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"Hi, I'm Superbug": AMR's Devastating Effect

“Hi, I’m Superbug”: AMRs Devastating Effects, is on antimicrobial resistance and its effect on global health, the global economy, and modern medicine. Addressing antimicrobial shortages, and looking on how to set up antimicrobial stewardship programs.
Heeta Patel
Grade 9

Problem

Antimicrobial Resistance: A Global Concern

Antimicrobial resistance makes many treatments that were capable become ineffective due to the evolution that occurs in bacteria, viruses, and fungi over time due to selective pressure. This makes them unresponsive to the medicines that were originally found for its treatment, resulting in uncontrollable spread and an infection becoming harder to cure. We are left with ineffective medication and infections that stay in the body, as the aftermath of this situation. However what accelerates this problem is that the mutations can be passed on, and help other bacteria develop characteristics that allow for them to develop a resistance as well. These resistance mechanisms are developed using the instructions that are provided by its DNA and can be found in plasmids, which allows the bacteria to share its DNA with others. Some may even develop several different resistance genes that accumulate in the DNA producing multidrug-resistant bacteria which have almost no treatment options remaining. These genes may be passed on by:
 
- Reproduction (Binary Fission): The DNA will replicate, and the bacterial cell will split into two daughter cells each with identical DNA as the parent cell.
- Conjugation: The donor connects through pilli to share their genes to the recipient.
- Bacteria have a relatively short life span, therefore at death the bacterial cell may leave its genes for others to collect.
 
These resistant bacteria will continue to thrive as the non-resistant bacteria will be easily killed off in an antibiotic rich environment. Giving the resistant bacteria less competition. The resistant bacteria are referred to as “superbugs,” and have many defense mechanisms that allow them to persist in their environment. This includes:
 
- Bypass effects of Antibiotics: Develop new cell processes that avoid using the antibiotic’s target Ex) Staphylococcus aureus can cause anything like skin infections to pneumonia. They have mutated which allows them to alter where the antibiotic has to target. 
- Restrict Access of the Antibiotic: The bacteria will limit or change the amount of entryways.
Ex) Gram-negative bacteria have a membrane that keeps antibiotics from entering.
- Get Rid of Antibiotics: Bacteria get rid of antibiotics through pumps in their cell walls.
- Change or Destroy the Antibiotic: Bacteria change or destroy the antibiotics by producing enzymes that break down the drug. Ex) Salmonella produces enzymes like B-lactamase that break down the antibiotic before they do any damage.
 
Team:CSU Fort Collins/Description - 2019.igem.org
 
I) How Antimicrobial Resistance Works: Antimicrobial resistance is becoming a growing problem, and can not be stopped. As the bacteria will mutate under selective pressure resulting in resistant genes that can be shared with other bacterial cells, and to other people.

Method

Method

To achieve success in finding an effective solution to antimicrobial resistance, and the problems it causes like ineffective medicine, expensive treatments, shortages of antimicrobials, and a decline in global health, I knew that an effective solution had to be created. My first step was collecting information from trustable, and credential sources, that allowed me to get the proper background information, and different perspectives into antimicrobial resistance. From the background information I collected into what antimicrobial resistance was, what antimicrobials are, and how the resistance develops, I looked into the causes to see if alternate solutions or ideas could be created. It was just as important to look at how spread occurs in a community, why shortages occur, what could happen to the economy if AMR continues to increase, and what other projects and research was going into helping to slow down resistant bacteria. From there I was able to get an idea into effective alternatives, and how to create antibiotic stewardship programs. Drawing a conclusion that more time has to be initiated into alternatives like vaccines, and probiotic and antibiotic combinations that could help resistant bacteria from occurring, and finding a cure to the resistant bacteria that exist. It is a way to address shortages of antimicrobials, and help save costs to the economy. Learning about the core elements and importance of developing proper antimicrobial stewardship programs (from CDC and WHO), I was able to say that emphasis has to be put into developing these programs on farms, to help slow spread in developing countries especially.

Research

What are Antimicrobials?

