Understanding Antimicrobial Resistance (AMR)
The concept of antimicrobial resistant or AMR mainly refers to the idea where the different types of microorganisms like bacteria, fungi, viruses and parasites are able to adapt and grow in spite of the presence of the medicines that can impact them. In case of AMR, the microorganisms are not at all affected although adequate medicines are applied as the microorganism are evolved against the particular medicines and as a consequence the drug is unable to affect the microorganisms (Hu, Logue and Robinson 2020). In this context, it can be reported that one of the most common cases of AMR is the Methicillin resistance in Staphylococcus aureus (MRSA) and it is responsible for a higher numbers of mortality cases every year around the world (Dadgostar 2019).
The use of the antibiotics has changed and revolutionized the practice of the medicines in the health care sectors by enabling the breakthroughs in the area of clinical medicines like surgical processes, organ transplant, myeloblative chemotherapy regimens. In this context, it is essential to mention the fact that the infectious diseases can longer be treated with the antibiotics due to the presence of AMR in near future. In the study of Dadgostar (2019) the researchers had correctly identified the association between the AMR and the health care sector including the health care costs and the overall health outcomes of the individuals as well. In this current study, the researcher mentioned that more than 2 million people in US are affected by the antibiotic-resistant illnesses in each year, leading to a minimum of 23,000 deaths per year (Dadgostar 2019). Moreover, the onset of the AMR diseases among the human being is also altering the immune system of the individuals to fight against the different complications among the vulnerable patients receiving different life saving therapies including the dialysis, surgery, chemotherapy and joint replacement (Nathan 2020). The revolution of the antibiotic use in the field of health care sectors has hastened the hands of the health care professionals in terms of prescribing the first line drugs and as a results the health care professionals have to use the last-resort classes of drug like polymyxins and carbapenems that are not easily available in the developing countries and along with this it is also very crucial to mention that those medicines have a lot of side effects and have higher costs that lead to death of the people of lower economic condition people (Marston et al. 2016). Thus, it can be reported that, in this way, the AMR is contributing indirectly to the mortality of the people of the country. It was reported that, currently, 4.1 per cent of new tuberculosis cases are reported to be multidrug-resistant in nature and the study also anticipated that in the countries like India, Russia, the Philippines, and South Africa will have a higher number of multidrug resistant TB cases by the end of 2040 (Dadgostar 2019).
In the paper, the researcher Dadgostar (2019) mentioned a few common causes responsible for accelerating the rate of AMR. In this context, the researcher identified that the overuse and the misuse of the antibiotics is one of the reasons of higher rate of AMR around the world. The use of the antibiotics even when they are not at all required is a common phenomenon among in the low and middle income countries due to the lack of knowledge about the proper use of antibiotics and this ultimately leads to the onset of AMR. This reason of AMR onset identified by Dadgostar (2019) was also supported by the study findings of Chen et al. (2021). In the study, the researchers reported to examine the association between the misuse of the antibiotics specifically in the low and middle income countries and the occurrence of the antimicrobial resistance conditions and thus the study aimed to evaluate the knowledge level of the medical students residing in Mali about the use of the antibiotics. The study utilized a cross-sectional survey design including the 446 medical students reading in public medical university. The data were collected by using the questionnaire followed by the data collection process by SPSS software. The study results reported that the average knowledge score of the students was 4.12 out of 10 and 391 students reported about the occurrence of the self-limiting diseases in the last year among them 197 asked for a doctor’s opinion and 151 students treated themselves. Among the 197 students, 81.2 per cent of the students were treated with antibiotics and on the other hand, among self-treated students 80.1 per cent used antibiotics that indicated about the fact that in either way the use of antibiotics was high among the medical students and it might contribute to the higher rate of AMR. The overuse of the antibiotics behind the reason of high rate of AMR was also supported by the study of Kardos (2017) as in the study the researcher reported that the overuse and the misuse of the drugs are directly associated with the development of the AMR. Along with this, the researcher also mentioned the fact that the patients contribute to the higher rate of AMR due to the incorrect dosing and alterations of the course durations that contradicted the findings of Dadgostar (2019) as in the study the researcher mentioned that the physicians unnecessarily prescribe the long course of antibiotics and in some cases, it was also noted that financial incentives also encouraged the doctors to prescribe antibiotics unnecessarily.
