Antimicrobial resistance: opportunity for Europe to establish global leadership
Authors: Joseph Robert Fitchett, Rifat Atun
Journal: The Lancet Infectious Diseases (2015)

Antimicrobial resistance heightens the prospect of readily curable infections becoming pathogens with pandemic potential. Although in high-income settings progress has been made to curb the rise of resistance,1European CommissionProgress report on the action plan against the rising threats from antimicrobial resistance.http://ec.europa.eu/health/antimicrobial_resistance/docs/2015_amr_progress_report_en.pdfDate: 2015Google Scholar the scarcity of new antimicrobial drugs remains a challenge. The Independent Review on Antimicrobial Resistance, launched in 2014, estimated a population reduction by 2050 of between 11 million and 444 million people in a world without effective antibiotics, and a reduction in the size of the global economy by 0·1–3·1%.2Taylor J Hafner M Yerushalmi E et al.Estimating the economic costs of antimicrobial resistance: model and results.http://www.rand.org/randeurope/research/projects/antimicrobial-resistance-costs.htmlDate: 2015Google Scholar The US Centers for Disease Control and Prevention estimates the direct costs of antimicrobial resistance at US$20 billion, with additional productivity losses of $35 billion.3Centers for Disease Control and PreventionAntibiotic resistance threats in the United States.http://www.cdc.gov/drugresistance/pdf/ar-threats-2013-508.pdfDate: 2013Google Scholar In Europe, historical estimates from 2009 suggest a direct and indirect cost of €1·5 billion.4European Medicines Agency and the European Centre for Disease Prevention and ControlThe bacterial challenge: time to react. A call to narrow the gap between multidrug-resistant bacteria in the EU and development of new antibacterial agents.http://ecdc.europa.eu/en/publications/Publications/0909_TER_The_Bacterial_Challenge_Time_to_React.pdfDate: 2009Google Scholar Notwithstanding the large discrepancies in these estimates and the wide uncertainties, the health, economic, and societal risks of antimicrobial resistance are simply too great to be ignored. Sometimes difficult to conceive in view of their ubiquity in health care, antibiotics have only been used routinely over the past 75 years. In that time, antibiotics have instrumentally shaped the quality of medicine and clinical practice that we see today. Beyond health care, antibiotics are widely used in the human food system, agriculture, and aquaculture.5Van Boeckel TP Brower C Gilbert M et al.Global trends in antimicrobial use in food animals.Proc Natl Acad Sci USA. 2015; 112: 5649-5654Crossref PubMed Scopus (1831) Google Scholar Existing strategies to address antimicrobial resistance focus on antibiotic prescriptions for human beings (both appropriate and inappropriate) and consumption by livestock. Regulation of livestock consumption is particularly challenging—in China and India alone, antibiotic consumption by livestock is expected to rise from more than 15 000 tonnes in 2010 to 40 000 tonnes in 2030.5Van Boeckel TP Brower C Gilbert M et al.Global trends in antimicrobial use in food animals.Proc Natl Acad Sci USA. 2015; 112: 5649-5654Crossref PubMed Scopus (1831) Google Scholar Whether effective mechanisms and policies can be implemented to ensure appropriate antibiotic use in livestock remains to be seen. The principle of one health will therefore be central to any progress in curbing antimicrobial resistance. Increasingly better quality data exist on the patterns of emerging antimicrobial resistance and of antibiotic usage. Europe has had success in reducing antimicrobial resistance, as documented by the European Antimicrobial Resistance Surveillance Network.6European Centre for Disease Prevention and ControlEuropean Antimicrobial Resistance Surveillance Network (EARS-Net).http://ecdc.europa.eu/en/activities/surveillance/EARS-Net/Date: 2015Google Scholar For example, cases of meticillin-resistant Staphylococcus aureus across hospitals in several countries have decreased each year after the introduction of infection control practices and local hospital guidelines. The level of success varies, however, across the 50 countries of the WHO European Region.4European Medicines Agency and the European Centre for Disease Prevention and ControlThe bacterial challenge: time to react. A call to narrow the gap between multidrug-resistant bacteria in the EU and development of new antibacterial agents.http://ecdc.europa.eu/en/publications/Publications/0909_TER_The_Bacterial_Challenge_Time_to_React.pdfDate: 2009Google Scholar, 6European Centre for Disease Prevention and ControlEuropean Antimicrobial Resistance Surveillance Network (EARS-Net).http://ecdc.europa.eu/en/activities/surveillance/EARS-Net/Date: 2015Google Scholar Ruth Kelly and colleagues7Kelly R Zoubiane G Walsh D Ward R Goossens H Public funding for research on antibacterial resistance in the JPIAMR countries, the European Commission, and related European Union agencies: a systematic observational analysis.Lancet Infect Dis. 2015; (published online Dec 18.)http://dx.doi.org/10.1016/S1473-3099(15)00350-3Google Scholar report new data to map the landscape and pattern of investment in antibacterial resistance research. Data from the European Union and the Joint Programming Initiative on Antimicrobial Resistance (JPIAMR) are included, incorporating public funding for research across 17 European countries, Canada, and Israel. The findings are revealing; between 2007 and 2013, €1·3 billion of research investment came from public sources, with