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Abstract
Antimicrobial resistance (AMR) is now a global threat. Its emergence rests on antimicrobial overuse in humans and
food-producing animals; globalization and suboptimal infection control facilitate its spread. While aggressive measures
in some countries have led to the containment of some resistant gram-positive organisms, extensively resistant
gram-negative organisms such as carbapenem-resistant enterobacteriaceae and pan-resistant Acinetobacter spp.
continue their rapid spread. Antimicrobial conservation/stewardship programs have seen some measure of success in
reducing antimicrobial overuse in humans, but their reach is limited to acute-care settings in high-income
countries. Outside the European Union, there is scant or no oversight of antimicrobial administration to
food-producing animals, while evidence mounts that this administration leads directly to resistant human
infections. Both horizontal and vertical infection control measures can interrupt transmission among humans, but
many of these are costly and essentially limited to high-income countries as well. Novel antimicrobials are urgently
needed; in recent decades pharmaceutical companies have largely abandoned antimicrobial discovery and
development given their high costs and low yield. Against this backdrop, international and cross-disciplinary
collaboration appears to be taking root in earnest, although specific strategies still need defining. Educational
programs targeting both antimicrobial prescribers and consumers must be further developed and supported. The
general public must continue to be made aware of the current scale of AMRs threat, and must perceive
antimicrobials as they are: a non-renewable and endangered resource.
Keywords: Antimicrobial resistance, Antimicrobial conservation, Antibiotic stewardship, Infection control, Hand hygiene,
Surveillance networks, Care bundles, Environment, Regulations, Human medicine, Animal medicine, Global health, World
Healthcare-Associated Infections Forum
Background
There is nothing new under the sun, least of all antimicrobial resistance (AMR) [1]. Microbes that are antibiotic producers have always needed to be resistant to
their own antibiotic. What is rapidly changing, however,
is the scale of this resistance and its impact on human
beings. Microbes have globalized along with their hosts,
while at the same time antimicrobial consumption by
* Correspondence: didier.pittet@hcuge.ch
1
Infection Control Programme and WHO Collaborating Centre on Patient Safety,
University Hospitals of Geneva, Rue Gabrielle-Perret-Gentil 4, 1205, Geneva,
Switzerland
Full list of author information is available at the end of the article
2013 Huttner et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly cited. The Creative Commons Public Domain Dedication
waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise
stated.
Page 2 of 13
Page 3 of 13
Figure 2 Community-associated, hospital-associated, and overall MRSA prevalences in the United States from 1999 through 2010.
From the Center for Disease Dynamics, Economics and Policy (www.cddep.org).
172 seepage samples [18]. Indeed, the obvious publication bias of data from the US and Europe likely creates a
distorted view of the current overall prevalence of and
mortality due to multi-resistant organisms. The burden
of drug-resistant infections in low-income countries is of
course difficult to quantify, but appears to be manifold
higher than those in high-income countries [19,20].
Organisms that are almost entirely community-acquired
such as Neisseria gonorrhoeae also continue to increase
their resistance. Once sensitive to penicillin, tetracycline
and fluoroquinolones, N. gonorrhoeae s current resistance
rates leave only ceftriaxone as viable therapy in many regions [21]. Unfortunately, this treatment of last resort is unlikely to hold: the H041 N. gonorrhoeae strain, which
carries high-level ceftriaxone and cefixime resistance, was
detected in Japan in 2011; [22] its phenotypic homologue,
F89, was isolated in France in 2012 [23].
The economic burden of AMR continues to climb.
The annual societal cost-of-illness for AMR is considered to be roughly $55 billion for the US alone [24],
though economists warn that this is likely an underestimate. Based loosely on the incremental cost related to
the additional treatment of resistant over susceptible primary infection, this estimate masks the critical economic
burden that arises when resistance leads to the loss of
many of the advantages in medical care that antimicrobials have enabled [25]. It also excludes the indirect
costs of resistance, such as prolonged morbidity, reduced
productivity and related social effects. Studies of such
broad scope have yet to be undertaken.
