Running head: ANTIMICROBIAL RESISTANCE

Antimicrobial Resistance
Christen Bowman
Western Washington University

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Antimicrobial Resistance

Medications that once killed certain strains of bacteria are no longer effective.
Bacteria, fungi, parasites and other forms of microbial life are developing resistance to
antimicrobial drugs at an alarming rate. Mankinds impact on their environment has led to the
development of strains of bacteria and other organisms that are dangerous to human health, but
increasingly difficult to kill. This paper will examine how the worlds human population has
contributed to the development of antimicrobial resistance. The intention is to briefly identify
what effect antimicrobial resistance (AMR) has on global health, particularly the poor, and
highlight several proposed solutions.
What is Antimicrobial Resistance?
AMR is an evolutionary process in which pathogens are exposed to antimicrobial agents
which create a lethal environment; while some microbes die, the stronger more resistant strains
survive. Microbes that survive the selection pressure go on to replicate, passing their acquired
resistance to subsequent generations. This leads to the evolution of increasingly stronger, more
resistant pathogens.
How are the poor affected? What causes AMR in low income countries?
People living in developing countries are a high risk population group that are greatly
impacted by AMR. Access to affordable, efficient healthcare services is not a reality for
numerous regions across the globe. Many low income areas are in remote locations, not easily
accessed by car or bus. Doctors, nurses, and other healthcare workers are often found in larger
urban areas, so rural areas remain underserved. People living in these areas often have to travel
long distances to receive care, the journey may not be possible for seriously ill patients. The
result is that patients often dont seek treatment until it is too late.

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Common third-world diseases such as tuberculosis, malaria, and pneumonia are

responsible for high rates of child mortality. In India for example, over 58,000 infants died in one
year from antibiotic resistant bacteria that they acquired from their mother (Laxminarayan,
2013). These once manageable diseases, are now becoming increasingly difficult to treat due to
limited access to care and lack of affordability. Even if these people do receive treatment, making
sure patients adhere to the medication regimen remains a challenge (Daulaire, Bang, Tomson,
Kalyango, & Cars, 2015).
Low income regions of the globe are severely impacted by AMR, but they also
significantly contribute to its dissemination. Some of the leading causes of antimicrobial
resistance in low income regions are related to poor adherence to treatment guidelines, which
results in inadequate dosing. Areas in Southeast Asia, for example, are finding that inadequate
dosing has led to severe outbreaks of drug resistant forms of malaria (Daulaire et al., 2015).
Financial restraints are one of the biggest challenges for low income countries due to
costly treatment regimens. Antimicrobial medications are expensive, which has led to drugs
being produced on the black market and sold as counterfeit. In some cases, pharmacies are
deceived by the low prices and consequently distribute medication that is of poor quality (Roca
et al., 2015).
What else contributes to AMR?
Antibiotic abuse among first-world countries has greatly contributed to the
development and spread of resistant strains of bacteria. Veterinary medicine directly contributes
to the spread of AMR through the misappropriation of antibiotics for use to stimulate growth
among livestock. Unfortunately, antibiotic misuse in livestock has resulted in negative
consequences for humans. For example, a bacteria called Escherichia Coli was originally

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discovered in 1980 among chickens in China, since then, the bacteria have mutated from a
zoonotic disease to a resistant strain of E.coli that is now capable of infecting humans The
resistant strain of E. coli was found in 2016 and carries the first identified case of the mcr-1 gene.
Bacteria that carry the mcr-1 gene are of significant clinical importance because mcr-1 makes
bacteria resistant to our last known class of antibiotics (Schwarz & Johnson, 2016). This
discovery is a major concern for both humans and animals alike.
Antibiotics have negative impacts on the environment as well, which has further allowed
for the spread of resistant microbes from animals to humans. The excessive use of antibiotics has
allowed the drugs to leach into water systems. Antibiotics that enter the environment through
water sources destabilize micro-ecosystems by killing off vulnerable bacteria. This
destabilization creates an ideal environment for resistant strains of bacteria that carry the mcr-1
gene to thrive and transfer resistance to other bacteria. Raw sewage and waste run-off generated
by animal farms creates crucial breeding grounds for bacteria that carry the mcr-1 gene.
Researchers emphasize that special attention should be focused on food production and water
sanitation to ensure that food and water supplies remain unadulterated by resistant microbes
(Roca et al., 2015).
The role of human medicine also has a profound effect on the development of antibiotic
resistant bacteria. Doctors have been known to prescribe antibiotics for viral infections or treat
patients with broad spectrum antibiotics before consulting laboratory culture and sensitivity
reports. Patients may not complete the full course of antibiotics due to side effects or simply
because their symptoms are alleviated after several doses. These circumstances create ideal
conditions for bacteria to survive, mutate, and quickly become resistant to antibiotics (WHO,
2015).