two-thirds of funding earmarked for novel therapeutics, but only €12·5 million of that funding was dedicated to the environment and €25·1 million to surveillance. A further mismatch shown by the study is the substantial variability of national-level studies; the UK accounted for almost 500 of the 1208 nationally funded studies, with Canada, the second largest contributor, coordinating about 100 studies during the same period. The results of the study by Kelly and colleagues7Kelly R Zoubiane G Walsh D Ward R Goossens H Public funding for research on antibacterial resistance in the JPIAMR countries, the European Commission, and related European Union agencies: a systematic observational analysis.Lancet Infect Dis. 2015; (published online Dec 18.)http://dx.doi.org/10.1016/S1473-3099(15)00350-3Google Scholar emphasise both the shortcomings of and hope for antimicrobial research funding. However, with concerted leadership, all states in the JPIAMR network and beyond should be able to reinforce their partnership, share best practices, and change the course of the status quo. The UK's leadership to prioritise antimicrobial resistance as an important global challenge is translating into tangible action,8Howard SJ Catchpole M Watson J Davies SC Antibiotic resistance: global response needed.Lancet Infect Dis. 2013; 13: 1001-1003Summary Full Text Full Text PDF PubMed Scopus (48) Google Scholar, 9Davies SC Fowler T Watson J Livermore DM Walker D Annual report of the Chief Medical Officer: infection and the rise of antimicrobial resistance.Lancet. 2013; 381: 1606-1609Summary Full Text Full Text PDF PubMed Scopus (155) Google Scholar but the strategy has room for improvement. A coordinated, global effort combining drug resistance, antibiotic pipeline, antibiotic usage, and investment data is urgently needed. Kelly and colleagues build on the published literature10Head MG Fitchett JR Cooke MK Wurie FB Hayward AC Atun R UK investments in global infectious disease research 1997–2010: a case study.Lancet Infect Dis. 2013; 13: 55-64Summary Full Text Full Text PDF PubMed Scopus (60) Google Scholar, 11Head MG Fitchett JR Cooke MK et al.Systematic analysis of funding awarded for antimicrobial resistance research to institutions in the UK, 1997–2010.J Antimicrob Chemother. 2014; 69: 548-554Crossref PubMed Scopus (21) Google Scholar and provide a basis for harmonisation to begin—at the very least on a European platform. As with any research programme, the quality and completeness of data are essential, and for these analyses to be complete, a real partnership needs to exist between public, philanthropic, and private funders. These partnerships are particularly important for antimicrobial resistance because of market failure,12Cooper M Shlaes DM Fix the antibiotic pipeline.Nature. 2011; 472: 32Crossref PubMed Scopus (370) Google Scholar the dependence on the pharmaceutical industry to deliver novel therapeutic drugs, and the social imperative to allocate limited resources responsibly with a sense of urgency. Furthermore, research and surveillance needs to be expanded beyond Europe, the USA, and Canada for antimicrobial resistance to be adequately controlled. With antibiotic sales data predicting influenza-like illness in the USA,13Polgreen PM Yang M Laxminarayan R Cavanaugh JE Respiratory fluoroquinolones use and influenza.Infect Control Hosp Epidemiol. 2011; 32: 706-709Crossref PubMed Scopus (22) Google Scholar early point-of-care diagnostics for overlapping clinical syndromes should be a priority area, particularly in low-income and middle-income settings. The global scientific and health policy communities must rise to the challenge of antimicrobial resistance (and opportunity) to develop resilient health systems for effectively managing resistance, redistribute collaborative research studies, and realign investments across countries. The human and economic cost of playing catch up is simply too great a risk to bear. We declare no competing interests. Public funding for research on antibacterial resistance in the JPIAMR countries, the European Commission, and related European Union agencies: a systematic observational analysisThis was the first systematic analysis of research funding of antibacterial resistance of this scale and scope, which relied on the availability and accuracy of data from organisations included. Large variation was seen between countries both in terms of number of projects and associated investment and across the six priority topics. To determine the future direction of JPIAMR countries a clear picture of the funding landscape across Europe and Canada is needed. Countries should work together to increase the effect of research funding by strengthening national and international coordination and collaborations, harmonising research activities, and collectively pooling resources to fund multidisciplinary projects. Full-Text PDF Open AccessGlobal leadership against antimicrobial resistance ought to include developing countriesAntimicrobial resistance is a universal problem and it should be tackled globally. The proportion of antibiotic-resistant organisms has increased in the USA, Europe, and Canada over the past decade. The concept of public funding to combat antibiotic resistance across 19 countries and at European Union level through the Joint Programming Initiative on Antimicrobial Resistance is promising. The notion that Europe could take the lead in combatting antimicrobial resistance, proposed by Joseph Fitchett and Rifat Atun in The Lancet Infectious Diseases,1 should be taken seriously. Full-Text PDF