Antimicrobial Resistance 101: Antimicrobial Resistance in the Future

Foreword

Antibiotics were a major breakthrough in science. Microorganisms such as viruses, bacteria, fungi, and more can be treated by antibiotics relatively simply. Upon the introduction of antibiotics, previously deadly illnesses could now be treated with incredible efficacy. However, the pathogens targeted by the first antibiotics soon started to become resistant.

Antimicrobial resistance is one of the biggest problems in modern medicine. There is evidence of bacterial infections evolving to become resistant to the complete arsenal of antibiotics. As a result, people are increasingly dying from simple infections that would not have been dangerous a few years ago. Because the situation is only going to get worse in the coming decades, it is time to think about alternatives.

The Antimicrobial Resistance 101 series will be mainly divided into the following chapters:

1. Antimicrobial Resistance 101: Evolution As a Driver of Resistance

2. Antimicrobial Resistance 101: Resistance Mechanisms

3. Antimicrobial Resistance 101: The Global Problem of Antimicrobial Resistance

4. Antimicrobial Resistance 101: The Clinical Burden of Resistant Microorganisms

5. Antimicrobial Resistance 101: Solutions to Antimicrobial Resistance

6. Antimicrobial Resistance 101: Antimicrobial Resistance in the Future

Antimicrobial Resistance 101: Antimicrobial Resistance in the Future

Over the course of this article series, having first explained the problem of antimicrobial resistance, the focus then turned to its implications and possible solutions. Resistance of microbes to medication is a natural phenomenon that will never cease to occur, given that it is a process of natural selection. The fact that it is a naturally occurring phenomenon, however, does not mean to say that it does not pose a great threat. A parallel can be drawn between the acceleration of global warming and antimicrobial resistance. Greenhouse gases warming the planet is not in itself a dangerous process. On the contrary; it is necessary for a stable atmosphere on Earth (ESAPA, n.d.). Yet, humans have severely increased the concentrations of greenhouse gases over a relatively short period, speeding up the process of global warming, that now poses a great threat to all humans and all ecosystems around the world. This also goes for antimicrobial resistance. Microbes have grown resistant to drugs for decades and will continue to do so far into the future. The problem is that, by not thinking about the effects of large and uncontrolled doses of drugs as medication, pathogens have grown resistant to so many drugs, at such an incredible pace, that doctors and scientists are worrying about whether or not simple infections will be able to be cured in the near-future.

Another characteristic that both climate change and antimicrobial resistance have in common, is that predicting the future of these problems is incredibly complicated. These problems are so complex that it is difficult to make predictions based on available data. Additionally, it is difficult to predict how humans will respond to these problems. The models available to study climate change itself have intrinsic levels of uncertainty, though they are found to simulate reality very well (Buis, 2020; & Cornwall, 2019). Evidently, it remains unknown when, and to what extent people around the world are willing to reduce the effects of climate change. As such, the United Nations has come up with five different scenarios, that each portray a possible reality in which governments around the world start to do everything in their power to mitigate climate change, or not (Climate Neutral Group, n.d.). The most optimistic, and perhaps naïve scenario is the world having cut all carbon dioxide emissions by 2050. The worst-case scenario is the one in which economies keep growing, while relying on fossil fuels, resulting in a doubling of carbon dioxide emissions by the year 2050, with very severe consequences (Climate Neutral Group, n.d.). So, while the pace at which the average global temperature can be modelled astonishingly well for the near future, predictions on future, long-term outlooks are much more difficult to make.

Figure 1: The scenarios proposed by the IPCC (Intergovernmental Panel on Climate Change) (Earth Observatory, n.d.).

The same is true for antimicrobial resistance. The World Bank Group has stipulated two scenarios; the low- and the high-impact AMR scenarios (World Bank Group, 2017). These scenarios have not been developed in detail. Therefore, the actions to prevent the high-impact scenario from becoming a reality are not well defined. Whichever of these scenarios will be true, or whether reality will be in between these two estimates, will dictate the extent to which antimicrobial resistance influences the world in the future. One thing that is certain, however, is that the global economy will be heavily impacted by things such as increasing healthcare costs. Additionally, trade will likely fall as a consequence of increasing rates of illness in both humans and livestock (World Bank Group, 2017). It is also important to note that although resistant microbes are being detected all over the world, developing countries will likely suffer significantly more because the healthcare systems in these countries are less developed.

The fact that the frequency by which resistant microbes are detected is rising is not the only concern. Over recent decades, microbes have become resistant in large numbers very rapidly. This has resulted in a hesitancy to produce new drugs, as they can only be used for a small time. It has therefore become decreasingly profitable for big pharmaceutical companies to invest in alternatives to current antimicrobials such as antibiotics, antivirals and antifungals (Cook & Wright, 2022). Moreover, if new drugs were to be discovered, governments and organisations will likely advise that healthcare experts keep these drugs as alternatives to be used only when all else has failed. Discovering drugs that are only used in a very limited amount of cases is not a lucrative business model (Jewell, 2022). So while more microorganisms are becoming resistant to the drugs available, there are also fewer new drugs being produced, aggravating the situation.

Figure 2: The timeline of antibiotics shows that in past decades, practically no antibiotics have been developed. This time is known as the discovery void (Reactgroup, n.d.).

