Estimating the impact of antimicrobial resistance
Authors: Nobuaki Matsunaga, Kayoko Hayakawa
Journal: The Lancet Global Health (2018)

Combatting antimicrobial resistance has been recognised as a priority for global public health. In 2015, WHO issued a global action plan on antimicrobial resistance and urged each country to formulate its own plan.1WHOGlobal action plan on antimicrobial resistance.http://www.who.int/antimicrobial-resistance/global-action-plan/enDate: 2015Date accessed: June 19, 2018Google Scholar According to WHO, information about antimicrobial resistance, such as its incidence, prevalence, and geographical distribution, is inadequate and, therefore, urgently needed.1WHOGlobal action plan on antimicrobial resistance.http://www.who.int/antimicrobial-resistance/global-action-plan/enDate: 2015Date accessed: June 19, 2018Google Scholar O'Neill's 2014 report2O'Neill J Review on antimicrobial resistance: tackling a crisis for the health and wealth of nations.https://amr-review.org/sites/default/files/AMR Review Paper - Tackling a crisis for the health and wealth of nations_1.pdfDate: 2014Date accessed: June 19, 2018Google Scholar presented numerous economic and epidemiological estimates related to antimicrobial resistance, including number of deaths attributable to antimicrobial-resistant infections; these numbers included deaths due to tuberculosis, malaria, and HIV. The report mentioned possible limitations of the estimates resulting from poor reporting and surveillance.2O'Neill J Review on antimicrobial resistance: tackling a crisis for the health and wealth of nations.https://amr-review.org/sites/default/files/AMR Review Paper - Tackling a crisis for the health and wealth of nations_1.pdfDate: 2014Date accessed: June 19, 2018Google Scholar However, the report did not provide detailed methods on how these numbers were calculated, and it is likely that numbers were underestimated because the incidence of infections caused by antimicrobial-resistant organisms from the European Antimicrobial Resistance Surveillance Network (EARS-Net) was used to estimate the number of resistant infections in countries not in EARS-Net. In The Lancet Global Health, Elizabeth Temkin and colleagues3Temkin E Fallach N Almagor J et al.Estimating the number of infections caused by antibiotic-resistant Escherichia coli and Klebsiella pneumoniae: a modelling study.Lancet Glob Health. 2018; 6: e969-e979Summary Full Text Full Text PDF PubMed Scopus (64) Google Scholar calculate worldwide estimates of the number and incidence per million population of bloodstream infections and serious inpatient infections (including bloodstream infections) caused by third-generation cephalosporin-resistant and carbapenem-resistant Escherichia coli and Klebsiella pneumoniae in 2014. These estimates are highly anticipated considering the global spread of extended-spectrum β-lactamase-producing organisms, as well as carbapenem-resistant Enterobacteriaceae.4Arcilla MS van Hattem JM Haverkate MR et al.Import and spread of extended-spectrum β-lactamase-producing Enterobacteriaceae by international travellers (COMBAT study): a prospective, multicentre cohort study.Lancet Infect Dis. 2017; 17: 78-85Summary Full Text Full Text PDF PubMed Scopus (256) Google Scholar, 5van Duin David Doi Yohei The global epidemiology of carbapenemase-producing Enterobacteriaceae.Virulence. 2017; 8: 460-469Crossref PubMed Scopus (470) Google Scholar, 6ResistanceMapThe Center for Disease DynamicsEconomics & PolicyAntibiotic resistance.https://resistancemap.cddep.org/AntibioticResistance.phpDate accessed: July 30, 2018Google Scholar The authors first calculated a uniform rate of serious infections caused by antibiotic-susceptible E coli and K pneumoniae using data from 17 countries (mainly European countries included in EARS-Net and the Central Asian and Eastern European Surveillance of Antimicrobial Resistance). They then used this rate, as well as country-specific population sizes and resistance levels, to estimate the number of resistant infections in 193 countries. Heterogeneity in the data was the major challenge in calculating the estimates. In a few Asian countries, resistance levels are much higher than in European countries.6ResistanceMapThe Center for Disease DynamicsEconomics & PolicyAntibiotic resistance.https://resistancemap.cddep.org/AntibioticResistance.phpDate accessed: July 30, 2018Google Scholar Also, the quality of the data on the level of resistance in each country varied and was fairly low in some Asian and African countries. To address this issue, the authors used not only an additive model but also three replacement models (25%, 50%, and 75%), and stratified results on the basis of degree of certainty about the estimates from each country. The authors estimated that third-generation cephalosporin-resistant E coli and K pneumoniae caused 6·4 million (interval estimate 3·5–9·2; additive model) or 4·6 million (2·5–6·6; 50% replacement model) bloodstream infections in 2014. Carbapenem-resistant strains were estimated to have caused 0·5 million (0·3–0·7; additive model) or 0·4 million (0·2–0·6; 50% replacement model) bloodstream infections. As the authors stated in their discussion, there were a few concerns regarding the methods used in the study, particularly associated with "use of a single incidence of serious infections caused by susceptible E coli and K pneumoniae for all countries",3Temkin E Fallach N Almagor J et al.Estimating the number of infections caused by antibiotic-resistant Escherichia coli and Klebsiella pneumoniae: a modelling study.Lancet Glob Health. 2018; 6: e969-e979Summary Full Text Full Text PDF PubMed Scopus (64) Google Scholar when multiple factors could affect the actual incidence. Nevertheless, the detailed description of the calculation process in appendix 1 of this manuscript will help facilitate similar research and likely improve approaches to estimating the impact of antimicrobial resistance. The data presented in this study might be used as a foundation for future research and represent an important step toward enhancing and prioritising actions against antimicrobial resistance worldwide. We declare no competing interests. Prevalence of dyslipidaemia among adults in Africa: a systematic review and meta-analysisThe prevalence of dyslipidaemia is high in the general adult population in Africa. Ongoing efforts to reduce cardiovascular diseases in Africa should integrate effective detection and treatment of dyslipidaemia. Full-Text PDF Open Access