Causes of antimicrobial resistance
The key promoter of antimicrobial resistance is the selection pressure caused by the use of antimicrobials.
Overuse occurs across multiple ecosystems whose detailed
analysis is beyond the present scope. Here we focus on
antimicrobial consumption in humans and animals.
Page 4 of 13
control study of more than 400,000 primary care patients from a single health care system in Pennsylvania
from 2005 to 2010 revealed exposure to crop fields
where swine manure was used as fertilizer as a significant risk factor for both community- and health
care-associated MRSA strains [38], echoing previously
reported data from the Netherlands [39].
Steps forward: successful strategies
Reductions in human-to-human transmission of resistant organisms have been well documented via both horizontal and vertical measures [42]. Horizontal measures
are not pathogen-specific and include interventions such
as improved hand hygiene and enhanced environmental
cleaning, both of which have been shown to interrupt
pathogen transmission effectively [28,43,44]. Vertical measures are pathogen-specific and include targeted and universal screening upon hospital admission (e.g., MRSA,
ESBL-producing gram-negatives) with or without preemptive isolation, often using novel molecular diagnostic techniques for rapid pathogen detection [45]. The decline in
MRSA prevalence in many European countries over the last
half-decade attests to the success of these approaches [41].
Newer strategies include the development of vaccines
specifically targeting resistant organisms. OmpA and FepA,
two immunogenic proteins found in ESBL-producing K.
pneumoniae, were recently identified as promising vaccine
gene candidates [46]. A vaccine composed of the outer
membrane vesicles of Acinetobacter baumanii is currently
being tested in animal models and appears to provide protection against at least some pan-resistant strains [47].
Other strategies are more indirect. The cytokine
interleukin-12 (IL-12) is being tested as an enhancer of
adaptive immunity in murine models infected with
N. gonorrhoeae, which appears to suppress cell-mediated
immune responses in the host. Local treatment of the mice
with IL-12 generated gonococcus-specific immunoglobulin
G and led to faster clearance of infection and induced resistance to reinfection, suggesting both a prophylactic and
Page 5 of 13
Table 1 Summary of abstracts presented at the 2013 World Healthcare-Associated Infections Forum
I. Antimicrobial use and resistance
Author
Short title
Study design
Balkhy et al.
Retrospective
Single adult ICU,
susceptibility study Saudi Arabia,
2004 2009
Setting
Key findings
Acinetobacter spp. was highly resistant
(70 90%) to all tested antimicrobials
including carbapenems (78% had four-class MDR)
Klebsiella spp. had low (0 14%) resistance with no
detected MDR
Carrel et al.
Retrospective
unmatched
case-control study
Veterans Affairs
Hospital, Iowa, USA,
2009 2011
Dantes et al.
Prospective,
population-based
surveillance study
USA, 2011
Datta et al.
Retrospective
case-cohort study
California hospitals
and long-term-care
facilities,
2005 2009
Gastmeier
et al.
Dramatic increase of
vancomycin-resistant enterococci in Germany with a belt
of high proportions
Prospective
surveillance study
Antimicrobial and
HAI point
prevalence study
37 hospitals, Greece,
2012
Gikas et al.
Retrospective
surveillance study
Hsueh PR
Prospective and
retrospective
surveillance
studies
Kaku et al.
Trends of antimicrobial
resistance in a Japanese
hospital
Retrospective
surveillance study
Mushtaq
et al.
Prevalence of carbapenemase
carriage among inpatients in
Karachi
Prospective
surveillance study
Reuland
et al.
Page 6 of 13
Table 1 Summary of abstracts presented at the 2013 World Healthcare-Associated Infections Forum (Continued)
Thu le et al.
Literature review
Vietnamese
hospitals,
2010 2012
Short title
Study design
Adler et al.