The development of new antimicrobial drugs will be an absolutely vital part of any strategy that aims to mitigate the effects of antimicrobial resistance. It will, however, not be the only element to form a solution (Jewell, 2022). New therapies, as discussed in the previous article of this series, will become increasingly important, as the number of useful drugs decreases over time. Most importantly, however, people are going to have to make behavioural changes. First and foremost, people need to stop taking antibiotics for every infection. In some countries, it remains relatively easy to obtain drugs, and so even for the common cold, a viral infection that cannot be cured by antibiotics, people are taking antimicrobials. This is increasing antimicrobial resistance while having no positive healthcare effect. Additionally, antimicrobials need to be used significantly less in agriculture, which has been discussed previously in this series. If people were to boycott meat for which many antibiotics have been used, and instead choose a more ecologically responsible producer which has not used such drugs, the industry will be encouraged to use antimicrobials less frequently (Jewell, 2022).

Things are going to get worse before they get better (Jewell, 2022), primarily because the damage already done is not reversible, and change cannot happen quickly and imminently. Whatever happens, the number of available and usable drugs will diminish as the number of resistant pathogens increases. Treatment will become more difficult, and the number of cases where treatment will have no effect will rise too. People will be sick more often, for a longer time and more severely. Procedures that used to be safe, including C-sections (surgery to deliver babies), and many other operations, will pose a larger risk of the patient acquiring infections. This scenario is a future perspective coined by Dr Muhammad Zaman in an interview with North Caroline State University (Jewell, 2022). Dr Zaman is a renowned professor of biomedical engineering at Boston University and has done much work on antimicrobial resistance. He believes that it is likely that the global burden will increase over the coming years. The further one looks into the future, however, the more difficult the burden of the crisis becomes to predict.

Figure 3: Simple measures can have big impacts on all antimicrobial resistance. Washing hands is such a measure (WHO, n.d. c).

Future predictions, in which antimicrobial resistance is much more of an issue than in the current world, are dire. Governments of the richer countries have launched plans to increase surveillance and detection of resistant pathogens, alongside plans to impose stricter regulation on using antimicrobials, specifically in agriculture (WHO, n.d. a). The policies differ greatly all over the world, however, and developing countries specifically are falling behind. Even if a handful of countries stop using all antibiotics, they will still suffer from the resistant pathogens emerging elsewhere on the planet. Therefore, international cooperation is required, as is voiced by more and more (inter)national agencies, that are growing increasingly worried about antimicrobial resistance (WHO, n.d. b).

Society finds itself at a crossroads, where humanity can choose to stay on the same, destructive path it has been on for years, or it can change direction as a result of lessons learned in recent decades. The ways in which humans influence the biosphere has become increasingly evident. An explosive increase in greenhouse gases has accentuated natural phenomena, such as droughts, storms, heatwaves and forest fires, leading to vast changes within ecosystems everywhere on the planet. Experts believe the biosphere is in the midst of the sixth mass extinction, primarily due to the unsustainable use of land, water, energy, and the impacts of climate change (Cowie, Bouchet & Fontaine, 2022). The quality of fresh water is decreasing rapidly due to its pollution. Plastic specifically has spread everywhere over the world, even in areas humans have never visited before (National Geographic, n.d.). And recently, the first microplastics have been found to be circulating in human blood (Carrington, 2022). And now, even outside of Earth, a layer of orbital debris is starting to become a less permeable layer of human rubbish. This layer is seen to be growing every time a satellite or a rocket launches, and nobody is trying to find ways to clean it up (NASA, 2021).

In other words, there are enormous problems that need to be faced in the coming years. What has become clear is that humans, and especially the capitalist societies of developed countries, must change their lifestyles and adapt to the needs of the planet. However, changing human behaviour is a long process that cannot be done overnight, and this should be taken into account in policies concerning biodiversity, intensive bioindustry and climate change. For example, instead of relying on governments to deal with all the problems that may arise, society should anticipate, imagine all possible scenarios and prepare plans to mitigate their long-term effects. That means that people should not remain arrogant, but rather, should be informed and educated to spark up debate across society. Within the context of antimicrobial resistance, this means that healthcare officials should educate people on the dangers and risks of using antimicrobials. All around the world, people should realise that taking antibiotics at the simplest symptoms of anything is not sustainable, nor useful. Farmers all around the world should be taught that feeding their animals the maximum amount of antibacterial and antivirals to prevent infections will not keep the herd healthier.

Figure 4: A big global change needs to be made to solve all of the problems that plague the world (Lueddeke, 2021).

In this 101 series, the problem of antimicrobial resistance has been covered on many levels. First, the process of resistance, in combination with evolution and natural selection, has been elucidated, after which it was discussed in detail how bacteria, viruses and fungi actually become resistant to drugs used to treat these organisms. In the third article, the global differences and similarities of the problem were discussed, both in terms of causes and consequences, after which the focus turned to what resistant infections mean in the clinic. In the previous article, one can read about promising techniques and interventions that may prove to be breakthroughs in fighting resistant pathogens.

Although it remains difficult to predict the future, it is sure that antimicrobial resistance will increase its burden on society in the near-future. All in all, humanity as a whole needs to make decisions and changes, in order to mitigate the threat that antimicrobial resistance and a palette of other enormous global problems pose.

Bibliographical References

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Visual Sources