The United Nations and the Urgent Need for Coordinated Global Action in the Fight Against Antimicrobial Resistance

Rising rates of antimicrobial resistance (AMR) increasingly threaten our ability to provide effective care for life-threatening infections. If this trend goes unchecked, annual deaths attributable to AMR are predicted to reach 10 million by 2050 and will outpace those from cancer, diabetes, diarrheal diseases, and automobile accidents (1). World leaders now acknowledge what infectious diseases physicians have argued for over a decadeinaction is not an option. On 21 September 2016, the United Nations (UN) will hold a high-level meeting on AMR, which is a historic opportunity to drive internationally coordinated efforts to address this urgent issue. Antimicrobial resistance is a complex problem requiring a multifaceted solution. Several expert bodies agree that well-coordinated, robustly funded efforts are needed to stem inappropriate antibiotic use in humans and animals; incentivize research and development (R&D) of new antimicrobial drugs, diagnostic tests, and vaccines; and conduct surveillance to identify evolving needs and evaluate interventions. World Health Day in 2011 was dedicated to AMR, and the Infectious Diseases Society of America released a set of recommendations for combating AMR focused on stewardship, R&D incentives, surveillance, and data collection that have since been echoed by key experts (2). Subsequently, the Centers for Disease Control and Prevention (CDC), World Health Organization, and Presidential Advisory Council on Combating Antibiotic-Resistant Bacteria have all issued similar calls to action (35). Now the UN is poised to act. Although individual nations have taken steps to address AMR, a global problem requires a global solution. High rates of inappropriate antibiotic use in hospitals, the community, and animals are key drivers of the crisis. A recent review of outpatient antibiotic-prescribing practices in the United States found that approximately 13% of all visits (about 154000000 per year) resulted in an antibiotic prescription, and about 30% of these were deemed unnecessary (6). Evidence-based strategies to decrease unnecessary antibiotic prescription for respiratory infection have been successfully implemented by the CDC and must be expanded (7). Many countries are taking steps to improve antibiotic-prescribing practices. In the United States, the Centers for Medicare & Medicaid Services has recently generated 2 proposals requiring antibiotic stewardship programs in hospitals and long-term care facilities. The UN can build on these efforts to foster a global commitment to antibiotic stewardship by providing resources to increase prescriber oversight of antimicrobial drug use while ensuring equitable access. Infection prevention is also critical: Keeping people healthy is the best way to avoid antibiotic use. As some people have suggested, the UN could, through various means, set global targets for reduced antibiotic use (8). Antimicrobial stewardship in animal health and agriculture must be promoted because antibiotic use contributes to the emergence of resistant bacteria and their spread to humans. Although many countries are curbing antibiotic use for growth promotion and routine disease prevention in livestock, inappropriate antibiotic use persists worldwide (5). The UN can lead efforts to help ensure uniform adoption of best conservation practices. Investment in antibiotic R&D is also critical. Our best efforts can slow AMR but not stop it. We need a robust, renewable pipeline of new antibiotics for today and for unknown future threats. Despite U.S. efforts by the Biomedical Advanced Research and Development Authority and National Institute of Allergy and Infectious Diseases and through the Generating Antibiotic Incentives Now Act, along with European efforts by the Innovative Medicines Initiative and others, antibiotic R&D has failed to keep pace with patient needs. Although the appropriateness of specific legislation incentivizing pharmaceutical development of new antibiotics has been controversial, we believe they are difficult and costly to develop and priced inexpensively given their societal value. Antibiotics are used for a shorter duration than most drugs and held in reserve to protect their utility; we therefore view them as less economically viable investments than other drugs. As the Presidential Advisory Council on Combating Antibiotic-Resistant Bacteria, Innovative Medicines Initiative, and others have suggested, publicprivate partnerships could bring together intellectual capital and financial resources to tackle the challenges of antibiotic R&D (5). The UN is uniquely positioned to drive global collaboration and facilitate the multinational teamwork needed for such an effort. Obtaining global data on antimicrobial use and resistance patterns in humans and animals is critical to fully understand AMR and evaluate interventions. Countries vary significantly on how to monitor antibiotic use. The European Surveillance of Antimicrobial Consumption Network makes robust data on antibiotic use from 34 countries in the European Union publicly available. In the United States, the CDC National Healthcare Safety Network contains an antibiotic use and resistance module for collecting such data; the National Action Plan for Combating Antibiotic-Resistant Bacteria has a goal of having 95% of all acute care hospitals reporting via this module by 2020 (5). In 2013, medical leaders in India published the Chennai Declaration to guide the formulation of a national policy on antibiotic resistance, including collecting data on antibiotic use, with a goal of having total physician participation within 5 years. Unfortunately, many nations, particularly those with insufficient resources and infrastructure, do not collect and report data in a regular, meaningful way. Surveillance should include standardized monitoring of antibiotic use at institutional, regional, and country levels to allow for comparative benchmarking with updating at least every 12 months. However, this will require adequate laboratory capacity using standardized methods. A comprehensive global effort to combat AMR must also include a robust, well-trained workforce. Infectious diseases physicians play a central role by caring for patients with or at risk for infection caused by AMR pathogens, leading stewardship programs, conducting R&D of new antibiotics and diagnostics, and providing expertise in efforts designed to measure antibiotic use and resistance (1). Individual nations alone cannot solve this global problem. The discovery of a transferable colistin resistance gene, mcr-1, in China in November 2015 is particularly worrisome because colistin is a last-resort antibiotic for multidrug-resistant bacteria (9). This gene may have emerged in part because of high levels of colistin use in agricultural settings. It was soon recognized in other countries in Asia, Europe, and North Americaincluding the United States (10). The threat of AMR is grave. Too many patients are out of options and are losing their lives to once treatable infections. A high-level, coordinated global response led by the UN is vitally needed.