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Interventions
The simple fact is that people everywhere have a right to be healthy. High cost and poor
access to care should not threaten the life of people living in underprivileged communities.
Unnecessary deaths can be avoided by allowing timely and complete access to appropriate
antimicrobial treatment. What is desperately needed by low income countries is a systematic,
well planned approach that is focused at the global level; the lack thereof further aggravates the
cycle of AMR (Roca et al., 2015).
Governmental officials in low income countries must intervene to develop programs that
ensure universal access to appropriate and effective antimicrobial treatment for their citizens.
Even with this level of intervention, more is needed. These programs must have local oversight,
consistent funding, and a legitimate supply of quality drugs. Oversight and funding will rely
heavily on national and international groups such as The United Nations Childrens Emergency
Fund (UNICEF) and the World Health Organization (WHO).
UNICEF-WHO published an article titled, Integrated Community Case Management:
Potential for Benefit to Malaria Programs, which describes how training community health
workers (CHWs) in poor countries has impacted the mortality rate of children under the age of
five living in underserved areas. The article reported that CHWs are able to asses, and effectively
manage care for children suffering from diarrheal diseases, malaria, and pneumonia by going
directly to the patients home to provide treatment. This community based approach provides
timely and effective treatment and is a promising method for providing care to underserved
populations across the globe (UNICEF, 2015).
Willing community members within rural underserved areas should be trained as
community health workers. The training would focus on specific aspects of disease management

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such as following-up with patients to ensure they are receiving benefit from their current
treatment, and guaranteeing that patients complete their medication regimen for the full course.
National authorities would be responsible for providing appropriate oversight of training,
medication distribution, and proper funding.
Although killing resistant bacteria is the main goal, we must also combat the source of
the mutated bacteria as well. Curbing antibiotic abuse among farmers is a necessary step towards
solving the global impact of AMR on food supply. One researcher exclaimed that that the use of
antibiotics for animal growth should be banned (Roca et al., 2015, p.23).
Additionally, efforts should be focused on educating veterinarians and farmers on the
consequences of antibiotic use in livestock. In regards to water sources, a strategy must be put in
place that focuses on improving sanitation systems for medical facilities and factory farms.
Other efforts should focus on combating the poor adherence to the World Health
Organizations recommendations for treating tuberculosis, malaria, and other diseases.
Inadequate dosing and poor quality drugs continue to create resistant microbial strains that cause
high mortality and are extremely difficult to treat. Appropriate treatment guidelines must be
clearly stated and followed by practitioners to avoid creating new resistant microbial species
(Roca et al., 2015).
Educational programs must be constructed to promote the appropriate use of antibiotics
and dispel the ignorance surrounding antimicrobial resistance. Instructional programs should
focus on physicians, healthcare workers, drug vendors and the general public. Physicians must
have access to the most current antibiotic prescribing guidelines. Additional surveillance
measures should be put into place by requiring physicians to track and report when they

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prescribe antimicrobial medications, this will help ensure that appropriate prescription guidelines
are being followed (Roca et al., 2015).
Antibiotic stewardship within healthcare facilities is a mandatory step in the fight against
drug resistant microbes. Antibiotic stewardship is an effort towards reducing the spread of AMR
bacteria and other microbes by implementing several aggressive measures. The first measure
would focus on education. This would include current antibiotic treatment guidelines and
educational assemblies to inform physicians, drug companies, and the general public on the
dangers of antibiotic misuse.
Other approaches are to impose restrictive measures on antibiotic use, by requiring
reports of susceptibility from labs. This restrictive measure would require physicians to have
laboratory reports that identify the microbial infection by testing samples of blood, urine and
sputum in the laboratory. With this data, the physician would be able to prescribe an antibiotic
that is specifically designed to kill that microbe, so that they would rely less on broad spectrum
drugs, which are known to contribute to AMR. Lastly, supplemental measures might include
management teams, computer programs, and infection control programs that monitor antibiotic
use.
What is the major impact of AMR?
Antimicrobial resistance (AMR) is not a new threat, it has been around for many years. In
particular, the E.coli resistant bacteria mentioned earlier went largely undetected for 25 years and
is only just now making headlines across the globe. The call for concern is not necessarily
because of significant clinical or public health impacts thus far. The fact is that Colistin is an
antibiotic that belongs to a class of drugs, polymixins, which is one of the last known lines of
defense against deadly infections (Schwarz & Johnson, 2016). The good news is that some

