Antimicrobial resistance: an urgent need for a planetary and ecosystem approach
Authors: Muhammad Asaduzzaman
Journal: The Lancet Planetary Health (2018)

Our planet is rushing towards a post-antibiotic era and the global burden of antimicrobial resistance is estimated to rise to 10 million annual deaths by 2050,1de Kraker ME Stewardson AJ Harbarth S Will 10 million people die a year due to antimicrobial resistance by 2050?.PLoS Med. 2016; 13: e1002184Crossref PubMed Scopus (625) Google Scholar a figure that can substantially increase if adequate measures are not taken. Antimicrobial resistance is an ancient but complex phenomenon that emerges in response to antimicrobial exposure. The abundance of existing scientific publications on antimicrobial resistance in an environmental context supports its inclusion in the planetary health agenda. Unfortunately, antimicrobial resistance is still a public health concern and it has not been considered a priority area to work on from an ecological perspective. Ecologists and Earth scientists have not been made aware of this situation and have not been included in discussions of control strategies between public health experts and social scientists. Woolhouse and colleagues2Woolhouse M Ward M van Bunnik B Farrar J Antimicrobial resistance in humans, livestock and the wider environment.Philos Trans R Soc Lond B Biol Sci. 2015; 70: 20140083Crossref Scopus (339) Google Scholar have shown that the problem of antimicrobial resistance is analogous to climate change and have urged the development of an intergovernmental panel to address the problem. Their justification for the need of this panel is logical because of the global magnitude of antimicrobial resistance, and because of its multidisciplinary involvement in pathogenesis and prevention pathways. Currently, there are no set targets for antibiotic use or global regulations for pharmaceutical waste disposal, unlike the regulations that control the level of carbon emissions. A more integrated implementation approach should be adopted for the resource-poor settings because of the highest burden of antimicrobial resistance in low-income and middle-income countries with extensive environmental transmission.3Alvarez-Uria G Gandra S Laxminarayan R Poverty and prevalence of antimicrobial resistance in invasive isolates.Int J Infect Dis. 2016; 52: 59-61Summary Full Text Full Text PDF PubMed Scopus (48) Google Scholar The less studied but enormous impact of antibiotics on the biogeochemical processes in the ecological system, especially on the production of toxic gases such as nitrous oxide and nitrite, has been discussed by Amsaleg and Laverman.4Roose-Amsaleg C Laverman AM Do antibiotics have environmental side-effects? Impact of synthetic antibiotics on biogeochemical processes.Environ Sci Pollut Res Int. 2016; 23: 4000-4012Crossref PubMed Scopus (133) Google Scholar Another important area that should be explored is the impact of antimicrobial resistance genes reaching the Earth's critical zone, which is the outer layer of the Earth that comprises soil, air, microbial agents, water, and rock.5Zhu YG Gillings M Simonet P Stekel D Banwart S Penuelas J Human dissemination of genes and microorganisms in Earth's Critical Zone.Glob Chang Biol. 2017; (published online Dec 20.)DOI:10.1111/gcb.14003Google Scholar Further studies on the impact of antibiotic residue at chronic, environmentally relevant concentrations are important to further address the issue of antimicrobial resistance. The prioritisation of antibiotics based on their effect on ecological processes is also necessary for regulatory purposes. In their review,6Huijbers PM Blaak H de Jong MC Graat EA Vandenbroucke-Grauls CM de Roda Husman AM Role of the environment in the transmission of antimicrobial resistance to humans: a review.Environ Sci Technol. 2015; 49: 11993-12004Crossref PubMed Scopus (237) Google Scholar Huijbers and colleagues discuss the plausible transmission of clinically significant resistant organisms from the environment to human beings. Many settings can harbour resistant bacteria, including fresh water, waste water, soil, air, dust, fresh produce, meat, wildlife, and even animal manure. A review by Costello and colleagues7Costello EK Stagaman K Dethlefsen L Bohannan BJ Relman DA The application of ecological theory toward an understanding of the human microbiome.Science. 2012; 336: 1255-1262Crossref PubMed Scopus (932) Google Scholar sheds light on the link between the human microbial ecosystem and disease caused by resistant bacteria. They describe the role of community ecology on individual gut microbiota, and the influence of local environmental diversity and selection pressures on resistance. The antimicrobial effect of heavy metals exists for a longer time in the environment, acting as an additional selective pressure and worsening the effect of antimicrobial resistance.8Yu Z Gunn L Wall P Fanning S Antimicrobial resistance and its association with tolerance to heavy metals in agriculture production.Food Microbiol. 2017; 64: 23-32Crossref PubMed Scopus (90) Google Scholar All these facts establish the urgency of acknowledgement of antimicrobial resistance as a distinct discipline in planetary health. One of the major solutions to this problem involves the adoption of environmental mitigation strategies. The most effective pathway to reducing selection pressures involves removal of antibiotic residues and development of new drugs. Medicinal plants and fungi have been used widely in the past to fight human and animal pathogens and could be the key to production of new antibiotics. A review by Savoia9Savoia D Plant-derived antimicrobial compounds: alternatives to antibiotics.Future Microbiol. 2012; 7: 979-990Crossref PubMed Scopus (331) Google Scholar states that 69% of antibiotics approved between 1981 and 2006 were derived from natural plant products. Ethnopharmacology, which involves the medicinal use of plants, is one of the major alternative pathways that are still available to control antimicrobial resistance. It is obvious that the ongoing policies for prevention of antimicrobial resistance will be ineffective if no interventions are made to tackle environmental reservoirs of antibiotic resistance, such as biofilms. Over time, the magnitude of resistance will surpass the threshold level.10Wallinga D Rayner G Lang T Antimicrobial resistance and biological governance: explanations for policy failure.Public Health. 2015; 129: 1314-1325Summary Full Text Full Text PDF PubMed Scopus (20) Google Scholar In addition to doctors and veterinarians, people from multiple disciplines (eg, ecologists, Earth and marine scientists, epidemiologists, ecological and health economists, microbiologists, wildlife experts, lawyers, pharmacologists, biochemists, hydrologists, metagenomics and modelling experts, social scientists, political leaders, and community leaders) must be called to action under the platform of planetary health. An international framework convention that tackles antimicrobial resistance by adopting a more ecological public health approach and includes firm legislation and political commitment can be a way forward. I declare no competing interests.