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Antimicrobial Resistance

Christian Tsepelis
Mr. Toole
ISU
Monday May 15, 2017
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Table of Contents

Preface Page 3
Significance Page 5
Religion Page 7
Background Page 8
Expert Page 10
Role of Control Page 12
Logic of Evil Page 14
Case Studies Page 16
Cambodia Page 16
India Page 19
Saudi Arabia Page 21
International Organizations Page 23
Canadian Connection Page 25
Solutions Page 27
Appendix Page 29
Works Cited Page 30
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Preface

Humans have been colonizing the Earth for centuries to create a sustaining populous but
there were already microorganisms like archaea, protists, fungi, viruses and bacteria that were all
throughout the planet. Certain people think that because they are on a microscopic level, they
cannot cause a big problem. That is not true because throughout time, humans have experienced
epidemics like ebola, malaria, zika, SARS and so much more. These popular epidemics
happened because of the misuse of antibiotics, antivirals, antiparasitics and antifungals. These
four treatment drugs are classified under antimicrobials which are agents that kill
microorganisms or stop their growth. The antimicrobial medicines do work but some strains of
different microorganisms develop a resistance gene naturally over time to a certain antimicrobial
(example antibiotic, antiviral, antimalarial and antifungal). What is concerning is the misuse and
overuse by doctors, accelerates the process of antimicrobial resistance. Antimicrobial resistance
is the effect of microorganisms changing to develop a resistance against antimicrobials. How
this works is the microorganism with the resistance gene reproduces to pass the resistance gene
down to the offspring which is an example of natural selection that was invented by Charles
Darwin. Antibiotics are medicines (such as penicillin) that destroys microorganisms. To
classify them easier, antibiotics only work for bacterial infections/diseases, antivirals only work
for viruses and antimalarials only work for malaria. Antibiotic resistance occurs when bacteria
change because of the antibiotics that are used to treat bacterial infections such as pneumonia or
a urinary tract infection. Bacteria, one of the popular microorganisms can reproduce to double
offspring every four to twenty minutes which creates a very big bacterial populus in just hours.
This is why resistance in bacteria spread so fast because of their reproduction rate. Bacteria are
also in humans intestinal areas that provides them with optimal climate and nutrition to survive
which contributes to the development and growth of bacteria.
Bacteria reproduce by binary fission. In this process the bacterium, which is a single cell,

divides into two identical daughter cells. Binary fission begins when the DNA of the
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bacterium divides into two (replicates). The bacterial cell then elongates and splits into

two daughter cells each with identical DNA to the parent cell. Each daughter cell is a

clone of the parent cell. When conditions are favourable such as the right temperature

and nutrients are available, some bacteria like Escherichia coli can divide every 20

minutes. This means that in just 7 hours one bacterium can generate 2,097,152 bacteria.

After one more hour the number of bacteria will have risen to a colossal 16,777,216.

Thats why we can quickly become ill when pathogenic microbes invade our bodies.

(Microbiology Society)

People cannot see the difference from antibiotic to antimicrobial resistance because bacteria are
the most common microbe to human knowledge. This is because bacteria have such fast
reproduction rates which increases the populus. Mentioned by Microbiology Society,
Escherichia coli (E-coli) divides every twenty minutes. E-coli is a bacterium that is prevalent in
cattle intestines and serious implications like kidney failure if left untreated. There are still cases
to this day where E-coli have been found resistant to generations of antibiotics. Society has
ultimately added onto the increasing problem of antimicrobial resistance by overuse and misuse
of antimicrobials.
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Significance

Antimicrobial resistance is important to prioritize and take care of or else as an expected

result, people will die. It goes beyond people dying though, antimicrobial resistance puts
pressure on political groups trying to prevent the spread of microbes and the economical impact
on other countries. Through years, humans have made the greatest achievements like treating
tuberculosis, HIV, pneumonia and malaria. It will not be long for these Millennium
Development Goals to diminish because of the inability to combat antimicrobial resistance. This
is mostly caused because of the overuse and misuse of antimicrobials to treat patients.
Antimicrobials should be the last resort of treatment for an infection or disease so the microbe
has less time to develop a resisting antibody. This is a global issue because effective treatments
and procedures of increasing infections caused by bacteria, viruses, parasites, and fungi are at
risk of failure causing the spread of antimicrobial resistance.

