A Global Analysis of Antimicrobial Resistance and its Drivers for the year 2021

The State of the World’s Antibiotics 2021 report by Center for Disease Dynamics, Economics & Policy (CDDEP), on the state of antibiotics introduces country dashboards that capture progress on indicators that track AMR and show what remains to be done to decrease the need for antibiotics and their inappropriate use. Antimicrobial resistance is a clear and present danger to global health. The index and dashboards are designed to help government officials, policymakers, and healthcare stakeholders assess and track AMR status over time and in relation to other countries, and then prioritize actions.

As the 2010–2020 decade ended, having witnessed a global effort to control antimicrobial resistance, the Covid-19 pandemic arrived as a reminder of the tremendous economic and social damage that infectious diseases can unleash. Among the casualties of Covid-19 is some of the progress made on antimicrobial resistance (AMR). Antimicrobials continue to be prescribed for viruses, and countries have reported increasingly high rates of resistance among drugs used to treat common infections. Resistance to first-line antimicrobials is now emerging among the pathogens that cause HIV, malaria, and typhoid fever, threatening global progress on health, particularly in low- and middle-income countries (LMICs).

One major driver of resistance is the overuse and misuse of antibiotics in human healthcare. Globally, antimicrobial consumption is accelerating worldwide, particularly in LMICs, as the drugs become more accessible and affordable. The use of antibiotics that the World Health Organization deems critically important for human health increased 91% worldwide and 165% in LMICs between 2000 and 2015. Vaccines against many infectious agents are available, but low vaccination coverage, coupled with unsafe water and sanitation, leave many people vulnerable to infection and dependent on antibiotics for treatment. Investments to increase vaccine coverage, improve water and sanitation, and implement antimicrobial stewardship in health facilities could mitigate AMR worldwide.

The other major factor driving resistance is the widespread use of antibiotics in agriculture and aquaculture. The fast-growing demand for animal protein has increased the use of antimicrobials in the animal health sector, where these drugs are used not only to treat and prevent infection but also to promote rapid growth. All countries need to develop and enforce laws and other policies to reduce the use of antibiotics in both terrestrial and aquatic food animals.

Access to life-saving antibiotics in LMICs remains an issue. Although AMR poses an urgent global public health threat, more people in LMICs die from lack of access to antimicrobials than from resistant infections. Global efforts to mitigate AMR must also increase access to affordable and clinically appropriate antimicrobials. Antibiotic research and development lags behind clinical need: drugs in the pipeline are not sufficient to counter the increasing resistance to current antimicrobials and maintain a strong arsenal of effective antimicrobials.

Key messages on changing patterns in antimicrobial resistance

• Antimicrobial resistance continues to rise as countries increasingly report high rates of resistance among antimicrobials used to treat common infections. Weighted average resistance levels are generally higher in low- and middle-income countries (LMICs).
• Resistance to first-line antimicrobial agents is rapidly emerging among the pathogens that cause HIV, malaria, and typhoid fever, threatening global progress in eliminating these infectious diseases.
• The Drug Resistance Index (DRI), which measures the average effectiveness of the set of antibiotics used to treat a given bacterial infection, is an effective tool for assessing and communicating trends in national AMR burden.
• Higher Drug Resistance Index values in LMICs may reflect a relatively lower level of antibiotic effectiveness due to limited access to newer, more effective antibiotics, revealing where resistance poses a more significant problem.

Key messages on Drivers of Resistance: Antibiotics in Human Healthcare

• The misuse and overuse of antimicrobials in the human health sector is a major driver of AMR.
• Globally, the use of antimicrobials is accelerating worldwide, particularly in LMICs, as antimicrobials become readily accessible and affordable. The use of WHO Watch antibiotics increased 90.0% worldwide and 165% in LMICs between 2000 and 2015
• Vaccines against many infectious agents are available, but low vaccination coverage, coupled with poor water, sanitation, and hygiene (WASH) infrastructure, leave many people vulnerable to infection and dependent on antibiotics for treatment.
• Investments to increase vaccine coverage, develop WASH infrastructure, and implement antimicrobial stewardship in health facilities could mitigate AMR worldwide.

Key messages on Drivers of Resistance: Antibiotics in Agriculture

• The enormous increase in the demand for animal protein has rapidly increased the use of antimicrobials in the animal health sector, where these drugs are used not only to treat and prevent infection but also to promote rapid growth.
• China and India represented the largest hotspots of resistance, with new hotspots emerging in Brazil and Kenya.
• All countries need to develop and implement legislation and other policies to reduce the use of antibiotics in both terrestrial and aquatic food animals.

Reference

Aditi Sriram, Erta Kalanxhi, Geetanjali Kapoor, Jessica Craig, Ruchita Balasubramanian, Sehr Brar, Nicola Criscuolo, Alisa Hamilton, Eili Klein, Katie Tseng, Thomas Van Boeckel, Ramanan Laxminarayan. 2021. State of the world’s antibiotics 2021: A global analysis of antimicrobial resistance and its drivers. Center for Disease Dynamics, Economics & Policy, Washington DC. Available at https://cddep.org/publications/the-state-of-the-worlds-antibiotic-in-2021/