Antimicrobial products kill or slow down the spread of microorganisms like bacteria, viruses, fungi, and protozoans, without harming or damaging the host. Alexander Fleming a physicist and microbiologist is known for his amazing discovery of the first effective antibiotic penicillin in 1928. He discovered that penicillium mold could wear down bacteria like Staphylococcus aureus, and by the mid 1940s they found that even low levels of penicillin could cure infections. It was then opened to the public, and sparked a new era of discoveries of new antimicrobials, and antibiotics. This era raised the life expectancy of an average human by 8 years between 1945-1972. Antimicrobials can be classified into many groups based on composition:

- Natural: Antimicrobials that are composed of natural materials from the environment, mostly plants and contain essential oils that can protect against certain microorganisms. Ex) neem leaf oil, oregano oil, garlic, honey.

- Synthetic: Made by chemical synthesis, but are man-made or by a synthetically formed compound as well. The antimicrobials are based on the structure of natural products. Ex) sulphonamides, cotrimoxazole, quinolones, chloromycetin (first synthetic antibiotic discovered by Parke-Davis team)

- Semi-Synthetic: These are antibiotics that are based on natural antibiotics, however one microbe is modified to help make it more advantageous. They may modify an antibiotic so they can act against a resistant bacteria, or cause fewer side effects. Ex) penicillin can have an addition of an amino group to the R group to form a semi synthetic antibiotic called ampicillin.

The antimicrobials can also be classified based on their role, and how they attack or target the bacteria. There are 3 main groups cell wall synthesis (beta lactam) , nucleic acid synthesis, and protein synthesis:

- Protein Synthesis Inhibitors: A substance that stops or slows the growth or rapid increase of bacterial cells by disrupting the processes of protein synthesis and production. Ex) tetracycline, chloramphenicol, and aminoglycosides

- B-lactam Antibiotics: Most commonly prescribed drug that was first discovered and started to be used by the general public since the 30s. It is a class of natural and semisynthetic antimicrobials that have a lactam ring. They work by stopping the mechanisms that are responsible for building the cell wall, and may even prevent nutrients from reaching the bacteria. Ex) penicillins, carbapenems, and monobactams

- Nucleic Acid Synthesis Inhibitors: It inhibits the cell from producing proteins by damaging or stopping the production of the DNA and RNA of the bacterial cells. Ex) quinolones, ansamycines, rifampicin

III) The 3 Main Groups of Antimicrobials: There are 3 main groups, cell wall synthesis, nucleic acid synthesis inhibitors, and protein synthesis inhibitors. Beta Lactams being one of the most commonly prescribed types of antibiotic.

 

What Causes AMR to Spread?

Organisms that carry antimicrobial resistance are found in people, animals, food, plants, and the environment. They are all linked closely together, and resistant genes can easily spread between them. Some of the main drivers of antimicrobial resistance is misuse and overuse, lack of clean water, poor sanitation for humans and animals, and poor infection and disease control in healthcare facilities and farms. Bacteria evolve differently depending on the environment and selective pressure. Therefore it makes antimicrobial resistance more common in some countries, and makes different countries have different types of resistant bacteria. Travellers can easily pick up these resistant bacteria by eating contaminated food or water, and touching contaminated surfaces. They will bring these bacteria back, and will spread to others through daily life activities. Antibiotic pollution is when unaltered antibiotics are secreted through humans and animals through feces. These contaminate sources like agricultural crops through finding their ways into water and soil through fertilizers, leaching, and runoff. Most of these crops are turned into food for us, or for animals, which all impact the general public. For example take the cholera that took place between 1848-1854 (diarrhoeal disease that can kill within hours if left untreated) in Soho London. Due to sewage that was dumped into rivers, it contaminated the water supply, leading to a huge spread of the disease, killing 600 people in one week. This can happen to us today, and is happening in some countries, where the slightest bit of cross contamination leads to the development of AMR. But antimicrobial resistance can hugely impact low and middle income communities, due to poor access to quality and effective antibiotics. Middle income countries like Thailand, Ecuador, Venezuela had high DRI (Drug Resistance Index) scores as antibiotics are cheap, less effective and highly accessible. This allows for resistant bacteria to persist and reproduce due to the misuse that occurs. Canada, Norway, and Finland had low DRI scores as antibiotics are expensive and more effective, which allows for bacteria to be killed off, and decreases the chances of mutations. India leads the world in antibiotic consumption per person, which resulted in them having the most drug resistant pathogens. Another huge attribute affecting this low, and middle income countries and their DRI scores is the lack of sanitation, hygiene, and proper enforcement. The last effective antimicrobial was discovered in 1987, and since then no other has been put into use for the public. Even if a very strong antibiotic is found, it will end up evolving and mutating at one point.