The World Health Organization (WHO) is a political group of regions that the
governments of those countries within the WHO regions dedicate their time and money to ensure
the highest attainability of health for people. Antimicrobial resistance is one of their top
priorities to find out where resistance is occurring, what type of microbe and what antimicrobials
it is resistant to.
Resistance in Klebsiella pneumoniae common intestinal bacteria that can cause

life-threatening infections to a last resort treatment (carbapenem antibiotics) has spread

to all regions of the world. K. pneumoniae is a major cause of hospital-acquired

infections such as pneumonia, bloodstream infections, and infections in newborns and

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intensive-care unit patients. In some countries, because of resistance, carbapenem

antibiotics do not work in more than half of people treated for K. pneumoniae infections.

(World Health Organization 2016)

This is an example of the K. pneumoniae bacterium putting pressure on the WHO. They are
forced to send carbapenem antibiotics in all regions in the world as a last resort. The countries
that the K. pneumoniae originated from would probably have an antibiotic resistance problem
because that is where the bacterium originated and developed. The result is that those
pathogenic bacteria now carry a resistance gene and carbapenem antibiotics have a less chance of
working on patients with the pathogenic infection.

Moreover, antimicrobial resistance has affected countries economies negatively in costly

ways. The cost in lives from AMR over the next 40 years could go as high as 10 million per
year with the cost to economic development as high as $3 trillion per year if current trends
continue (Utt 179). This is viable because there are lots of factors that contribute to expenses
for people and the economy within the country they are living in. It takes time to isolate
antibiotics for certain bacteria, this is the role of a biochemist. Once isolated, the antibiotic goes
through test protocols so that it is an effective drug to distribute. These antibiotics are
manufactured in large amounts which would be very costly to run. The pharmaceutical stores
receiving these large amounts of antibiotics are costly and affect their countries GDP. This
process can be wasted if certain bacteria are resistant to these antibiotics before the antibiotics
are given to patients by doctors. Also, the country just spent a large amount of money through
its GDP for antibiotics that have little to no effect for the population needing treatment. This
vast majority of money spent can also be wasted in a different way. Pharmacists play a key role
in treating patients with infections/health problems. Their stewardship towards patient health
dictates the correct or incorrect use of antibiotics. Overusing or misusing antibiotics is a factor
that accelerates antimicrobial resistance.
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Religion

Religion seems to be separate from scientific points of view on topics like how the
universe was created and why things are what they are but in a threatening spread of
antimicrobial resistance, religion and science for once are on the same page. Some faiths
participate in stopping the spread because they realize that this global concern affects everyone
no matter the religion or society. By different faiths doing this, it creates a stronger faith-based
connection.

A workshop hosted on December 12, 2016 located in Rome, Italy served as a conference
for catholic organizations, including health associations, to develop collaborative and individual
actions to combat antimicrobial resistance. Participants in the workshop included expertise in
the fields from medicine and education to communications and logistics to help address the
challenges faced around the globe. It was hosted by Ken Hackett who was a big influence in the
workshop. Kens credentials include:
U.S. ambassador to the Holy See.
President of Catholic Relief Services (CRS), serving through Asia and Africa.
Board of the Pontifical Commission Cor Unum
Knight Commander of the Papal Order of Saint Gregory the Great
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Faith and science sometimes argue points with their own evidence because they are both
separate groups that contribute to the world individually in their own ways. However, they both
do work well together on topics that affect the world as they should with a global concern like
AMR. Societies, governments, and organizations should be more aware of the rising problem
and should do something about it like Ken Hackett who went out of his way to find ways to
combat antimicrobial resistance and make a stronger faith-based engagement.

Background

Life would be very painful without antibiotics. The pre-antibiotic era was this painful
era. Of course this was around World War I and most of the deaths and infections came from
this war. There were high numbers of casualties and the horrific nature of the wounds caused
by shrapnel and shells contaminated with soil had not been encountered before (Runcie 1).
These infections and wounds were not treatable because there were no antibiotics so a lot of
soldiers lost their lives or limbs from these infections. The only medicine or sanitation used for
soldiers was iodine which is a minimal antiseptic. For patients who had extreme cases of bad
infections, potassium permanganate was used but again it was a mild antiseptic.

Just after World War II ended, Alexander Fleming accepted his nobel prize in 1945 for
inventing the first antibiotic called penicillin. Before this invention, patients would often die
from infections because there was no cure to combat pathogenic bacteria. Fleming warned that
his invention can be useless. There is the danger that the ignorant man may easily underdose
himself and by exposing his microbes to nonlethal quantities of the drug making them resistant
(Zimmer 2016). Fleming was right, we now encounter a similar but bigger global problem.
Antimicrobial resistance always had been an issue, it was just in the form of bacteria since
Fleming invented penicillin. If doctors tried to kill bacterial infections with higher doses of
penicillin, natural selection would just breed more resistant bacteria. During that time, scientists
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were discovering other antibiotics and if bacteria became resistant to penicillin, they would be
able to switch to a different antibiotic.