Characteristics of an outbreak
caused by OXA-48-producing
CRE in a neonatal ICU in
Jerusalem
Combined
Neonatal ICU, Israel,
retrospective and 2012
prospective
before-after cohort
study
Prevention of Staphylococcus
aureus infection in the NICU:
routine surveillance and
decolonization
Combined
Brazilian NICU,
retrospective and 2010 2012
prospective
before-after cohort
study
Baltieri et al.
Setting
Key findings
Before-after study
Fournier
et al.
Prospective
surveillance study
38 hospitals, France,
2010 March 2013
Grall et al.
Experimental
animal models
(porcine, canine,
murine)
France, 2013
Short title
Study design
Setting
Key findings
Awang Jalil
et al.
Before-after study
Neonatal ICU,
Malaysia,
2012 April 2013
Bailin et al.
Two-stage
Tertiary care hospital,
combined
USA, 2011 2012
retrospective and
prospective cohort
study
Bavestrello
et al.
Impact of intervention on
antimicrobial consumption in
aquaculture in Chile
Before-after
economic analysis
Page 7 of 13
Table 1 Summary of abstracts presented at the 2013 World Healthcare-Associated Infections Forum (Continued)
Edmunds
et al.
Canadian provinces,
2000 2010
GuzmanBlanco et al.
Pan-American Health
Organization guideline for
treatment of infectious
diseases in Latin America
International
guideline
Koo et al.
Appropriateness of continued
use of empirical vancomycin
Retrospective
cohort study
Ling et al.
Case-control study to
determine risk factors for CRE
carriage
Retrospective
matched (1:2)
case-control study
Mehtar and
Hara
Antimicrobial stewardship in
Africa-humble beginnings
Descriptive
epidemiologic
study
African hospitals,
2011 2012
Impact of a regional
intervention program to
control carbapenemaseproducing Klebsiella
pneumonia (CPKP)
Before-after study
17 hospitals, Italy
(Emilia-Romagna),
2011 2013
Before-after study
Moro et al.
Ndoye
Community
hospitals, Senegal,
2008 2012
Nicolle
Antimicrobial stewardship in
long-term-care facilities: what
is effective?
Systematic
literature review
Published studies
retrieved through
Medline & Embase,
1998 2013
Nussenblatt
et al.
Pulcini and
Carlet for
WAAAR
Prospective
observational
study
ICUs in a single
tertiary care center,
USA, 2009 2010
A multidisciplinary initiative to
save antibiotics: the World
Alliance Against Antibiotic
Resistance
Cross-disciplinary
alliance
42 countries
represented, 2011
Page 8 of 13
Table 1 Summary of abstracts presented at the 2013 World Healthcare-Associated Infections Forum (Continued)
Skov et al.
Ongoing
campaign
Danish general
practitioners and
general public,
2012
ACP: antimicrobial conservation program; AMR: antimicrobial resistance; BSI: bloodstream infections; CAFO: concentrated animal feeding operation; CDI: Clostridium
difficile infection; CRE: carbapenem-resistant enterobacteriaceae; ESBL: extended-spectrum beta-lactamase; ESCMID: European Society of Clinical Microbiology and
Infectious Diseases; HAI: healthcare-associated infection; ICU: intensive care unit; KPC: Klebsiella pneumoniae carbapenemase; LTCF: long-term-care facility;
MDR: multi-drug resistant; MDRO: multidrug-resistant organism; MRSA: methicillin-resistant Staphylococcus aureus; MSSA: methicillin-susceptible S. aureus; NICU: neonatal
intensive care unit; OPE: OXA-48-producing enterobacteriacae; SSI: surgical site infections; UTI: urinary tract infection; VAP: ventilator-associated pneumonia;
VRE: vancomycin-resistant enterococci.
therapeutic role for IL-12 [48]. Should these newer approaches make it to the clinic, however, their long-term efficacy will be no more absolute than that of the antibiotics
developed before them: the development of resistance is a
dynamic process.