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Colistin resistant strains of bacteria are still susceptible to several other classes of antibiotics;
even so, the potential for Colisitin resistant bacteria to exchange genetic material with other
species of drug resistant bacteria is a serious threat that cannot be ignored. (McKenna, 2015)
Gene transfer between bacteria can occur in several ways. In the case of Colistin resistance, a
bacteria carries the genetic code, or mcr-1 gene, and then passes that gene to another bacteria.
An alarming feature of bacteria that carry the mcr-1 gene, is that they have the capability of
transferring the gene to other bacteria quite easily.
The major concern is if bacteria carrying the mcr-1 gene pass it on to other resistant
bacteria, such as carbapenum-resistant Enterobacteriaceae, it has the potential to create a bacteria
that is resistant to multiple antibiotics. (McKenna, 2015) This type of multi-drug resistance is
referred to as pan-resistance, in which the microbe is not killed by multiple drugs. Panresistance is a serious threat to global health that would have devastating consequences,
especially on the worlds poor. (CDC, 2016) Whats even more alarming is that pharmaceutical
manufacturers have stopped research on the creation of new antibiotics because it is an expensive
investment with a limited financial return. (Roca et al., 2015) (Please see Appendix A to view a
logic map that represents different elements of human involvement and how they are
interconnected to create the complex problem of AMR).
Conclusion
Antimicrobial resistance is having devastating effects on the worlds poor and little is
being done about his presently. World leaders must begin to implement effective interventions
that target the worlds poor, wealthy countries, veterinary and human medicine, so that
mankinds future generations will be able to treat simple infections. If the world does not take

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antimicrobial resistance seriously, we may find that once harmless pathogens, become the cause
of countless deaths.

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References

Center for Disease Control and Prevention. (2016). Discovery of first mcr-1 gene in E. coli bacteria
found in a human in United States. Retrieved from
http://www.cdc.gov/media/releases/2016/s0531-mcr-1.html
Daulaire, N., Bang, A., Tomson, G., Kalyango, J. N., & Cars, O. (2015). Universal Access to Effective
Antibiotics is Essential for Tackling Antibiotic Resistance. Journal of Law, Medicine & Ethics.
4317-21. Doi:10.1111/jlme.12269
Laxminarayan, R., Duse, A., Wattal, C., Zaidi, A., Wertheim, H., Sumpradit, NCars, O. (2013).
Antibiotic resistancethe need for global solutions. The Lancet Infectious Diseases
Commission. Retrieved from http://doi:10.1016/S1473-3099(13)70318-9
McKenna, M. (2015, May 26). National Geographic [blog]. Long-dreaded superbug found in human and
animal in U.S. Retrieved from http://phenomena.nationalgeographic.com/2016/05/26/colistin-r 9/
Roca, I., Akova, M., Baquero, F., Carlet, J., Cavaleri, M., Coenen, S. Vila, J. (2015). The global
threat of antimicrobial resistance: science for intervention. New Microbes and New Infections.
Volume 6, 22 29.DOI: http://dx.doi.org/10.1016/j.nmni.2015.02.007
Schwarz, S., Johnson, J. (2016). Transferable resistance to colistin: a new but old threat. Journal of
Antimicrobial Chemotherapy. 71(8). 2066-2070. http://doi:10.1093/jac/dkw274
The United Nations Childrens Emergency Fund. (2015). Overview and latest update on integrated
community case management: Potential for benefit to malaria programs
http://www.unicef.org/health/files/WHO-UNICEF_iCCM_Overview_and_Update_(FINAL).pdf

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World Health Organization. (2015). Global action plan on antimicrobial resistance. Retrieved from
http://apps.who.int/iris/bitstream/10665/193736/1/9789241509763_eng.pdf?ua=1
World Health Organization. (2014). Antimicrobial resistance global report on surveillance. Retrieved
from http://apps.who.int/iris/bitstream/10665/112642/1/9789241564748_eng.pdf

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Appendix A

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