Antibiotics were also good for business for income. When pharmaceuticals found new
antibiotics, they advertised them to fight against resistance. They also tried to grow their
business by persisting doctors to prescribe antibiotics more often. Not surprisingly, the level of
antibiotic-resistant infections strongly correlates with the level of antibiotic consumption
(Goossens 2005). If a patient came in to treat his/her cold, doctors would prescribe antibiotics
even though the common cold is a virus not a bacterium which had no effect on the patient. So
in time, antibiotics and resistant bacteria were at an arms race. Unorthodox procedures of
prescribing antibiotics accelerates the resistance in bacteria. While resistant bacteria form and
spread, doctors develop new antibiotics. In the past couple of years, new resistant microbes have
arisen like malaria (parasite) and zika (virus). This now has progressed onto different
microorganisms and it is harder to treat because these are totally different microorganisms than
bacteria.
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Expert

Dr. Brad Spellberg is an infectious disease expert and leader in the field of developing
ways to fight drug resistant infections. He is a Chief Medical Officer at the Los Angeles
county-university of Southern California Medical Center. Spellberg received his BA in
Molecular Cell Biology-Immunology and then attended medical school at UCLA where he was
awarded with many academic honors. His research is focused on immunology, vaccinology, to
clinical research and outcomes, improvement work related to delivery of care, focusing on safety
net hospitals. He wrote a book on the problem called the Rising Plague and told Frontline that
science behind developing new tools is in trouble unless the culture changes around drug
resistance. This was an interview with Dr. Spellberg, conducted by Sarah Childress, a senior
digital reporter at Frontline on May 30, 2013.

Can you explain to me resistance, and how did that come about?

Antibiotic resistance has been with us for millions and probably billions of years.

Resistance is just the bacteria not dying from the antibiotics that they are exposed

to.Antibiotics are bacterial weapons. They have been waging war among themselves for

billions of years with these weapons, and if theyre going to make the weapon, they have

to learn how to resist it so they dont kill themselves. In nature, widespread right now is a

lot of antibiotic resistance to drugs we havent even invented yet, but they already know

how to resist. (Spellberg)

Spellberg refers to antibiotics as weapons meaning that they can be used to treat people
but they can also cause resistance. Antibiotics can also develop naturally in the environment.
He mentions in another question that humans dump antibiotics into the environment and that the
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susceptible bacteria die off while the resistant ones live to reproduce to start a large resistance. It
is survival of the fittest.

But we had something to do with this, right, through the overuse of antibiotics and maybe the
carelessness with them?

The more antibiotics we use, the faster resistance spreads. Its simple Darwinian natural
selection.

Spellberg describes resistance as a Darwinian natural selection. This means that the
bacteria that are able to resist the certain antibiotics can live to reproduce which causes the
offspring to carry a resistance gene and develop a large populous in a short period of time. The
bacteria that fail to develop a resistance gene are killed by the antibiotics and no resistant
bacteria arise. This is the theory of natural selection by Charles Darwin.

What really needs to be done in public policy today thats not being done?

I think that we need to rethink how the economies of antibiotics discovery and

development is done, how would companies make money doing this, because we do need

a private component to discovery and development. Its very expensive and risky. You

need entrepreneurial spirit to come in and discover and develop drugs, but we need to

figure out how to partner the public with private and create public-private partnerships to

change the economics so that we can get the drugs we need discovered and developed.

(Spellberg)

He explained very well a solution in public policy that should be done. Partnering
private with public can help make new technology and innovation to fight resistance in
the private sector which can provide better efficiency through public services. Also, it
helps reduce government debt and can spend on other government services.
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Role Of Control

Control relates to power in a sense that whoever has control over something must have
power. In antimicrobial resistance, healthcare professionals have control over supplementing
antimicrobials. All people will receive care in a medical setting at some point which means
antimicrobial resistance can affect anyone. It rightfully should be the professional's role to treat
diseases/infections because they have been trained to practice safety stewardship. According to
the Centers for Disease Control and Prevention (CDC), inpatient healthcare providers should,
Follow relevant guidelines and precautions at every patient encounter and Prescribe antibiotics
wisely (CDC 1). In most cases this happens because of the medical training and guidelines the
health care providers go through but that is not guaranteed. Healthcare professionals can misuse
their power by supplementing wrong dosages of antibiotics and using antibiotics for wrong
treatments like the common cold.

