Antimicrobial resistance

Fact sheet N194 Updated May 2013

Key facts

Infections caused by resistant microorganisms often fail to respond to conventional treatment, resulting in prolonged illness, greater risk of death and higher costs. Tuberculosis strains resistant to isoniazid and rifampicin (multidrug-resistance - MDRTB) require treatment courses that are much longer and less effective. WHO estimates that there are about 630 000 MDR-TB cases in the world. Resistance to earlier generation antimalarial medicines such as chloroquine and sulfadoxine-pyrimethamine is widespread in most malaria-endemic countries. A high percentage of hospital-acquired infections are caused by highly resistant bacteria such as methicillin-resistant Staphylococcus aureus (MRSA) or multidrug-resistant Gram-negative bacteria. New resistance mechanisms have emerged, making the latest generation of antibiotics virtually ineffective.

What is antimicrobial resistance?

Antimicrobial resistance (AMR) is resistance of a microorganism to an antimicrobial medicine to which it was originally sensitive. Resistant organisms (they include bacteria, fungi, viruses and some parasites) are able to withstand attack by antimicrobial medicines, such as antibiotics, antifungals, antivirals, and antimalarials, so that standard treatments become ineffective and infections persist increasing risk of spread to others. The evolution of resistant strains is a natural phenomenon that happens when microorganisms are exposed to antimicrobial drugs, and resistant traits can be exchanged between certain types of bacteria. The misuse of antimicrobial medicines accelerates this natural phenomenon. Poor infection control practices encourages the spread of AMR.

Why is antimicrobial resistance a global concern?

AMR kills

Infections caused by resistant microorganisms often fail to respond to the standard treatment, resulting in prolonged illness and greater risk of death. The death rate for patients with serious infections treated in hospitals is about twice that in patients with infections caused by nonresistant bacteria.

AMR hampers the control of infectious diseases

AMR reduces the effectiveness of treatment, thus patients remain infectious for a longer time, increasing the risk of spreading resistant microorganisms to others.
AMR threatens a return to the pre-antibiotic era

Many infectious diseases risk becoming untreatable and uncontrollable, which could derail the progress made towards reaching the targets of the health-related United Nations Millennium Development Goals set for 2015.
AMR increases the costs of health care

When infections become resistant to first-line medicines, more expensive therapies must be used. The longer duration of illness and treatment, often in hospitals, increases health-care costs and the economic burden to families and societies.
AMR jeopardizes health-care gains to society

The achievements of modern medicine are put at risk by AMR. Without effective antimicrobials for care and prevention of infections, the success of treatments such as organ transplantation, cancer chemotherapy and major surgery would be compromised.
AMR threatens health security, and damages trade and economies

The growth of global trade and travel allows resistant microorganisms to be spread rapidly to distant countries and continents through humans and food.

Facts on antimicrobial resistance

In 2011 there were an estimated 630 000 cases of MDR-TB among the worlds 12 million cases of TB. Globally, 3.7% of new cases and 20% of previously treated cases are estimated to have MDR-TB, with substantial differences in the frequency of MDR-TB between countries. Extensively drug-resistant TB (XDR-TB, defined as MDR-TB plus resistance to any fluoroquinolone and any second-line injectable drug) has been identified in 84 countries globally.

Percentage of MDR-TB among new TB cases, 19942010 pdf, 730kb

Percentage of new tuberculosis cases with MDR-TB jpg, 546kb

A high percentage of hospital-acquired infections are caused by highly resistant bacteria such as methicillin-resistant Staphylococcus aureus (MRSA) and vancomycinor multidrug-resistant enterococciGram-negative bacteria .

Staphylococcus aureus (hospital isolates): percentage of methicillin-resistant strains, 2007, Latin America and the Caribbean pdf, 151kb

Ciprofloxacin is the only antibiotic currently recommended by WHO for the management of bloody diarrhoea due to Shigella organisms, now that widespread resistance has developed to other previously effective antibiotics. But the rapidly increasing prevalence of resistance to ciprofloxacin is reducing the options for safe and effective treatment of shigellosis, particularly for children. AMR has become a serious problem for treatment of gonorrhoea (caused by Neisseria gonorrhoeae), involving even "last-line" oral cephalosporins, and is increasing in prevalence worldwide. Untreatable gonococcal infections would result in increased rates of illness and death, thus reversing the gains made in the control of this sexually transmitted infection. New resistance mechanisms, such as enzymes produced by the bacteria that destroy last generation antibiotics, have emerged among several Gram-negative bacilli and have rapidly spread to many countries. This can render ineffective powerful antibiotics, which are often the last defense against multi-resistant strains of bacteria. This new resistant mechanism is encountered in ordinary human pathogens (e.g. Escherichia coli) that causes common infections such as urinary tract infection. Resistance to earlier generation antimalarial medicines such as chloroquine and sulfadoxinepyrimethamine is widespread in most malaria-endemic countries. Falciparum malaria parasites resistant to artemisinins are emerging in South-East Asia; infections show delayed clearance

(meaning that the parasite remains in the blood for longer), after the start of treatment and increased morbidity and mortality.