IV) The Spread of Antimicrobial Resistance in the Community

 

Misuse and Overuse

Misuse and overuse of antimicrobials often occurs because patients will pressure, and ask to receive unnecessary prescriptions. One-third to one-half of antibiotic use in humans is unnecessary or inappropriate according to the Centers for Disease and Control. One common mistake that occurs is that some will accidently take antibiotics for a viral infection, which will result in the medicine attacking the harmless, beneficial bacteria in your body. This can promote resistance in the harmless bacteria, or even allow the harmful bacteria to replace the harmless ones. It is important that we let milder viral infections run their course, and don’t ask for antibiotics because they are only ever used for bacterial infections. But if we are prescribed antibiotics we have to take the full amount written (and if the doctor says not to finish the course or you have expired antibiotics anywhere in your home it should be given back to the pharmacy where it will be properly disposed). We should not save antibiotics for “next time” or for other family members to use. Misuse of antibiotics can also occur in the agricultural and food industry when they are used as animal growth promoters on farms or in aquaculture. Using non therapeutic antibiotics on farms can transmit resistant genes into humans, through runoff that leaches into water, and food like meat. Overuse of antibiotics has made certain bacteria resistant to some of the most powerful antibiotics today. Taking antibiotics appropriately will prevent future more serious, dangerous and expensive situations from occurring.

II) The Cost of Misuse and Overuse: Misuse and overuse of antimicrobial products increases the spread of antimicrobial resistance. Using antibiotics when not necessary, not finishing courses, and not properly disposing antibiotics are all forms of misuse.

 

Self Medication

Self medication is a human behaviour in which an individual uses a substance and self administers the treatment for minor physical illnesses. Self medication of antibiotics is an inappropriate use, and is contributing to antimicrobial resistance, increasing health care costs and resulting in higher mortalities and morbidities. While in most countries legislation doesn't allow people to buy antimicrobials over the counter, some places have not properly enforced this law. This situation is known as “the fuel for the evolution of resistant microbes.” Another way self medication can be defined is as the selection and use of medications based on self diagnoses. Self diagnosing has led to people not getting professional consultation, that leads to severe diseases, resistant bacteria, drug dependence, and has become a form of misuse. Antimicrobials are usually found being sold without a prescription in developing countries.. A study in Saudi Arabia found a 78.7% self medication rate of antimicrobials. A study in Pakistan showed that 15.2% of self consumed antimicrobials were taken for viral illnesses like colds, flus, fevers, and sore throats. The lack of education and enforcement on this issue has had a huge influence on the public. For example, a study was conducted in Malaysia where a total of 649 students (medical and non-medical students) reported they self medicate, and 89% believe it is good and acceptable, however that isn’t the case. But now people have access to online pharmacies, aside from community ones, that allow for antimicrobials to be sold without a valid prescription. Ex) A study was conducted in China looking if pharmacies would sell medicine without a valid reason.Three undergrad medical students would go to the pharmacies and give the reason “they need antibiotics for a trip.” From 675 community pharmacies from 9 provinces, 86% gave antibiotics without any prescription. From 220 online pharmacies from 9 provinces, 79% gave antibiotics without any prescription. Antimicrobial resistant bacteria has become common in these communities, as they have frequent non-prescription use.

 

The Economic Effect of AMR

The cost of antimicrobial resistance is significant to the economy. AMR not only leads to death, disabilities, and prolonged illnesses, but it also results in longer hospital stays, and the need for more expensive medicines.  This sets a financial challenge for most people and the government as well. The rapid growth and global spread of multi and pan-resistant bacteria causes infections that are not treatable with existing antibiotics. Without effective antimicrobials, the success of modern medicine in treating infections, including major surgeries and cancer chemotherapy will be at an increased risk. The top resistant organisms are methicillin-resistant staphylococcus aureus (MRSA), pseudomonas aeruginosa, klebsiella pneumoniae, escherichia coli, and acinetobacter baumannii. These are bacteria that have become resistant to multiple antibiotics and are usually found in the care settings.