Humans also have control over prescribed antibiotics or antimicrobials. When getting
prescribed, the patient should follow directions from the prescriber and antibiotic container.
Patients should also know when antibiotics would be prescribed. Antibiotics do not fight
infections caused by viruses like colds, most sore throats and bronchitis, and some ear infections.
Unneeded antibiotics may lead to future antibiotic-resistant infections (CDC 2). This leads to
antimicrobial resistance by accelerating the production of resistant microbes because of humans
not properly using and following the right techniques to treat infections and diseases.

The government has the most control because of the money allocated to companies to
find ways to combat AMR and ensure safety amongst the different areas that are affected. An
example of this is governmental funding in the United States,

In fiscal year 2016, Congress appropriated $160 million for CDC to fight AR. With these

investments, CDC implemented the Antibiotic Resistance Solutions Initiative, which is

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improving national infrastructure to detect, respond, and contain resistant infections

across healthcare settings and communities. (CDC 4)

The government funding helps the CDC distribute the money to fifty state health departments,
six major local health departments, and to Puerto Rico. This key investment will change how the
CDC and public health partners combat antibiotic resistance.

In Canada, the government is also funding organizations like WHO because of the
increasing mortality rate and to combat AMR. Minister of Health, Jane Philpott decided that,
Canada needs to address the growing issue and provide support by funding because it is a global
concern and it is hard to gather support when other countries are not informed. So in return,
Canada is backing its commitment with a $9 million investment to the World Health
Organization (WHO) in support of a comprehensive global approach to combating AMR
(Public Health Agency of Canada 2016). During Antibiotic Awareness Week, this is the largest
single year contribution to the WHO during this week so Canada gets to address this global
health challenge. In general, professional prescribers, humans, and government share the right to
contribute their own responsibility to stop antimicrobial resistance. With each group doing their
task, antimicrobial resistance can be easier to capture and eradicate so that countries can continue
to prosper.
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Logic Of Evil

The logic of evil means that if something is done that is seen as evil, is it really evil or is
it justified and effective? For example, Hitler was an evil man and what he did was evil and
cruel but from his perspective, it was logical, effective, and organized. He slaughtered jews for
economic reasons. The logical part is that even though the holocaust was evil, Hitler united all
of Germany and its allies to become a superpower. This compares to antimicrobial resistance
with the healthcare professionals being evil. Healthcare professionals back in history around
when Fleming invented penicillin were a major contribution to antimicrobial resistance. They
did not pay attention to upcoming resistance because they were inventing other antibiotics.
Having a diverse set of antibiotics is important because they can apply to different infections and
diseases. Doctors prescribed antibiotics as a first resort because they wanted to make money for
their business. Logically it makes sense that they would do that even though it can cause a
multitude of resistance. This method of persistently prescribing antibiotics influenced patients
and populations that antibiotics can cure almost anything which made more patients visit the
doctor and return created a better profit gain.

The government has done their part in combating AMR. Governments have realized that
this is a global threat and they are ultimately in charge of what happens. The evil lies with
pharmaceutical companies after all they are the ones that make antimicrobials and drugs anyway.
The evil is associated with pharma companies because they need money to develop new agents
to combat antimicrobial resistance. Without money, pharma companies cannot make new drugs
or agents which means resistance keeps on building. So now governments have supported
companies to develop new agents and new solutions to release to the public and organizations.
Last year, The U.S. governments Biomedical Advanced Research and Development Authority
says it will invest up to $170 million to help AstraZeneca Plc move new antibiotics toward the
market and has similarly supported Glaxo with as much as $200 million (Gale 3). Glaxo is a
big pharma company and now that it has received two-hundred million after spending one billion
on antibiotics over the past decade, Glaxo has come up with a new product called geopotidacin
to combat multidrug resistant E-coli. So the pharmaceutical companies had to keep on
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prescribing similar antibiotics for years because they could not make their money back if they
invested in development of new antibiotics without funding or financial support.
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Case Studies