Finally, it should be noted that morbidity and mortality
from infectious diseases were already declining sharply before the advent of antimicrobials and most vaccines: the
implementation of sewage systems more than halved child
mortality due to diarrheal illnesses by the early 20th century in several European countries [49]. This backbone of
public health is now more critical than ever; effective sanitation systems worldwide are needed to decrease transmission of resistant microbes via wastewater.
Strategies to reduce consumption
Page 9 of 13
Figure 3 A decline in human per capita outpatient antibiotic use in North America and France has been documented over the past
decade. From the Center for Disease Dynamics, Economics and Policy (www.cddep.org).
conservation programs and awareness campaigns are essentially non-existent in many developing nations, where
antimicrobial consumption data are lacking though, paradoxically, easy access to mass-produced, sometimes diluted (subtherapeutic) antimicrobials often is not.
Efforts to reduce antimicrobial consumption in foodproducing animals date from as early as 1969, with
Swanns recommendation calling for a ban on the nontherapeutic use of antimicrobials in animals and agriculture in the United Kingdom [59]. Such a ban was highly
contentious then, as now, and obstacles to its implementation are abundant in numerous countries.
Facilitating the development of novel antibiotics
Efforts are under way in some Western nations to fasttrack the development of desperately needed novel antimicrobials. The research and development required to bring
one antimicrobial successfully to market can exceed 1 billion, thus many in the pharmaceutical industry have prioritized drugs with a wider market and indications for
long-term usage. A few public-private partnerships have
been established, among them the Innovative Medicines
Initiative (IMI), a joint undertaking between the European
Commission and the pharmaceutical industry. The IMI
acts as a neutral third party by supporting collaboration
among experts from industry and academia, and seeks
to accelerate antimicrobial discovery and development
Globalization and current widespread agricultural practices prevent hospitals and patients from existing in a secure void. These external realities can quickly upend the
benefits accrued by years of methodical AC and infection control measures in any one hospital, as demonstrated by the events following the admission of a sole
patient harboring a carbapenemase gene to a US hospital
[60].
Clinical interventions remain crucial, but they cannot
suffice in the face of AMRs current magnitude and crossdisciplinary complexity. Wide-ranging and highly coordinated efforts on several societal levels are imperative to
slow the course of AMR. Policies requiring the tracking of
antimicrobial dispensing in humans and animals are urgently needed. Data sharing and harmonization across national borders and industrial sectors, including pharma
and biotechnology, are essential. Table 2 lists the ten most
For industry:
10 Continue to develop and advance point-of-care rapid diagnostic
tests to avoid the prescription of antibiotics for viral infections and
allow more targeted therapy
Page 10 of 13
Conclusion
Antimicrobial resistance is a clear and present danger.
Immediate and coordinated measures must be taken
worldwide to safeguard remaining antimicrobials and facilitate the development of novel antimicrobials. Bans on
nontherapeutic antimicrobial consumption in livestock
must be effectively championed despite strong resistance
from industrial sectors. Conservation programs must be
further optimized and implemented in other, non-acute
healthcare settings such as long-term-care facilities. Educational programs targeting both antimicrobial prescribers and consumers must be further developed and
supported. The general public must continue to be made
aware of the current scale of AMRs threat. International
collaboration among researchers and policy-makers
must solidify to effect lasting reductions in the spread of
antimicrobial resistance.
Competing interest
The content of this paper expresses the views of its authors and in no way
represents the position of their affiliations.
Authors contributions
AHr conceived and drafted the manuscript and produced the different
versions. DP and SH provided an extensive review of the first draft of the
manuscript. SH, JC, SC, HG, VJ, AHs, and DP reviewed the manuscript and
provided important intellectual content. All authors have read and approved
the final version of the manuscript.
Acknowledgments
We thank Isabelle Caniaux for her outstanding support and organization of
the 4th WHAI Forum. We thank all participants, listed below, for stimulating
discussion.