- This following information was collected from a hospital in Ontario, and shares the direct and indirect costs of AMR. The 5 infections stated could cost  $9.9 million to manage at an acute care center with 400 beds. In addition this hospital has recorded that these infections have the cost of 2.1 million dollars, and another 1.1 million dollars to manage these patients. The number of deaths at this hospital annually is 149 cases of them 45 are due to resistant bacteria. If we were to extrapolate this data to 100% the cost could rise to $30 million and nearly 700 deaths annually. - In Canada there are about 250,000 cases of AMR, with 5,400 deaths due to resistant infections. If this continues, by 2050 Canada will face an annual of 7,000 deaths and make healthcare costs go up to $6 billion. 

- In India almost 50,000 newborns die from sepsis ( when the body's response to an infection damages its own tissues) due to pathogens resistant to first-line antibiotics. The mortality of infectious diseases in India today is 417 per 100,000 persons. By 2050 there will be 2 million deaths in India.

-According to the Center of Disease and Control more than 2.8 million antibiotic resistant infections occur, and 35,000 people die costing the healthcare system $20 billion.

If this is the case in multiple countries, the cost on global health and the economy is unimaginable. It is estimated that by 2050, the world will suffer 10 million deaths, and will cost the global economy $10 trillion. In a high AMR impact scenario an additional 24 million people will be forced into extreme poverty by 2030, and it will mostly occur in low income countries. If new antibiotics were to be introduced, and we don’t change our ways they will suffer the same fate.

 

Interactions Between AMR in Hospitals

Nosocomial infections (healthcare associated infections) affect up to 15% of all hospitalized patients, due to persistent microbial contamination, and the growing resistance in these microbes. These infections can happen anywhere in a hospital, nursing home, long-term care facility, and surgical centers. Nosocomial infections may spread indirectly through respiratory droplets, airborne spread, and common sources, or just through direct contact between patients, workers, and visitors. Hospitals have become a reservoir of pathogens, and are spreading resistant strains of bacteria to the general public like clostridium difficile, the main agent for health care- associated infective diarrhea. For a long time hospital cleaning was an aesthetical requirement, but as they realized microorganisms can survive for long periods of time on surfaces they knew that a solution had to be found. However so far sanitation has totally been based on chemical disinfectants, but it is shown that 50% of surfaces are not properly decontaminated by these products, and that recontamination can occur as fast as 30 minutes. Chemical sanitation is not only making bacteria found in hospitals develop resistance to the sanitizer itself, but antibiotics too. Different patients, workers and visitors have developed different resistant bacteria which can all be spread amongst them. Scientific evidence shows that correct and appropriate cleanliness of hospital environments, and proper hand hygiene is the only way to stop resistant microbe transmission. Many strategies are being developed to help solve this issue, and promote a safer environment for all. This includes:

- Screening: Some places screen for resistant bacteria by swabbing the nose, rectum, armpit, or a combination of body sites with a q-tip or sponge, that is sent to a laboratory and is tested. Depending on these test results proper precautions will be taken to protect the patients and others.

- Emitted UV Light: In some rare situations depending on the intensity of light and the position of the lamp, it is shown to help against multi resistant gram-negative bacteria, and offers better cleanliness, however it isn’t yet refined to become an effective substitute. 

- Self-Disinfecting Systems: Using metals like iron, copper, and silver to kill bacterial cells. For example silver ions can bind to thiol groups which are present in bacterial cell wall proteins  inactivating them. Copper can generate reactive oxygen species which can damage microbial lipids, nucleic acids, and proteins leading to cell death.

V) Nosocomial Infections: It is important that antimicrobial stewardship programs, clean practices, better sanitation, and proper hand hygiene is developed in health care centers, to prevent the spread of resistant nosocomial infections.