Cambodia

Located in Southeast Asia bordering the Gulf of Thailand is Cambodia. It has

experienced an economic growth period in the last decade. This is partly from the tourism sector
in Cambodia. Attractions like, Angkor Wat, Bayon Temple, Banteay Srei, and Koh Ker are
popular sites to visit when in Cambodia. There are other sectors that contribute to Cambodias
economic growth,
The tourism, garment, construction and real estate, and agriculture sectors accounted for
the bulk of growth. Around 600,000 people, the majority of whom are women, are
employed in the garment and footwear sector. An additional 500,000 Cambodians are
employed in the tourism sector, and a further 50,000 people in construction. (The World
Factbook)
Unfortunately, Cambodia is still one of the poorest countries in Asia and a major factor
contributing to poverty is antimicrobial resistance. Due to the tropical climate, mosquitoes are
prevalent which means the Plasmodium falciparum parasites are located in some mosquitoes,
which creates a disease known as malaria. Artemisinin combination therapies (ACT) which is an
antimalarial drug was used in the 1990s to combat an untreatable malaria in Cambodia where a
resistance formed to all antimalarial drugs at that time. In 2005, while malaria was endemic in
Cambodia the World Health Organization prioritized ACTs as first line treatments for all
falciparum cases because none of the previous antimalarial drugs were working.
Artemisinin resistance was first identified in clinical studies in 2006; however, the
retrospective analysis of molecular markers has indicated that artemisinin resistance
likely emerged prior to 2001 and the widespread deployment of ACTs in Cambodia.
(WHO 5)
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Before ACTs were used as a first line treatment, there was already a resistance. This was not
the World Health Organizations fault because Cambodia was suffering from resistance to
previous antimalarials in the 1990s so a new drug therapy was developed (ACT) to slow down
and potentially eliminate the falciparum parasite. In April 2013, WHO launched a report called
Emergency response to artemisinin resistance (ERAR) in the Greater Mekong Subregion (GMS)
which includes Cambodia primarily because that is where the artemisinin resistance emerged.
This report encouraged malaria partners to professionally coordinate with each other to provide
more information for containment of artemisinin resistance and to strengthen regional support.
WHO has received and partnered with:
The Australian Department of Foreign Affairs and Trade and the Bill & Melinda Gates
Foundation to strengthen the coordination and technical support for artemisinin resistance
containment activities in the GSM. The project is implemented by the WHO Global
Malaria Programme, the WHO Regional Office for South-East Asia, the WHO Regional
Office for the Western Pacific and WHO country offices. A regional hub has been
established in Phnom Penh, Cambodia to support and help coordinate the activities.
(WHO 5)
This was a report for other countries to help eradicate this spread. Fortunately, theses companies
and charities have joined and helped WHOs ERAR report, WHO was able to accumulate $100
million (US) for an artemisinin initiative to eliminate and contain artemisinin resistance in
Cambodia and other close areas it has spread to. A goal and study was set by the Malaria Policy
Committee of WHO in September 2014 to eliminate P. falciparum in Cambodia and the GMS
region by 2030. Since this study was prioritized, the artesunate-mefloquine antimalarial drug has
been reintroduced for first line treatment and has been reported to have 100% efficiency and very
minimal resistance.

As this study continues to contain the artemisinin resistance, only time can tell if a new
resistance could arise to a reintroduced antimalarial or a further spread of artemisinin resistance
through southeast Asia. Eliminating this antimicrobial resistance can bring this country's
standards up. Economically, tourists could be less scared to travel to Cambodia because malaria
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is gone, even poverty could gradually lessen because no barrier like malaria is forcing people to
lower their living standards. This chance could only be done if antimicrobial resistance is
eliminated in malaria but because of Cambodias tropical climate, mosquitoes have been isolated
in Cambodia specifically due to ideal conditions. Cambodia has a mortality rate of 6.8 per
100,00 people due to malaria. Cambodia can also be the cause for Malarial resistance if it
spreads to other parts in the world. This can easily happen from migration of infected humans to
other parts of the world where this resistance of malaria can spread in ideal living conditions
such as Uganda and Kenya. This is why antimalarial resistance and the P. falciparum parasite
should be eliminated.
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India

India is a country in South Asia that is the seventeenth largest country by area and second
in populous with over 1.2 billion people. It is associated with the Indian Ocean and it shares land
borders with Pakistan, China, Nepal, Bhutan, Myanmar and, Bangladesh. In 2015, the economy
of India was ranked seventh in the world by GDP. After the economic reforms in 1991, India
was one of the fastest growing economies and is considered to be a new industrialised country.
However, it continues to face the challenges of corruption, poverty, malnutrition, and inadequate
public healthcare. Improper antimicrobial stewardship is what makes India so popular with
different types of antibiotic resistance. It was reported that, India has emerged as the world's
largest consumer of antibiotics with a 62% increase in popping habits over the last decade
(TNN 1). Popping is the habit to take pills or antibiotics in the most unnecessary circumstances
like during a mild cold. This decreases the time for antibiotic resistance to develop. In India, E.
coli showed resistance ampicillin, naladixic acid and, co-trimoxazole between 2004 and 2007.
Then from 2008 to 2013, different strains of E. coli had built another resistance to two other
third-generation antibiotics including carbapenems.

