The Lancet Infectious Diseases Commission
Antibiotic resistance—the need for global solutions

https://doi.org/10.1016/S1473-3099(13)70318-9Get rights and content

Summary

The causes of antibiotic resistance are complex and include human behaviour at many levels of society; the consequences affect everybody in the world. Similarities with climate change are evident. Many efforts have been made to describe the many different facets of antibiotic resistance and the interventions needed to meet the challenge. However, coordinated action is largely absent, especially at the political level, both nationally and internationally. Antibiotics paved the way for unprecedented medical and societal developments, and are today indispensible in all health systems. Achievements in modern medicine, such as major surgery, organ transplantation, treatment of preterm babies, and cancer chemotherapy, which we today take for granted, would not be possible without access to effective treatment for bacterial infections. Within just a few years, we might be faced with dire setbacks, medically, socially, and economically, unless real and unprecedented global coordinated actions are immediately taken. Here, we describe the global situation of antibiotic resistance, its major causes and consequences, and identify key areas in which action is urgently needed.

Section snippets

The rise of resistance

The decreasing effectiveness of antibiotics in treating common infections has quickened in recent years, and with the arrival of untreatable strains of carbapenem-resistant Enterobacteriaceae, we are at the dawn of a postantibiotic era.1 In high-income countries, continued high rates of antibiotic use in hospitals, the community, and agriculture have contributed to selection pressure that has sustained resistant strains,2 forcing a shift to more expensive and more broad-spectrum antibiotics. In

How did we end up here?

The lack of understanding of the unique features and risk of resistance has paved the way for the present epidemic. Moreover, few studies have been done on the magnitude of the burden to convince policy makers of the urgent need to react. Since the penicillin era, antibiotics have been viewed as wonder drugs that could be prescribed without fear of harm, despite early warnings of consequences such as antibiotic resistance and side-effects.70, 71 Their use has spread into many non-medical areas,

Diagnostic uncertainty drives irrational use

Diagnostic (viral or bacterial cause) or prognostic (life-threatening or self-limiting infection) uncertainty makes it difficult for clinicians to know when to provide and when to withhold antibiotic treatment. Consequently, antibiotics are overused in hospitals and outpatient settings, resulting in increased antibiotic resistance52 and the pandemic spread of highly resistant bacterial clones.128 Findings of studies of patients with acute cough—one of the most common reasons for consultation in

Antibiotic use in animals

Use of antibiotics in animals and its potential effect on human health has been a controversy for at least half a century, presently fuelled by the crisis of resistance. Predictably the debate is polarised. Results of scientific studies have sometimes been conflicting, which is confusing for readers unfamiliar with the context. Although the discussion here is restricted to terrestrial animals excluding honeybees, aquaculture is also important in the overall discussion.

Use for growth promotion

The growth-promoting

A global balance

To tackle antibiotic resistance needs not only a renewal of the depleted pipeline of novel antibacterial drugs, but conservation of those now in use. A failure to do so might lead to rolling back major achievements in modern medicine.176 Because resistance inevitably follows antibiotic use, the paradox is that populations—both in industrialised countries and LMICs—can face challenges of access and excess. Even in high-income countries, antibiotic use ranges widely, with three times greater

An underestimated burden

Over the past decade, antibiotic resistance has risen alarmingly worldwide.220 Among the key players, including global health donors, pharmaceutical companies, technical agencies, and governments,221 patients and physicians have the strongest effect on resistance rates, because selection and spread of resistant organisms is mainly a local process based on practices in individual hospitals and communities.222

In LMICs with weak health systems, the effect of antimicrobial resistance on health and

The need for new antibiotics

Antibiotic discovery has stalled, but we do not know how to restart the engine. The golden age of antibiotic discovery between 1929 and the 1970s saw more than 20 new classes of antibiotic reach the market.310, 311 Since then, only two new classes have reached the market.312, 313 Analogue development seems to be drying up because the number of analogues that can be derived within one class is finite.1 The attitudes of regulators and payers have also discouraged development of so-called “me too”

Antibiotics today

Most antibiotic chemical scaffolds in present clinical use were discovered more than 50 years ago. These discoveries mainly came as a result of mining the bioactive chemicals produced by soil bacteria. The large effect of these new antibiotics in treating infections and enabling new medical procedures was tempered somewhat early in their use by the emergence of resistant strains of pathogens and eventually their spread, along with their genes, across the globe.4 Later, many antibiotic scaffolds

Measuring the extent of the problem and its consequences

The generation of reliable, relevant, and up-to-date information will be essential to respond to the negative effects of antibiotic resistance on public health. The poor understanding of the unique features and risks of antibiotic resistance is an important cause for the global complacency paving the way for the present crisis. Few studies have been done on the magnitude of the burden of antibiotic resistance and its contributions to excess mortality to convince policy makers of the need to

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