious clinical consequences," the authors wrote.
The data also show high rates of resistance to third-generation cephalosporins in BSIs caused by E coli, which is the most common BSI-causing pathogen worldwide. In addition, a significant difference was observed between the proportion of patients with BSIs caused by third-generation cephalosporin-resistant E coli in LMICs and those in higher-income countries: 58.3% vs 17.5%. A similar difference was observed in the proportion of patients with BSIs caused by methicillin-resistant S aureus (MRSA)—33% vs 15%.
BSIs caused by MRSA and E coli with resistance to third-generation cephalosporins have been identified by the WHO as two important AMR Sustainable Development Goal indicators. The authors say the higher rates of resistance seen in LMICs for these indicators suggest that less-resourced countries are more heavily affected by AMR, and that underlying causes "need to be investigated as a matter of urgency."
Another concern is the extremely high resistance to carbapenems found in BSIs caused by Acinetobacter. "The median carbapenem resistance of 65.48% in BSIs caused by Acinetobacter spp., an emerging pathogen causing hospital infections, depicts a dire scenario," the report states.
In 4 of the 21 countries that reported resistance data for gonorrhea infections, resistance to ceftriaxone—one of the two remaining antibiotics that are effective against N gonorrhea—surpassed 5%, the level at which health officials recommend discontinuing treatment. The report notes that confirmed gonorrhea treatment failure is being increasingly encountered and "more information is needed to adequately plan control actions."
Data gaps need addressing
The WHO says that despite the increasing participation in GLASS and the improvement in AMR surveillance systems in many countries, better and more representative AMR data are needed to understand what's driving rising resistance levels, what interventions might slow resistance, and how AMR is affecting human health in different countries.
To help fill these data gaps, the agency says it is fostering increased lab capacity in countries, encouraging the use of molecular methods like whole-genome sequencing, moving toward population-based surveys in countries that have low testing coverage, and developing methodologies to help countries estimate AMR-attributable mortality.
"GLASS continues its path to improving the monitoring of global AMR trends and to identifying drivers of AMR," the report concludes. "WHO seeks the consolidation of this system to enhance the knowledge and evidence base to inform effective and sustainable control strategies."