A study emerged in 2009 about a fifty nine year old diabetic Swedish male of Indian
origin that went to a hospital in Stockholm showing signs and needed treatment for a urinary
tract infection and bed sores. The male named Anand Gharad had recently returned from India
where there was abscess around the buttocks area and had been hospitalised in India. Diabetics
are somewhat known to be susceptible to this. It was thought that the urinary tract infection and
the bed sores were acquired from his stay at the hospital in India. The only problem with the
infection was that no antibiotics were working to heal the infection, not even carbapenems which
are the strongest class of antibiotics:
A routine urine test threw up something extremely unusual. The bacterium causing the
infection, as the doctors analysing the case wrote in the journal Antimicrobial Agents and
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Chemotherapy, was the familiar Klebsiella pneumonia, which is one of the most frequent
causes of pneumonia and bloodstream infections in hospitalised patients. (Bhutia 1)
Klebsiella pneumonia evolved around the same time as E. coli. The city of New Delhi where the
Swedish male was hospitalised while in India was thought to have been where the Klebsiella
pneumonia emerged. The parasite was not only found in hospitals but, It was discovered in
New Delhis drinking water (Bhutia 2). The Indian government did not believe this suggestion
by healthcare professionals and strict rules were enforced not to take any biological samples out
of the country but British researchers smuggled out samples to study. Instead of dealing with
this healthcare issue, researchers got caught up with what to name the resistance gene.

Although antimicrobial resistance is a diverse problem in India, it is mostly from the

healthcare system. In India, around 5% of GDP is spent on health out of which public health
sector contributes to 0.9% and a major portion of the remaining is by the private health sector
(Kumar 3). In the private health sector, doctors are poorly trained and potentially unlicensed.
This leads to irrational prescriptions and inappropriate uses for antibiotics which provides
favourable conditions for resistant microorganisms to emerge and spread and increase
antimicrobial resistance. Merging this problem with the lack of knowledge from the consumers
and public regarding the use of antibiotics and self medication increases chances of resistant
strains emerging. There are many consequences of AMR. The patient with a resistance remains
sick for a longer period of time where in return treatments are prolonged and usually more
expensive. Hospitals also have consequences where, a person with a resistance case or infection
that is hospitalised for long periods has increased chances of spreading that resistance case or
infection through the hospital and even through communities.
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Saudi Arabia

Saudi Arabia is a country located in the Middle East and is known most for the
production and distribution of oil. But there is more to it than oil, Saudi Arabia occupies most of
the Arabian Peninsula, along with the Red Sea and the Gulf of Aqaba. Saudi Arabia's close
connected countries are, Jordan, Iraq, Kuwait, Qatar, United Arab Emirates, Oman, Yemen and,
Bahrain. Saudi Arabia holds the world's largest sand desert called the Rub Al-Khali or Empty
Quarter. Its popular oil region is located in the eastern province along the Persian Gulf. Saudi
Arabia is also holder of the Islamic religion and has two holy shrines known as the Mecca and
the Medina. It is an oil based economy with strong government controls over economic
activities. The economy has around 16% of the world's petroleum reserves and ranks as the
largest exporter of petroleum. The petroleum sector accounts for roughly 87% of budget
revenues, 42% of GDP, and 90% of export earnings (The World Factbook). The country wants
to expand the private sector to diversify the economy in return to employ more Saudi nationals.
However the major city Riyadh is struggling to reduce unemployment to its own nationals.

In Riyadh, a report by Ramanan Laxminarayan was posted in 2010 about antimicrobial

resistance prevalence in an adult intensive care unit (ICU) at a tertiary centre. The patients in the
ICU were experiencing a spread of multi-antibiotics resistant pathogens. A study was done to
isolate the different pathogenic strains that were multiresistant and the results showed that the
most isolated microorganism was Acinetobacter baumannii which is a gram-negative bacterium
that causes an infection in organ transplants. The bacterium is often isolated in hospitals and is a
water organism that survives and colonizes in patients urine. This bacterium was multidrug
resistant (MDR) because of a cross infection with resistant strains during treatment and had
spread in the ICU at the hospital.
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The main reason why MDR bacteria are spreading and emerging in Saudi Arabia is
because there are unfit laws and regulations for obtaining and distributing antibiotics to fight off
bacteria which eventually breed into pathogenic strains that are MDR. Findings from a study
done in 2010 in Riyadh, Saudi Arabia, showed that antibiotics could readily be obtained without
a prescription in 244 (78%) of 327 pharmacies (Habibzadeh 1). Unfortunately, these
pharmacies can unprofessionally prescribe these antibiotics because it can bring in more income
for the doctors/pharmacists, provide the easiest way to get rid of the infection/case, or even
because of lacking knowledge towards prescriptions. Patients do not criticise or question why
this is the first immediate option that is being prescribed to them because it looks bad on them to
criticise or question a doctor.