Percentage of patients with P. falciparum parasitaemia on day 3 after treatment with an artemisinin-based combination therapy (20062010) pdf, 530kb

Resistance is an emerging concern for treatment of HIV infection, after the rapid expansion in access to antiretroviral medicines in recent years; national surveys are underway to detect and monitor resistance. Because of the constantly evolving nature of influenza, resistance to antiviral drugs is continuously emerging. By 2012, virtually all circulating A viruses in humans were resistant to amantadine and rimantadine, while the frequency of resistance to the neuraminidase inhibitor oseltamivir remains low (1-2%) and no resistance to zanamivir has been detected. Antiviral susceptibility is monitored through the WHO Global Surveillance and Response System.

What accelerates the emergence and spread of antimicrobial resistance?

The development of AMR is a natural phenomenon. However, certain human actions actually accelerate the emergence and spread of AMR. AMR is a complex problem driven by many interconnected factors so single, isolated interventions have little impact and coordinated actions are required. Underlying factors that accelerate the emergence and spread of AMR include:

lack of a comprehensive and coordinated response; weak or absent antimicrobial resistance surveillance and monitoring systems; inadequate systems to ensure quality and uninterrupted supply of medicines; inappropriate use of antimicrobial medicines, including in animal husbandry; poor infection prevention and control practices; insufficient diagnostic, prevention and therapeutic tools.

WHO's response
WHO is guiding the response to AMR through:

fostering coordinated actions by all stakeholders;

creating policy guidance, support for surveillance, technical assistance, knowledge generation and partnerships; fostering innovation, research and development.

WHO calls on all key stakeholders, including policy-makers and planners, the public and patients, practitioners and prescribers, pharmacists and dispensers, and the pharmaceutical industry, to act and take responsibility for combating antimicrobial resistance.

Antimicrobial resistance: conserving lifesaving medicines takes everyones help

September 2013 The early 20th century was a time of ground-breaking scientific progress. One major advance was the development of penicillin and other antibiotics that has prevented thousands, even millions of people from dying of bacterial infections. As the century progressed, a wealth of better medicines led to stronger weapons against malaria, tuberculosis, and other communicable diseases. By the end of the millennium, new medicines meant that even HIV could become more of a chronic disease. But if the world does not move now to preserve the ability to treat infectious diseases that played such a key part in increasing life expectancy and improving human health, the 21st century may see the reversal of that progress.

Spread of antimicrobial resistance (AMR)

The challenge now is that medicines risk becoming less effective, said Dr Keiji Fukuda, WHOs Assistant Director-General overseeing the Organizations work on antimicrobial resistance. There are two main problems. First, people may have taken medicines unnecessarily, or not as they should be taken. Second, the medicines have not always been top quality. The natural reaction of bacteria, viruses and other pathogens is to fight back against the medicines people take to get rid of them. If people dont take medicine long enough, or if the drugs arent strong enough, resistant pathogens can survive and spread. This, in turn, means that people can remain ill longer and may be more likely to die.

WHO/S. Hollyman Misuse of medicines in people is not the only problem, however. The development of antimicrobial resistance is also driven by widespread use of antibiotics in livestock to promote growth and prevent illness. The spread of antibiotic resistance in livestock contributes to the spread of resistance in humans through food-borne illness and other routes of infection. The spread of resistance is further exacerbated by travel and population movement, making it easier for drug-resistant forms of a disease to spread to more people, and from one location to another. Antimicrobial resistance is a global problem with serious local impacts, adds Dr Sylvie Briand, Director of Pandemic and Epidemic Diseases. Conserving todays medicines for as long as possible will take action from everyone.

WHO action on AMR

Conserving our existing anti-infective medicines is only one of many areas of action needed. The WHO is therefore:

working to raise the awareness of antimicrobial resistance so more people involved in care-giving to both people and animals and in agriculture sectors can ensure that these medicines are used properly and appropriately; providing guidance and technical expertise to improve infection prevention and control in health-care and community settings; helping countries strengthen surveillance for early detection and their laboratory capacity for better, quicker analysis of drug resistance and its impact on the population; collaborating with other organizations, academia, civil society and industries that can join efforts to tackle the AMR threat; creating new business models to enable development of new tools to detect, treat or prevent these diseases.