Antibiotic resistance, stewardship, and consumption
Authors: Cédric Abat, Philippe Gautret, Didier Raoult
Journal: The Lancet Planetary Health (2019)

We read with interest the work of Peter Collignon and colleagues,1Collignon P Beggs JJ Walsh TR Gandra S Laxminarayan R Anthropological and socioeconomic factors contributing to global antimicrobial resistance: a univariate and multivariable analysis.Lancet Planet Health. 2018; 2: e398-e405Summary Full Text Full Text PDF PubMed Scopus (293) Google Scholar in which the authors studied the effect of cofactors on the prevalence of precise antibiotic resistance profiles. Amongst their discoveries, the authors identified inverse relationships between global antibiotic consumption and the antibiotic resistance profiles that they studied. Although some of the links they published remain for us unclear, these inverse relationships between antibiotic resistance and antibiotic consumption confirm our Alice's living croquet theory.2Raoult D Alice's living croquet theory.Int J Antimicrob Agents. 2016; 47: 249Summary Full Text Full Text PDF PubMed Scopus (16) Google Scholar Indeed, this theory, based on the game croquet illustrated in the novel Alice in Wonderland, suggests that it is impossible to predict the future for living beings, as the living world is governed by several factors and interactions that no single mathematical model can explain. As this tenet can also be applied to antibiotic resistance, all simplifications including stating that antibiotic consumption in humans and animals favours the emergence of antibiotic resistance appear inherently wrong. First, antibiotic resistance is not new and might result from a long history of intermicrobial conflict.3Rolain J-M Abat C Jimeno M-T Fournier P-E Raoult D Do we need new antibiotics?.Clin Microbiol Infect. 2016; 22: 408-415Summary Full Text Full Text PDF PubMed Scopus (66) Google Scholar Second, in patients hospitalised at our institution for bacteraemia and cerebrospinal fluid infections, the proportion of infections caused by invasive meticillin-resistant Staphylococcus aureus decreased from 31·0% in 2001 to 12·8% in 2015, which occurred without any screening or isolation procedures being performed.3Rolain J-M Abat C Jimeno M-T Fournier P-E Raoult D Do we need new antibiotics?.Clin Microbiol Infect. 2016; 22: 408-415Summary Full Text Full Text PDF PubMed Scopus (66) Google Scholar We recently identified in low-income and middle-income countries that the increases in antibiotic consumption inversely paralleled deaths caused by Streptococcus pneumoniae and Haemophilus influenzae, leading us to warn against the inclination to limit antibiotic consumption in these countries.5Abat C Gautret P Raoult D Benefits of antibiotics burden in low-income countries.Proc Natl Acad Sci. 2018; 115: e8109-e8110Crossref PubMed Scopus (9) Google Scholar The results from Collignon and colleagues1Collignon P Beggs JJ Walsh TR Gandra S Laxminarayan R Anthropological and socioeconomic factors contributing to global antimicrobial resistance: a univariate and multivariable analysis.Lancet Planet Health. 2018; 2: e398-e405Summary Full Text Full Text PDF PubMed Scopus (293) Google Scholar support our conclusions. We declare no competing interests Anthropological and socioeconomic factors contributing to global antimicrobial resistance: a univariate and multivariable analysisReduction of antibiotic consumption will not be sufficient to control antimicrobial resistance because contagion—the spread of resistant strains and resistance genes—seems to be the dominant contributing factor. Improving sanitation, increasing access to clean water, and ensuring good governance, as well as increasing public health-care expenditure and better regulating the private health sector are all necessary to reduce global antimicrobial resistance. Full-Text PDF Open AccessAntibiotic resistance, stewardship, and consumptionPeter Collignon and colleagues1 aim to improve understanding of global antibiotic resistance drivers by quantifying associations between antibiotic resistance and potential contributing factors. A recent systematic review including 565 studies primarily reporting patient-level data found that antibiotic exposure, underlying disease, and invasive procedures had the greatest evidence of being antibiotic resistance drivers.2 Given the small evidence base for the role of community factors,2 we fully concur with Collignon and colleagues about the importance of considering such factors in the spread of antibiotic resistance. Full-Text PDF Open AccessAntibiotic resistance, stewardship, and consumption – Authors' replyWe agree with Koen B Pouwels and colleagues, that association does not mean cause and effect. In our paper, we acknowledged limitations in using national-level data on antibiotic usage and resistance patterns, and that antibiotic use is an important factor in antibiotic resistance. We note that our results, which show that the spread of resistant bacteria by anthropological factors is at least as important as antibiotic use, are supported by other studies.1 Full-Text PDF Open Access