Fortunately this case in Saudi Arabia did have many solutions. Policies were made to
target this outbreak immediately and it was contained. Other companies extracted samples of the
harmful strains and developed more useful antibiotics. What really needs to be done is that their
should be new adoptions of policies to train more in the prescribing field, increased regulations
for antibiotic prescriptions and increased security for public access to antibiotics.
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International Organization

Many international agencies such as World Health Organization, European Centre for
Disease Prevention and Control, and World Health Assembly have prioritized AMR as an
international public health issue but there is still a challenge to contain the resistant parasites.
The increasing threat of ineffective antimicrobials is a global issue and needs to be dealt with at
an international level. One organization that coordinates most of the national efforts to eliminate
AMR is the World Health Organization or known by the acronym, WHO. This organization
aims to improve public healthcare systems, policies, and overall health of patients at an
international level. At the sixty-eighth World Health Assembly in May 2015, the World Health
Assembly endorsed a global action plan for AMR. The draft of the global action plan is to
ensure, for as long as possible, a continued use of successful treatment and prevention of
infectious diseases with effective and safe medicines that are quality-assured, used in a
responsible way, and accessible to all who need them. By doing this, it can bring a whole new
view to countries that are cleaner because of no resistant antimicrobials. As stated in the global
action plan for antimicrobial resistance, for this goal to be achieved, there are five strategies:
1. to improve awareness and understanding of antimicrobial resistance;
2. to strengthen knowledge through surveillance and research;
3. to reduce the incidence of infection;
4. to optimize the use of antimicrobial agents; and
5. develop the economic case for sustainable investment that takes account of the needs
of all countries, and increase investment in new medicines, diagnostic tools, vaccines
and other interventions. (Chan 7)

This is a team effort that needs to happen. WHO works through 150 countries with six
different regions. The WHO cannot as an international agency advocate for the world by
themselves, that's why other companies are mutually invested in stopping AMR.
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WHO is working closely with the Food and Agriculture Organization of the United
Nations (FAO) and the World Organisation for Animal Health (OIE) in a One
Health approach to promote best practices to avoid the emergence and spread of
antibacterial resistance, including optimal use of antibiotics in both humans and
animals. (WHO)

All countries need national action plans on AMR. Greater innovation and investment are
required in research and development of new antimicrobial medicines, vaccines, and
diagnostic tools.

Similar to WHO, is the European Centre for Disease Prevention and Control network.
In regards to antimicrobial resistance, the ECDC believes that the public is accountable for
changing the progression of resistance strains, however the general public is unaware of the
issue. To resolve this problem, the ECDC decided that the initial step was to increase
awareness which the public can then alter their everyday lives accordingly. The European
Centre for Disease Prevention and Control has created an infographic that depicts the various
aspects which antimicrobial resistance spreads in society (appendix figure 1). The infographic
further explains how each societal factor, contributes to the spread of resistance.
 25

Canadian Connection

Canada, is a country not known for poor healthcare and poor sanitation, but known for
high health standards. Canada was ranked thirty out of 191 countries by WHO for health,
responsiveness, fairness in financing, and how efficient the healthcare systems are. This
analysis allows lower ranked countries to compare the structure of their healthcare systems.
There still seems to be some cases of antimicrobial resistance even though Canada has a high
ranking in healthcare systems. This is reality and that factors like immigration can contribute
to the spread of antimicrobial resistance in diverse communities like Toronto. In Canada,
total medical care costs with antimicrobial resistant organisms (AROs) is estimated at $1
billion annually. Antimicrobial resistance is a growing issue to prevent and treat infections
from common urinary tract infections to more serious bloodstream infections.

Between 2010 and 2014 nearly half of Escherichia coli and Klebsiella pneumoniae
tested from urinary tract infections were resistant to antibiotics commonly used for
treatment. Resistant specimens of Shigella, which can cause severe intestinal illness,
made up 4.7% of all samples tested in 2014 compared to only 1.8% in 2010. Resistant
specimens made up 11% of isolates tested in 2014 from invasive Candida glabrata
infections. (Public Health Ontario 1)

The health impacts are substantial. Patients can contract AROs while in a hospital which
leads to patients being hospitalised for longer periods of time which can lead to emotional and
financial burdens for the patient's family. This also contributes to an economic burden
because of increased healthcare costs and absenteeism. The longer these AROs exist in
hospitals and even communities, the greater opportunity for transmission to other individuals.