AMR and Its Impact on Healthcare Outcomes
Another reason of higher AMR rate identified by Dadgostar (2019) is the agricultural use of antibiotics as it is considered as one of the major contributors of the AMR in the human beings as well. For example, it can be mentioned that almost 80 per cent of the antibiotics sold to the individuals are directly applied to the food eaten by the animals and thus when they are consumed by the human beings the antibiotics are deposited to the body of the human beings. Apart from that, animals are also given different antibiotics to prevent them from different diseases and consuming those animals leads to deposition of the antibiotics in the human body as well. The use of antibiotics in the agricultural field and the occurrence of AMR is also supported by the study of Kasimanickam, Kasimanickam and Kasimanickam (2021) as in this study the researchers highlighted the role of antibiotic use in agriculture and the onset of AMR as it is reported that the antimicrobials are mostly used in the food animal production and for enhancing the production and the efficiency of the livestock the antimicrobials are used randomly which eventually contribute to the development of AMR. On the contrary to this, the study findings of Ashfaq et al. (2020) stated that the use of the antibiotics has enhanced in case of both agriculture and the veterinary sector for enhancing the breeding of stock and livestock as a part of the therapeutic and non-therapeutic use of the antibiotics which eventually contributed to the higher rate of AMR among the human beings.
Another factor identified by Dadgostar (2019) is the income level of the individuals which encourages the individuals to eat more protein and to meet the needs of the foods the application of the antibiotics is also enhanced. It is reported that the significant rise of the worldwide antibiotic use is basically due to the excessive consumption of the antibiotics specifically in the developing countries that is resultant of the increasing incomes of the people as well. Moreover, the rise in the growth domestic products or GDP in the lower- and middle-income countries of the world also have positive correlation between the antibiotic consumption of those countries as well. This finding of Dadgostar (2019) was also supported by the study of Van Boeckel et al. (2015) in which the researchers reported that the due to the improvement of the socioeconomic status of the people the quality of life of the people is also improved which eventually encourage them to consume more animal proteins that may require for the business personnel to apply huge amount of antibiotics to maintain the health of the livestocks in the developing countries as well.
The improvement of the travel routes for human beings and the animals due to the advancement of the transportation system it has become easy to disseminate the antimicrobial resistance in different countries of the world. After getting exposed to the resistant pathogens, the travellers are likely to return colonized and infected the resistant microbes after returning to their country as well. In the study of Frost et al. (2019) the researchers also reported the association between the international travelling and the development of the AMR among the travellers due to the transmission of the highly resistant strains of the microorganisms in the body of the travellers.
Overuse and Misuse of Antibiotics Leading to Higher AMR Rates
The research result of Dadgostar (2019) also identified the economic impact of AMR and it was reported that the cost of the AMR is very high irrespective of the country location and for example, the estimation provided by the CDC had been mentioned by Dadgostar (2019). As per the information of CDC, it was reported that the overall cost of antimicrobial resistance is $55 billion in each year in the United States that included about $35 billion for loss of productivity and $20 billion for cost of the health care sectors. In this context, it can be reported that the annual global GDP may decrease by almost 1 per cent and it is estimated that there will be loss of 5 per cent to 7 per cent in the developing countries by the end of 2050 that is almost $100 to $210 trillion. Ahmad and Khan (2019) also had raised their concerns for the pandemic of AMR across the different countries of the world and eventually it has become a serious threat to the public health due to its rising costs. The problem of AMR is not at all bounded to the economic impact rather it has equally impacted the medical and social perspective which contradicted the findings of Dadgostar (2019). The impact of AMR is catastrophic as it includes the health care providers, patients, pharmaceutical organizations and the national and international policy makers. The impact of the AMR is also associated with the medical poverty trap in case of the lower and middle income country people. The result of the Dadgostar (2019) did not mention about the medical treatment costs of the AMR specifically in the lower and middle income country people and in the study of Founou, Founou, and Essack (2017) the researchers reported about the treatment costs due to the AMR in the developing countries of the world. In this systematic review and the meta-analysis, the researchers aimed to assess the economic as well as the clinical impact of the antibiotic use in the developing countries and the existing literatures were selected from the Medline via PubMed and Web of Sciences published between the January 01, 2000 to December 09, 2016. The study results reported that among the 27033 patients identified from the 40 studies after considering the inclusion and exclusion criteria of the study, it was reported that the mortality was also associated with the resistant nature of the bacteria in a statistically significant manner. The presence of ESKAPE pathogens was associated with the higher medical treatment costs of the patients having the non-communicable disease related morbidities and they were marked as the high-risk population as well. This finding of higher burden of costs on the people of the developing countries was aligned with the findings of Dadgostar (2019) as in this the study the researcher reported that the presence of this disparity and the onset of poverty trap due to the cost of the AMR treatment would also evident the disparities between the developing and the developed countries of the world.
