Chapter four

Antimicrobial resistance
(AMR)

Yohannes Mulugeta
1
 Key points of the chapter
 Introduction

 Causes of Antimicrobial resistance

 Impacts if AMR on Health

 Global burden of AMR

 One Health approach to address AMR

 AMR Prevention and control measures

2
 Antimicrobial resistance (AMR) refers to the
Introduction
ability of microorganisms, such as bacteria,
viruses, parasites, and fungi, to resist the
effects of antimicrobial drugs.

It occurs when these microorganisms mutate

or acquire resistance genes, rendering the
drugs ineffective in treating infections
caused by them.
3
Introduction AMR makes infections harder to treat and
increases the risk of disease spread,
severe illness, and death.

WHO has declared AMR as one of the

top 10 global public health threats facing
humanity.

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 Causes of AMR
 AMR is a natural evolutionary process that
microorganisms use to avoid destruction and survive
the effects of antimicrobials.

 However there are several drivers that have

accelerated this process.

 The misuse and overuse of antimicrobial drugs in

human, animal health, and agriculture contribute to
the development and spread of AMR.
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 Causes of AMR
 Factors such as inappropriate prescribing practices, self-
medication, incomplete treatment courses, and the use of
antibiotics as growth promoters in livestock can
accelerate the emergence of resistant microorganisms.

Poor water quality sanitation and This provide

hygiene, inadequate IPC conditions in which
resistant organisms can
practices, inappropriate food emerge, multiply and
handling spread
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 The Causes of Antibiotic Resistance

1. Overuse and Misuse 3. Factory Farming

Antibiotics are often overprescribed or Factory farming contributes to the
used improperly, leading to the spread of antibiotic-resistant bacteria as
development of resistant bacteria. antibiotics are used on healthy
livestock.

2. Lack of New Antibiotics 4. Global Travel and Trade

The lack of development of new The global movement of people, goods,
antibiotics has led to the overuse and and animals has allowed for the rapid
misuse of existing antibiotics, spread of antibiotic-resistant bacteria
contributing to the evolution of resistant and genes across borders and continents
bacteria.
The Causes of Antibiotic
Resistance
Natural (Biological) Causes AMR

 In the presence of an antimicrobial,

microbes are either killed or, if they
carry resistance genes, survive.

 These survivors will replicate, and

their progeny will quickly become the
dominant type throughout the
microbial population.

https://www.niaid.nih.gov/research/antimicrobial-
resistance-causes 9
 Mutation
 Most microbes reproduce by dividing every few hours, allowing them to evolve
rapidly and adapt quickly to new environmental conditions.

 During replication, mutations arise and some of these mutations may help an
individual microbe survive exposure to an antimicrobial.

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Gene Transfer  Microbes may get genes from each other,
including genes that make the microbe drug
resistant.

 Bacteria that have drug-resistant DNA may

transfer a copy of these genes to other
bacteria.

 Non-resistant bacteria receive the new DNA

and become resistant to drugs.

 In the presence of drugs, only drug-resistant

bacteria survive.

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 Impact of AMR on Human Health
 AMR affects the effectiveness of treatment options for various
infectious diseases, including bacterial infections, tuberculosis,
HIV/AIDS, malaria, and healthcare-associated infections.

 It can lead to increased morbidity, mortality, and treatment costs

of health care.

 AMR also hampers the success of medical procedures, such as

surgeries, transplants, and cancer chemotherapy, which rely
heavily on effective antimicrobial drugs.