 

Finding A Cost Effective Solution To Antimicrobial Shortages

In this era of bacterial resistance it is no longer easy to choose the best antimicrobial to help treat an infection. It has become quite complex and proper consideration has to be taken on the impact of antimicrobial resistance on the infection. Therefore resulting in one, or multiple antibiotics being prescribed depending on the specific strain in the environment and the selective pressure. Some may not have developed a resistance, and some may be multi-drug resistant. This has resulted in shortages and discontinuation of multiple antimicrobials. For example an antimicrobial like penicillin is now rarely prescribed and has become less effective, resulting in shortages for antibiotics that can be used to treat bacterial infections in the respiratory system and throat. With a lack of research into new drugs antimicrobial shortages are prone to occur, and we either have to find a solution or an alternative.

Vaccines: The future of antimicrobials isn’t looking that clear. Vaccines can become an effective alternative, as they will help reduce the spread of antimicrobial resistance, but also help the global economy be saved from costs treating these resistant infections. We need vaccines to help stop the spread of resistance and help people's immune systems be able to recognize and defeat these strains. More research and time has to be put into developing effective vaccines, not only helping the economy to save money, but stop the misuse and overuse of antimicrobials.

Probiotics: Antibiotics are effective against most common diseases, but resistance is increasing. The combination of probiotics (live bacteria and yeasts that are good for you)  and antibiotics has been observed to reduce the incidence, duration and/or severity of antibiotic-associated diarrhea. Statistical analysis has shown that a probiotic paired with an antibiotic resulted in a 66% reduction of C difficile-associated diarrhea (common in hospitals). This contributes to better adherence to the antibiotic prescription and thereby reduces the evolution of resistance. However the effect probiotics have directly on AMR is still under research, this combination may be a solution to antimicrobial resistance.

Communication and Proper Legislation: Proper communication should occur from marketers of antimicrobial products regarding potential shortages. Tracking resistance patterns and sales of different prescribed antibiotics will help for proper action to be taken. If proper legislation is enforced on the proper usage of these products, the major effects it costs will be taken away, slowing down the spread of antimicrobial resistance, and helping to reduce shortages.

 

COVID-19

The spread of the novel coronavirus has led to the confirmation of proper hand hygiene being hugely important. The World Health Organization had recommended alcohol based hand sanitizers, when there isn’t access to wash your hands.  However while hand sanitizers have been used since the last decades to help control the spread of microbial-born diseases worldwide, it is said that the overuse of hand sanitizer can lead to antimicrobial resistance. The repeated exposure to these alcohol based disinfectants tends to allow microbes to slowly mutate and make them resistant, and continue to survive. In addition this results in non-resistant microbes to be eliminated and resistant ones to strive, and be spread. This is not an occurrence just for the coronavirus but many other infections as well. It is perfectly fine to use 60% or more alcohol based hand sanitizers when you don’t have access to wash your hands. But if you do or as soon as you do, you should follow the proper instructions on how to do so with soap. As lathering scrubbing the soap against your hands physically destroys and removes germs from your skin and entering into your body. Antibiotics will not be effective for the coronavirus, as it is a viral infection, and by taking antibiotics we will harm the beneficial cells in our body. This would all be a form of misuse, and what we need is a vaccine. The emergence of finding effective vaccines is necessary. Some have already been found and administered, like Pfizer, Moderna, and Johnson and Johnson. Vaccines will become an effective way to help slow down the spread of AMR, and become a replacement for antimicrobials. Effectively preventing resistant bacterial infections, transmission, and reducing antimicrobial misuse.

Reduce the spread of COVID-19: Wash your hands infographic - Canada.ca

VI) Covid 19: The Coronavirus has helped prove the importance of proper hand hygiene, as overuse of hand sanitizers can lead to antimicrobial resistance. When you wash your hands you are physically destroying the germs. The technique is important, not the type of soap.