Association Between Antibiotics Misuse and Antimicrobial Resistance
Along with the direct monetary effect, the AMR also has secondary economic burden on the people and in this context it can be reported that this process generally takes place when the antibiotics generally used for lowering risks of pathogenic infections cannot be used due to the presence of AMR and this eventually challenge the treatment process by lowering the success rate of different surgical process and this ultimately enhance the health care costs leading to greater burden to the health care system of the country as well (Dadgostar 2019). Moreover, the global trade would also be affected due to the AMR as like human beings the AMR will also affect the animals in terms of morbidity and mortality. The enhancement of the resistance to microbials will also make the treatment process difficult for the veterinary doctors and this will eventually affect the productions and trade of livestock leading to the price increment of the protein due to the reduction in protein sources like meat, milk, egg and the information of the research of Dadgostar (2019) also revealed that this effect will be higher in case of the developing countries mainly.
While discussing about the surveillance system for AMR, it can be reported that the Dadgostar (2019) did not mention about any surveillance system for AMR and thus it can be marked as one of the weaknesses of the current research. However, there are a few common tools monitoring the AMR. In the study of Nielsen et al. (2020) the researchers had reported about the fact that the integrated AMR surveillance programs need the regular evaluation so that they can serve the purpose properly and this will also help the to strengthen the use of the system in the clinical care setting leading to effective treatment as well. In this current study the researchers aimed to identify the effectiveness of the evaluation tools associated with AMR so that the proper tool can be chosen as per the requirement. In this regard, it can be reported that to assess three different tools and they were (a) AMR-PMP—the Progressive Management Pathway tool on AMR processed by the Food and Agriculture Organization (FAO) of the United Nations, (b) SURVTOOLS developed in an FP7-EU project ‘RISKSUR’ and (c) NEOH developed by the EU COST Action ‘Network for Evaluation of One Health’. The study results reported that the AMR-PMP and NEOH are most appropriate tool in case of thorough assessment of the whole surveillance system. For enhancing the support services for the AMR, the World Health Organization has launched a program named GLASS or Global AMR Surveillance System. According to the report of World Health Organization (2021) it was reported that the after the implementation of this program, 68 countries around the world had submitted the findings associated with BSI, 37 for gastrointestinal infections, 47 UTI and 27 for gonorrhoea. Over the year, more countries had enrolled for this surveillance system as a part of the improvement of the AMR status for that particular country or region as well (World Health Organization 2020).
Agricultural Use of Antibiotics and AMR
The health care professionals may face a few ethical issues while treating the patients having the problems of AMR and in the study of Dadgostar (2019) the researcher did not identify the ethical issues associated with AMR. According to the study of Oerther and Oerther (2020) the researchers reported that the registered nurses primarily face three ethical challenges associated with AMR. Firstly, the nurse practitioner must have to find out the safest ways to protect and promote the health and well being of the patients to safeguard the patients from the possible threats raised by AMR. While considering, its impact on the population health, it can be reported that in case of the registered nurse fails to do so the adverse health outcomes even fatal outcomes may occur which eventually enhance the burden of the treatment as well. The second ethical concern that the nurse may face is associated directly with the treatment process as along with time the amount of AMR increases and simultaneously the efficiency of existing antimicrobic drugs continues to decrease. During that time the nurse practitioners should take required actions so that the health and wellbeing of the patients can be restored (Oerther and Oerther 2020). Failing to do so can significantly affect the satisfaction level of the patients in the hospital care setting as well (Boiko, Gulliford, and Burgess 2020). The third ethical issue that the nurse practitioners may face is associated with the balancing of moral interest of the different people including the upcoming generations during the determining and vindicating a sequence of action that “normally” would not be ethically tolerable such as refusing to prescribe an antimicrobial therapy and depending on the expectation that the infection is self-limiting in nature (Oerther and Oerther 2020). In this regard, it is also very crucial to mention that the for conserving the availability and the efficacy for the future use of the drug or medicine must not compromise the needs of current patients as it can impact the treatment outcomes towards a negative manner. Hence, the nurse practitioners should take required actions to ensure the health, safety and the safe treatment outcomes of different patients. Apart from that, the government of the particular country should also consider the interests of the whole population including the people of lower socioeconomic group during the formation of the AMR policy (Parsonage et al 2020).
As a part of the future research after critiquing the study of Dadgostar (2019), further research can be done to minimize the adverse impacts of AMR in terms of the societal and economic perspective so that the strategic harmony and the operational planning can be maintained in a proper manner. Apart from that, the future research processes can also focus on the different strategies for lowering the impact of AMR and also should try to improve the existing strategies to control the problem as well.