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 The Impact of Antimicrobial Resistance on Society and Healthcare

Impact on Healthcare Impact on Agriculture Impact on Communities

and Animal Husbandry and Society
AMR puts a strain on
healthcare systems and
threatens the ability of The overuse of antibiotics in AMR will affect everyone in
medical professionals to agriculture and animal society, including vulnerable
treat infections effectively, husbandry can lead to drug- populations, causing
leading to increased costs, resistant bacteria that can increased morbidity and
morbidity, and mortality infect humans through food or mortality rates and
rates. direct contact. economic losses.
All-age rate of deaths
attributable to and
associated with bacterial
antimicrobial resistance
by GBD region, 2019

https://www.thelancet.com/
journals/lancet/article/
PIIS0140-6736(21)02724-0/
fulltext

Copyright © 2022 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC
The Lancet 2022 399629-655DOI: (10.1016/S0140-6736(21)02724-0) 14
BY 4.0 license Terms and Conditions
Global deaths (counts)
attributable to and
associated with
bacterial antimicrobial
resistance by infectious
syndrome, 2019

Copyright © 2022 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license
Terms and Conditions
15
The Lancet 2022 399629-655DOI: (10.1016/S0140-6736(21)02724-0)
Global deaths (counts)
attributable to and
associated with
bacterial
antimicrobial
resistance by
pathogen, 2019

Copyright © 2022 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license Terms and Conditions

16
The Lancet 2022 399629-655DOI: (10.1016/S0140-6736(21)02724-0)
Global Health threat (estimates for 2019)
1.27 million deaths per year are directly caused by bacterial AMR.

4.95 million deaths per year are associated with bacterial AMR (more than
HIV, TB and Malaria combined)
1 in 5 deaths caused by AMR occurred in children under the age of five –
often from previously treatable infections
6 Priority bacterial pathogens account for >70% of the AMR deaths

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Global Burden of Antimicrobial Resistance (AMR)

Impact on Human Health Impact on Animal Health

Antibiotic-resistant infections kill at least Many animals are routinely given
700,000 people annually. antibiotics, contributing to the spread of
resistance

Impact on the Environment Impact on the Economy

Antibiotics in agricultural runoff lead to Antimicrobial resistance is projected to
the emergence of resistant bacteria in the cost up to $100 trillion by 2050.
environment.
• By 2050, the death toll
from antimicrobial
resistance could be up to
10 million.

• This would overtake cancer

as a leading cause of death
worldwide. Credit: UNEP
One Health  The One Health approach is instrumental in addressing AMR
as it recognizes the interconnectedness of human health,
Approach to animal health, and the environment
address  AMR is a complex problem involving humans, animals, and
AMR the environment as reservoirs and transmission pathways for
resistant microorganisms

 The One Health approach advocates for collaborative efforts

across sectors to promote responsible antimicrobial use,
surveillance, and infection prevention and control

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Global Health  AMR is recognized as a significant global health threat

Threat of AMR  It has the potential to reverse the progress made in

controlling infectious diseases and poses challenges to
achieving the Sustainable Development Goals related to
health, poverty reduction, and food security

 AMR can spread between countries through travel, trade,

and migration, emphasizing the need for international
collaboration and cooperation

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 Global Initiatives to combat AMR
 The World Health Organization has developed a Global Action
Plan on AMR, which provides a roadmap for countries to develop
national action plans

 The tripartite collaboration between WHO, the Food and

Agriculture Organization , and the World Organisation for Animal
Health aims to address AMR across human health, animal health,
and agriculture sectors

 By implementing the principles of One Health, stakeholders can

work together to preserve the effectiveness of antimicrobial
drugs, protect human and animal health, and ensure the
sustainable use of these critical resources for future generations.
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 People-centred approach to addressing antimicrobial
resistance in human health

 The WHO people-centered approach aims to address AMR) in the human

health sector by focusing on people's needs and access to health services.

 The approach consists of 13 core interventions, based on four pillars:

1. Infection prevention,

2. Access to essential health services,

3. Timely diagnosis, and

4. Quality-assured treatment.
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People-centred approach ….

 These interventions are designed to address AMR programmatically,

putting people, their needs, and equitable access to health services at the
center of the response.

 The people-center core package can support the design and prioritization
of actions in the human health sector, integrated with broader health
system strengthening and pandemic preparedness and response plans.

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Definitions of the four implem
entation levels (community,
primary care, secondary and
tertiary care, national and/or
subnational level)

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 Six steps for sustainable
implementation of national
action plans on AMR

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People-centerd approach …..