 

Antimicrobial Stewardship

Antimicrobial stewardship is a way to improve how antibiotics are prescribed by clinicians and used by patients. By improving how antimicrobials are prescribed and its proper usage will allow to treat infections, and protect patients from harms caused by misuse. “It will help in the combat of antibiotic resistance,” as stated by the CDC. Antimicrobial stewardship also focuses on the appropriate selection, dosing, route and duration of antimicrobial therapy that allows for optimal power. It is important to initiate and sustain an effective antimicrobial stewardship program. There are a couple of key elements necessary for antimicrobial stewardship in the hospital and nursing homes. These following core elements of antibiotic stewardship are outline by the Centres for Disease Control and Prevention:

Leadership Commitment: It has become important to show the commitment and support that is needed for proper use of antimicrobials. It is important to have the support of seniors like a chief medical officer or director of the pharmacy. Having regular meetings and reporting stewardship activities to the board on a regular basis.

Accountability: It is important to have a leader of the program that can manage and help lay down clear responsibilities and expectations for the most optimal outcomes. This may be a physician or nurse.

Drug Expertise: It is important to have the engagement of a pharmacist that can help lead implementation efforts to improve antibiotic use.

Action: Implement strategies like preauthorization (requires prescribers to gain approval prior to the use of certain antibiotics) and get reviews from experts.

Tracking: It is critical to see opportunities for improvement. Tracking allows the program to monitor prescribing, see the impact of the strategies implemented, and be able to see the resistance patterns that are occurring.

Reporting: It is important to share the information received on antibiotic use and resistance to leaders, so they can work, and create plans accordingly.

Education: Antibiotic stewardship is a way to help support proper prescribing. It is important that the program shares knowledge on proper prescribing to pharmacists, nurses, and prescribers about the effects of antimicrobial resistance.

Antimicrobial stewardship programs are essential to slow down the spread of AMR due to misuse, and to avoid nosocomial infections. Alberta Health Service has its own stewardship program that has allowed many essential influential protocols to be passed. Antimicrobial resistance is stated in as one of the top 10 health crises facing humanity, and it has become extremely important to share global awareness (Nov 18 -24 is World Antimicrobial Awareness Week).

VII) Elements for Creating Antimicrobial/Antibiotic Stewardship Programs

 

Spreading Awareness

The only solution to slow down antimicrobial resistance is a one health approach, and it requires the collaboration of multiple disciplines working locally, nationally, and globally to achieve the  optimal health of all.

Global:

The tripartite collaboration between The World Health Organization, Food and Agriculture Organization of the United Nations, and the World Organization for Animal Health have worked together to form the global action plan which surveils antimicrobial use and sets guidelines for the globe to exert. The World Health Organization has also set out a priority pathogen list with a list of 12 families of resistant bacteria that need antibiotics urgently.

National:

The World Health Organization, Food and Agriculture Organization of the United Nations, and the World Organization for Animal Health have collaborated in assisting countries to refine their national plans, that can be adapted to meet circumstances and their available resources. “Many countries are taking concrete steps towards the responsible use of antimicrobials in agriculture,” says Maria Helena Semedo, FAO Deputy Director-General. It has become a priority to help low and middle income countries be guided to responsible antimicrobial use in animals, plants, and humans.

- Canada is addressing antimicrobial resistance by releasing a federal framework for proper use of antimicrobials in Canada. They are working in areas of surveillance, stewardship, and innovation. In addition  it has become important to shine light on proper alternatives for the agricultural sector, and strengthen the promotion of proper antimicrobial use in this section as well. The Canadian Integrated Program for Antimicrobial Resistance Surveillance and the Canadian Nosocomial Infection Surveillance Program are all helping to track antimicrobial use, and helping hospitals in Canada become safer from resistant infections.

- The Indian Network for Surveillance of Antimicrobial Resistance and The Food Safety and Standards Authority of India are working together to help support and track the increasing amount of resistant bacteria. In addition they are all closely following the dairy sector (cattle especially), livestock, aquaculture, and poultry industries to help regulate antimicrobial use in India. It has become important that proper legislation is enforced.

- The UK Department of Health and the United Nations has launched the Fleming Fund that helps low and middle income countries address AMR.

Local/Individual:

It has become important that local communities initiate proper usage of antimicrobials to citizens, and as individuals we follow these rules to help slow down the spread of antimicrobial resistance.

- The University of Calgary is focusing research (27 projects) on treatment optimization, policies and commercialization, AMR surveillance, and infection prevention, and control through a pan-Alberta platform called the one health consortium.

