SUPPLEMENT ARTICLE
Globalization of Antimicrobial Resistance:
Epidemiological Challenges
Rosamund J. Williams
Anti-infective Drug Resistance Surveillance and Containment, Communicable Disease Surveillance and Response, World Health Organization,
Geneva
(See the article by Tenover on pages S108–15)
Globalization of antimicrobial resistance is a reality, but before the relative impact of global versus local spread
of resistant microorganisms can be quantified, surveillance capacity and information transfer must be greatly
enhanced.
The globalization of antimicrobial resistance is a reality.
Over and above the increasing rate of emergence of
new resistance phenotypes, the opportunities for such
strains to spread from person to person and between
humans, animals, plants, and other environments are
increasingly recognized. Transmission of resistant
strains both locally and globally needs to be appreciated
when designing interventions to contain antimicrobial
resistance. International travel has increased enor-
mously over the recent years resulting in the multi-
plication of opportunities for resistant microorganisms
to be carried rapidly from one geographic location to
another. Furthermore, the globalization of trade and
the increased contribution that developing countries are
making to the global market in, for example, meat,
provide additional chances for the spread of resistant
strains (and/or resistance genes).
Once imported by the returning traveller, resistant
strains vary in their propensity for spread according to
the route of transmission of the species. The spread of
drug-resistant Plasmodium species from an infected
traveller returning to North America or northern Eu-
rope to other individuals is extremely unlikely. Resistant
strains of Salmonella typhi and Shigella dysenteriae, both
Reprints or correspondence: Dr. Rosamund J. Williams, World Health
Organization, 20 Ave Appia, 1211 Geneva, Switzerland (williamsr@who.int).
Clinical Infectious Diseases 2001; 33(Suppl 3):S116–S7
 2001 by the Infectious Diseases Society of America. All rights reserved.
1058-4838/2001/3306S3-0003$03.00
S116 • CID 2001:33 (Suppl 3) • Williams
widespread in many developing countries, pose little
risk of widespread dissemination in developed coun-
tries if adequate standards of hygiene are observed. In
contrast, importation and subsequent dissemination in
the local population of resistant strains of gonorrhea
[1] and respiratory pathogens [2], including tubercu-
losis [3] is well documented. Hospital pathogens such
as methicillin-resistant Staphylococcus aureus have been
imported, for example, when injured patients are re-
patriated after initial hospital treatment.
Our ability to detect the emergence and global spread
of resistant microorganisms is hampered by the weak-
ness, or total lack, of adequate surveillance of anti-
microbial resistance [4]. Interpretation of existing sur-
veillance data is hampered by the multiplicity of
methods used to detect resistance and by difficulties in
assessing the quality of the data. Considerable effort
and resources are being committed by the World Health
Organization and other partners including the phar-
maceutical industry, to improve surveillance capacity
through training, laboratory strengthening, and pro-
vision of external quality assurance schemes [5], but
there is still much to do.
Even where good quality resistance surveillance data
exist, they are frequently not translated into informa-
tion for public health action. For too long, the sur-
veillance of antimicrobial resistance has operated
among a relatively “closed” circle of hospital micro-
biologists, clinicians, and infection control staff, pro-
viding information for local action and publications,
but not adding to the understanding of the impact of resistance
in terms of rates of morbidity and mortality, and costs. There
is a need for greater epidemiological rigor in resistance sur-
veillance systems so that results can be linked to the incidence,
prevalence, and outcome of infection. Resistance data need to
be transformed into information that can be interpreted by
public health policymakers and the flow of this information
needs to be improved. Lastly, there is a need for a timely sharing
of data internationally so that trends can be monitored and
emerging resistance phenotypes recognized. Antimicrobial re-
sistance is a global problem that requires local, national, and
global responses; surveillance is key to understanding the mag-
nitude and trends of resistance and to evaluating the impact
of interventions [6].
Globalization of Antimicrobial Resistance • CID 2001:33 (Suppl 3) • S117
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