Pillar 1: Prevention

5. Universal access to WASH and waste management to mitigate AMR

6. Implementation of IPC core components to mitigate AMR

7. Access to vaccines and expanded immunization to manage AMR

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People-centred approach …..

Pillar 2: Access to essential health services

8. Health services for the prevention, diagnosis and management of infectious

disease syndromes are available and affordable for all

9. Uninterrupted supply of quality-assured, essential health products for the

10. prevention, diagnosis and management of infectious disease syndromes

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People-centred approach …..

Pillar 3: Timely, accurate diagnosis

11. Good-quality laboratory system and diagnostic stewardship to ensure clinical
bacteriology and mycology testing

Pillar 4: Appropriate, quality-assured treatment

12. Up-to-date evidence-based treatment guidelines and antimicrobial
stewardship (AMS) programmes

13. Implementation of regulations to restrict non-prescription antimicrobial sales

https://www.who.int/news/item/19-10-2023-13-critical-interventions-that-support-countries-to-
address-antimicrobial-resistance-in-human-health

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AMR Prevention and control measures

 Due to complex nature of the AMR, multispectral

collaboration is demanding

 To combat AMR, comprehensive strategies and

interventions are needed, this include IPC measures.
 These measures aim to prevent the spread of infections,
reduce the need for antimicrobial treatment, and promote
responsible antimicrobial use

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 AMR Prevention and control
measures
1. Hand Hygiene

2. Vaccination

3. Infection Prevention in Healthcare Settings

4. Surveillance and Monitoring

5. Antimicrobial Stewardship

6. Infection Control in Agriculture

7. Public Education and Awareness

8. Policy measures

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 1. Hand Hygiene
 Proper hand hygiene is one of the most effective
ways to prevent the transmission of infections

 This includes regular hand washing with soap

and water or using alcohol-based hand sanitizers

 Promoting hand hygiene practices among

healthcare workers, patients, and the general
public can significantly reduce the spread of
resistant microorganisms

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 2. Vaccination
 Immunization plays a vital role in preventing infectious
diseases and reducing the need for antimicrobial
treatment

 Widespread vaccination programs can help prevent

infections caused by bacteria and viruses, reducing the
overall burden of disease and subsequent antimicrobial
use

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Importance of vaccination

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3. Infection Prevention in Healthcare Settings

 Implementing infection prevention and control measures

in healthcare facilities is crucial to prevent healthcare-
associated infections and subsequent antimicrobial use

 This includes proper sterilization and disinfection of

medical equipment, adherence to standard precautions,
and effective environmental cleaning

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 4. Surveillance and
Monitoring
 Robust surveillance systems are essential for monitoring
patterns of resistance and identifying outbreaks of
resistant infections

 Surveillance can help healthcare facilities and public

health authorities identify areas of concern, implement
targeted interventions, and track the effectiveness of
infection control measures

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 5. Antimicrobial
Stewardship
 Antimicrobial stewardship programs aim to promote the
appropriate use of antimicrobial drugs, optimizing their
effectiveness and minimizing the development of resistance

 These programs involve educating healthcare professionals about

responsible prescribing practices, implementing guidelines for
antimicrobial use, promoting the use of narrow-spectrum
antibiotics when appropriate, and monitoring antimicrobial
consumption

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 6. Infection Control in
Agriculture
 Implementing infection prevention and control measures
in agricultural settings is crucial to reduce the use of
antimicrobials in livestock production

 This includes good animal husbandry practices, proper

hygiene and sanitation in animal housing, vaccination of
animals, and responsible use of antimicrobials under
veterinary supervision

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 7. Public Education and
Awareness
 Raising public awareness about AMR and the importance of
infection prevention and control is essential

 Education campaigns can promote proper hygiene practices,

appropriate use of antimicrobial drugs, adherence to vaccination
schedules, and understanding the implications of AMR for
individual and community health

 It's important to note that these measures should be

implemented in a comprehensive and integrated manner,
involving collaboration across healthcare settings, veterinary
medicine, agriculture, and public health sectors

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 8. Policy measures

 Policy measures, such as regulatory

frameworks, guidelines, and
international agreements to promote
responsible use and stewardship

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