Benedetta Allegranzi (WHO), Antoine Andremont (France), Rifat Atun (UK),
Lidao Bao (China), Hanan Balkhy (Saudi Arabia), Luis Bavestrello (Chile), Marc
Bonten (The Netherlands), Jean Carlet (France), Yehuda Carmeli (Israel), Otto
Cars (Sweden), Peter Collignon (Australia), John Conly (Canada), Sara
Cosgrove (USA), Alexander Friedrich (The Netherlands), Petra Gastmeier
(Germany), Abdul Kulakkattil Ghafur (India), Achilles Gikas (Greece), Marek
Gniadkowski (Poland), Herman Goossens (Belgium), Thomas Gottlieb
(Australia), M. Lindsay Grayson (Australia), Manuel Guzman (Venezuela),
Stephan Harbarth (Switzerland), Loreen Herwaldt (USA), Nordiah Hj Awang
Jalil (Malaysia), Alison Holmes (UK), Po-Ren Hsueh (Taiwan), Bi Jie Hu (China),
Susan Huang (USA), Vincent Jarlier (France), William Jarvis (USA), John
Jernigan (USA), James Johnson (USA), Mitsuo Kaku (Japan), Eui-Chong Kim
(South Korea), Keith Klugman (USA), Jan Kluytmans (The Netherlands),
Ramanan Laxminarayan (India), Thi Anh Thu Le (Vietnam), Moi Lin Ling
(Singapore), John McGowan (USA), Maryn McKenna (USA), Cliodna McNulty
(UK), Shaheen Mehtar (South Africa), Dominique Monnet (ECDC, self-funded
Page 11 of 13
observer), Maria Luisa Moro (Italy), Margaret Murphy (Ireland), Dilip Nathwani
(UK), Babacar Ndoye (Senegal), Lindsay Nicolle (Canada), Eli Perencevich
(USA), Trish Perl (USA), Carmen Lucia Pessoa Da Silva (WHO, self-funded
observer), Didier Pittet (Switzerland), Rosana Richtmann (Brasil), Christine
Rozan (France), Matthew Samore (USA), Kent Sepkowitz (USA), Wing Hong
Seto (China), Sanjeev Singh (India), Robert Skov (Denmark), Arjun Srinivasan
(USA), Evelina Tacconelli (Italy), Paul Tambyah (Singapore), Christiana
Vandenbroucke-Grauls (The Netherlands), Andreas Voss (The Netherlands),
Timothy Walsh (Australia), Bob Wachter (USA), Henrik Wegener (Denmark).
Funding
bioMrieux organized the 4th World Forum on Healthcare-Associated
Infections. The funding body had no role in the collection and interpretation
of data presented, including the writing of the manuscript, nor in the
decision to submit the manuscript.
Author details
1
Infection Control Programme and WHO Collaborating Centre on Patient Safety,
University Hospitals of Geneva, Rue Gabrielle-Perret-Gentil 4, 1205, Geneva,
Switzerland. 2Fondation Hpital St Joseph, Paris, France. 3Division of Infectious
Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland,
USA. 4Department of Medical Microbiology, Vaccine and Infectious Disease
Institute, University of Antwerp, Wilrijk, Belgium. 5Department of Infectious
Diseases and Immunity, Imperial College London, The Centre for Infection
Prevention and Management, London, UK. 6Laboratory of Bacteriology-Hygiene,
Assistance Publique-Hpitaux de Paris, Hpital Piti-Salptrire, Universit Pierre
et Marie Curie-Paris 6, Paris, France. 7Department of Medical Microbiology and
Infection Control, Radboud University Nijmegen Medical Centre and
Canisius-Wilhelmina Hospital, Nijmegen, The Netherlands.
Received: 31 October 2013 Accepted: 31 October 2013
Published: 18 November 2013
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from the 2013 World Healthcare-Associated Infections Forum. Antimicrobial Resistance and Infection Control 2013 2:31.