But still antimicrobial stewardship dictates the increasing chances of an antimicrobial

becoming resistant. Antimicrobial stewardship is the practice of using antimicrobials only
 26

when necessary, which lessens the opportunity for organisms to become resistant (Public
Health Ontario 4). Stewardship remains important as the uses of antimicrobials in Canada is
higher than many other countries. Canada ranks eleven out of twenty nine countries based on
the use of antimicrobials outside of hospitals.

Fortunately, the minister of health released a plan called Antimicrobial Resistance

and Use in Canada: A Federal Framework For Action in 2014 to protect the health of
Canadians through leadership, partnership, innovation, and action in public health. This plan
is still ongoing and will continue to until AMR is gone. Canada and the World Health
Organization have close working relations,

The Government of Canada is engaged with international jurisdictions and

organizations in global efforts to address antimicrobial resistance. This Framework
represents an important step in responding to the global call for action on
antimicrobial resistance. (Public Health Agency of Canada 50)

This partnership with WHO acknowledges that Canada is working towards the elimination of
AMR internationally. Canada is also a good country to partner with internationally because
of how highly ranked the healthcare systems are. Canada is already taking significant action
to address the threat of antimicrobial resistance domestically and internationally. However
much more remains to be done by all levels of government, industry, non-governmental
sectors (private) and the general public. By working together internationally and within the
different levels of government, antimicrobial resistance can be reduced in return for
Canadians safety in health.
 27

Solutions

Solutions are what solve problems and prevent chaos from infringing upon earth and
mankind. Antimicrobial resistance is a severe global issue that mainly will affect humans and
will diminish the population. But these are predictions and can be proven wrong if
organizations, governments, and citizens work together. Firstly, antimicrobial resistance does
not just emerge unless there is a valid reason or issue that contributes to it. This is where
governments and their citizens need to cooperate because that is where AMR starts. The lack
of treatment structure towards health cases from patients is where the resistance develops.
For example, if pharmacists or doctors prescribe antibiotics for a common cold, it will be
ineffective because a cold is the result of a virus and antibiotics only work for bacterial
infections. If pharmaceuticals lack this knowledge, antibiotic resistance will develop and
MDR strains will develop from early prescription of antibiotics. A solution for this can be
mandatory courses that cover when to prescribe antibiotics in different patient cases.

Secondly, doctors and pharmacists would not prescribe antimicrobials unless they had
them. In 2014, 38,340 kilograms of antimicrobials were purchased by hospitals in Canada,
at a cost of just greater than $104 million (Government of Canada 1). This rate has been
fairly stable for the next couple of years which is ideal. Places like India that purchase a
disproportionate amount unsurprisingly lowers their GDP. This will be unnecessarily hurting
Indias economy. A solution to this can be asking for money to be donated from
organizations like WHO. India is one of the six WHO regions for AMR and the WHO strives
to help health standards increase all over the world. A problem with this can be political
turmoil over money or support between Indias government and the WHO because India is
known for self medication and wasting antimicrobials which WHO or other organizations
could of donated.
 28

Lastly, one of the problems that help spread AMR through different parts of the world
is migration. It is very hard to stop migration just to contain AMR because legally the
migrant(s) did nothing wrong contract a type of resistance. An example of this could be if
someone that contracted malaria with an antimalarial resistant parasite in Kenya then
travelled to Uganda, the resistant malaria parasite would spread in Uganda because of the
tropical climate ideal for mosquitoes. Now that this resistance has been isolated in two
different locations, with constant migration between the two countries, a MDR parasite might
emerge causing more harm to the countries because of cross contamination by migration. A
solution for this, could be that to target the country with the MDR resistance so that it can be
contained easier. A mass group of countries and organizations need to eliminate this quickly
before it spreads to other parts of the world. A combined effort speeds the process of
containment a lot quicker.

If more countries and organizations work together socially, economically, and

politically, a chance of diminishing or eliminating antimicrobial resistance as a global issue
can happen and can result in raising the standard of living. Organizations like the WHO are
already getting started with solutions.

WHO is providing technical assistance to help countries develop their national action

plans, and strengthen their health and surveillance systems so that they can prevent

and manage antimicrobial resistance. It is collaborating with partners to strengthen the

evidence base and develop new responses to this global threat. (WHO 4)

Our world as a society is conflicted with the spread of antimicrobial resistance and it is never
too late to become aware and help do something by donating or participating in events to
combat the spread of antimicrobial resistance, because we are the ones that started in the first
place.
 29

Appendix
 30

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