Developing new antimicrobial treatments and prevention strategies requires considerable time and resources. In the short term, we would do well to focus on readily enforceable regulatory changes which been proven to effectively stall or reduce levels of antimicrobial resistance.
An antimicrobial agent is one which has antibacterial, antiviral, antiparasitic or antifungal properties. The emergence and spread of antimicrobial resistance (AMR) is an urgent problem about which every thinking person ought to be concerned. For example, if current trends continue, many bacteria which could previously be inhibited or killed by a variety of antibiotics may become resistant to all or most of them – in fact, instances of this are already emerging. Much of modern medicine is dependent to some extent on antimicrobials. Without antimicrobials, the infection risks associated with carrying out even the most minor surgical procedures are amplified immensely, and we can wave goodbye to organ transplants, chemotherapy and a range of other treatments. Without immediate action we are heading for an era in which even minor infections and injuries may prove fatal. A much cited figure – originating from a 2014 AMR review chaired by the English economist Jim O’Neill – estimates that, in the year 2050, the number of deaths attributable to AMR will be approximately 10 million. In other words, almost 2 million more attributable deaths than estimated for cancer; in fact, more than the deaths estimated for cancer, cholera, measles, road traffic accidents and tetanus combined.
The AMR problem is a global issue. In 2014, the World Health Organization (WHO) published the most comprehensive global report on AMR to date, which included data from 114 countries. The report found that significant gaps exist in the tracking of antibiotic resistance, and that high levels of resistance have now been observed in all regions of the world. Anyone looking to get a glimpse of the global AMR picture would do well to read a short article published on the website of the American Society for Microbiology last May, in which nine researchers from around the world – from Africa, Asia, The Middle East, South America and Europe – were asked to describe the current state of the AMR problem in their own countries. Eight out of the nine researchers told the now all-too-familiar horror stories about the general public’s lack of awareness of the factors which contribute to the emergence and spread of AMR, as well as the lack of sufficient monitoring programmes and regulations to prevent the misuse and overuse of antibiotics in food production (e.g. as growth promoters), in veterinary medicine and in human medicine (e.g. as ineffective treatments for viral infections). The two African respondents claimed that the over-the-counter availability of antibiotics in their countries was often associated with improper self-medication, widespread sale of imitation antibiotics, and the establishment of illicit private health clinics run by unqualified individuals. Other problems observed by the researchers included the administration of antibiotics at concentrations which are based on clinically-educated guesses, ignoring the importance of rigorous antibiotic sensitivity testing; lack of proper hygiene in hospitals and veterinary facilities, leading to increased rates of transmission and infection; the existence of considerable environmental reservoirs of antibiotic-resistant pathogens, and the lack of funding, equipment and qualified personnel to carry out in situ investigations and surveillance.
However, as I read the article I was pleasantly surprised to find that, unlike the reports given by all of the other researchers, the report given by Riika Ihalin – an Academy Research Fellow at the University of Turku in southwest Finland – was unusually positive.
The dogma of inevitable resistance and the fact that high levels of resistance have now been observed in all regions of the world can make the fight against AMR seem futile. However, it is also the case that when researchers, administrators and healthcare workers collaborate to raise awareness of the AMR problem; when antibiotics are used only as prescribed; when suitable vaccines are administered against important bacterial pathogens; when appropriate standards of hygiene are maintained; when strict quality control measures, infection control measures and routine surveillance methods are implemented in food production, veterinary medicine and human medicine, levels of AMR can be kept low, and in some cases they can even be reduced.
Finland has a long history of implementing systematic AMR surveillance schemes. Small-scale, systematic antimicrobial susceptibility investigations began back in the 1960s and 70s, and large-scale studies which involve researchers from all around the country have been carried out since the 1980s. A recent report from a group of Finnish clinical microbiologists founded in 1991, known as the Finnish Study Group for Antimicrobial Resistance (FiRe) – whose main task is “to produce reliable and comparable data on the susceptibility of the 15 clinically most important bacteria in Finland” – has shown that although the levels of resistance observed in some clinically-relevant bacterial strains in Finland has increased somewhat in recent years (e.g. cefuroxime-resistant Escherichia coli), in some cases the prevalence of antibiotic-resistant bacterial strains has remained quite low (e.g. the majority of Acinetobacter, Enterobacter cloacae, Enterococcus faecalis, Staphylococcus aureus, Klebsiella pneumoniae and vancomycin-resistant Enterococcus faecium strains), and in other cases levels of resistance have even decreased slightly (e.g. Streptococcus pneumoniae, trimethoprim-resistant K. pneumoniae, and E. coli strains resistant to first-generation cephalosporins). This is thought to be the result of the implementation of comprehensive and systematic monitoring programmes in hospitals; the harmonizing of antimicrobial susceptibility testing methods in order to facilitate meaningful long-term studies; the cautious, well-regulated use of antibiotics in food production, veterinary medicine and human medicine; and outreach campaigns ensuring that the general public are well-informed about the potential risks of the misuse and overuse of antibiotics.
An earlier FiRe report explained the origins of the group and the commitment of its members to preventing the emergence and spread of AMR:
Practically all Finnish clinical microbiology laboratories which perform antimicrobial susceptibility testing have participated in the FiRe network since the beginning. After the first meeting, FiRe has gathered together regularly twice a year, for an annual meeting and educational workshops on current topics on susceptibility testing and resistance surveillance. Participation in these meetings has always been abundant.
In 2011, Finland became the first country in Europe to relinquish the antimicrobial susceptibility testing standards of the American Clinical and Laboratory Standards Institute (CLSI) – first implemented in 1996 – in favour of the standards of the European Committee on Antimicrobial Susceptibility Testing (EUCAST), which are more frequently updated. Many countries are now beginning to follow in Finland’s footsteps.
Of course, the severity of the AMR problem in a given country is influenced by a wide range of factors in addition to those listed above: for example, a hospital in a popular tourist destination, which experiences large influxes of people from all around the world, is perhaps more likely to record a greater number of antibiotic-resistant infections than a similar hospital that serves a more local, homogeneous population. Although Finland has nowhere near as many annual international tourist arrivals as countries such as France, the US, Spain, China and Italy – the top 5 most visited – it is still ranked far higher than many countries which have much worse AMR problems. In other words, Finland maintains control of its AMR issues more effectively than many countries which have lower annual international tourist arrivals. Hence, there must be another reason for Finland’s success. Perhaps the most straightforward explanation is that they are simply just doing all – or at least most – of the things scientists have been saying for decades that we ought to be doing to combat AMR. They are organized, committed and persistent.
All that needs to be done now is to convince other countries to follow suit.