As a part of the actions to improve health care outcomes for AMR, preventive strategies can be recommended. One of the main sources of AMR is international travel and thus screening the travellers can be an effective way to improve the outcomes of AMR in terms of preventing the spread. In the study of Arieti et al. (2020) the researchers reported about the effectiveness of the antimicrobial resistance travel tool that is an interactive evidence based educational tool to prevent the spread of antimicrobial resistance spread through the travellers. The study also reported about the fact that this particular tool can provide a lot of essential information to the health care professionals that can help them to implement and strengthen the infection control measures and for travellers it will serve as the awareness program regarding the AMR before travelling to a particular country. The effectiveness of the education program for improving the knowledge level about AMR was also supported by the study of Price et al. (2018) as in this study the researcher reported that behavioural changes among the public and improvement of the knowledge level about AMR can improve the health-related outcomes correlated with AMR. In this systematic review study, the researchers searched five databases for finding the relevant studies published between 2000 to 2016. The study results reported that the use of the mass media campaign for increasing the awareness level of the general population were most common among the identified interventions. The effectiveness of the mass media campaign was also supported by Chaintarli et al. (2016) as in this current study the researchers reported that a new awareness drive named Antibiotic Guardian (AG) was introduced in the United Kingdom as a part of the 2014 European Antibiotic Awareness Day plans along with an internet-based pledge scheme to upsurge promise from medical professionals and associates of the public to lessen antimicrobial resistance (AMR). The researchers reported to conduct the survey among 2478 AGs. The study result revealed that the half of the study participants gathered more knowledge about the AMR and the people who were confuse about AMR had reported about greater knowledge level after the program implementation (OR = 3.10, 95 % CI: 1.36-7.09). The participants also developed a sense of responsibility towards tackling AMR after the awareness program (growing to 70.5 per cent at post-campaign from 58.3 per cent of participants during pre-campaign.).
The Role of Antibiotic Use in Agriculture on the Onset of AMR
Another important strategy to improve the health outcomes AMR is associated with the development of the government policies. In every county of the world specifically the developing countries, the government must consider the issue of AMR as a serious public health issue and thus the government along with the other stakeholders should play a crucial role to combat the issue. The government should put policies and the regulations in proper place to enforce the practical access and utilization of antimicrobials (Hobæk and Lie 2019). The government should also provide training to the health care professionals to improve their understanding about AMR. Moreover, during the making of different policies related to the AMR, it can be reported that the government should make relevant policies and legislation to prevent the production and delivery of sub-standard medicines and resources to apply these policies and to impose penalties to defaulters the governmental officers must be engaged. Furthermore, governments must address the distribution of antimicrobials without a prescription and make it illegal for unlicensed and unqualified individuals to dispense medications. There is also a need to educate the public about the dangers of AMR to public health (Ayukekbong, Ntemgwa and Atabe 2017).
Conclusion
From the above analysis of the existing literatures, it can be stated that the issue of AMR is a serious public health issue that must be addressed on a basis of priority. In case of AMR, the microorganisms are not at all affected although adequate medicines are applied as the microorganism are evolved against the particular medicines and the drug becomes non-functional. The revolution of the antibiotic use in the field of health care sectors has hastened the hands of the health care professionals in terms of prescribing the first line drugs and as a result the health care professionals have to use the last-resort classes of drug. The overuse and the misuse of the antibiotics is one of the reasons of higher rate of AMR around the world. The use of the antibiotics even when they are not at all required is a common phenomenon among in the low and middle income countries. The overuse and the misuse of the drugs are directly associated with the development of the AMR. Animals are also given different antibiotics to prevent them from different diseases and consuming those animals leads to deposition of the antibiotics in the human body as well. The antimicrobials are mostly used in the food animal production and for enhancing the production and the efficiency of the livestock the antimicrobials are used randomly which eventually contribute to the development of AMR. The pandemic of AMR across the different countries of the world eventually has become a serious threat to the public health due to its rising costs. The problem of AMR is not at all bounded to the economic impact rather it has equally impacted the medical and social perspective. For enhancing the support services for the AMR, the World Health Organization has launched a program named GLASS or Global AMR Surveillance System. The health care professionals may face a few ethical issues while treating the patients having the problems of AMR. In case of the registered nurse fails to do so the adverse health outcomes even fatal outcomes may occur which eventually enhance the burden of the treatment as well. The second ethical concern that the nurse may face is associated directly with the treatment process as along with time the amount of AMR increases and simultaneously the efficiency of existing antimicrobic drugs continues to decrease. As a part of the actions to improve health care outcomes for AMR the use of the education program, government policy formation and its implementation and awareness programs for the public can be mentioned and recommended.
References
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