- As individuals it is important we follow proper hand hygiene, don’t misuse antimicrobials (follow schedule, don’t save), and get immunizations. It is important we follow reliable sources as proper education and knowledge plays a huge aspect on proper usage.

VIII) A One Health Approach: The collaboration of local communities, nations, and the globe is needed to help address antimicrobial resistance that spreads through different sectors in the community.

Data

Data

IX) Antibiotic Approval: This graph was created by Clearvue Health and it shows how there was a great amount of creation, approval, and production of antibiotics in the late 1900’s (known as the golden era of discovery of novel antibiotics). However due to the increasing cases of more resistant bacteria, and many even being multi-drug resistant, fewer antibiotics have been developed and approved.

 

X) DRI Scores: This graph was created by the World Bank. Middle and low income countries like Thailand, Ecuador, Venezuela, and India had high DRI (Drug Resistance Index) scores as antibiotics are cheap, less effective and highly accessible. This allows for misuse and ineffective treatment. However Canada, Norway, and Finland had low DRI scores as antibiotics are expensive and more effective. Allowing for effective treatment, and they have stricter protocols, and information sent to educate the public on misuse.

 

XI) Effect on Global Economy: This graph was created by the World Bank to show the effect of antimicrobial resistance on the global economy. As presented the low case assumes a 5% resistance rate. The middle case assumes that the resistance rate will be 40%. The high case represents a 100% resistance rate. If the spread of AMR doesn’t slow down, it could cost the global economy 10 trillion dollars by 2050.

 

XII) Spread of AMR: This graph was created by CDDEP ResistanceMap. It shows how most bacteria have developed a resistance to common antibiotics that are prescribed. This shows how bacterial cells will continue to evolve and develop resistant genes under a selective pressure. We can’t stop antimicrobial resistance but we can slow it down.

 

XIII) Spread in Nursing Homes: This graph was created by Infect Control Hosp Epidemiol. It shows the annual amount of cases of antibiotic resistant bacteria, C. difficile, and both in patients, visitors, and workers in nursing homes. Spread has to be properly contained in hospitals through proper sanitization, hand hygiene, and tracking, or else rates of nosocomial infections will increase, and develop resistance.

Conclusion

Conclusion

There will never be an end or solution to stop antimicrobial resistance. We cannot control or establish laws that can stop or conduct people’s daily lives, to avoid the spread of resistant bacteria. It is spread through both indirect and direct contact, developing resistant bacteria in people that may have never been exposed to the infection or antibiotic itself. Costing more for effective treatment and medication to be taken and posing financial challenges for them, and health care systems. It leads to ineffective medicine, higher mortalities and morbidities, antibiotic shortages, and a huge stress on the economy. However there is a probability of slowing the expansion of antimicrobial resistance down, but it will require the attention of the global population.  We can administer rules and regulations that take care and teach the public the adverse effects of misuse of antimicrobials, like throwing them away without finishing a course, sharing with others, and saving for the “next time.” We can find effective ways to deal with shortages that are caused by antimicrobial resistance, with alternative situations like vaccines, pairing with probiotics, and proper communication with antimicrobial marketers and the government. First world countries can unite and help developing countries into enforcing proper antimicrobial usage, establishing antimicrobial stewardship programs, and find ways to make effective, expensive treatments become affordable. It is just as important to help the global agricultural industry, and other farmers in helping to stop antimicrobial resistance in animals and plants. This may be by setting rules on antimicrobial usage on farms, and setting protocols for farmers to make sure the spread of resistant bacteria is contained in the area if antimicrobials are used. Encouraging proper hand hygiene is also very important for everyone. Antimicrobial resistance is one of the top ten health risks facing humanity, and is estimated to cause 10 million deaths and cost the global economy $10 trillion by 2050. If communities, nations, and the globe do not collaborate to form a one health approach global health, and modern medicine is at stake.

 

My Future Changes and Ideas on This Project

Through collecting research on antimicrobial resistance, and becoming informed about the direct and indirect effects it has in hospitals, farms, agriculture, the public, global health, and the economy. It has become crucial to find an effective solution in slowing the spread down. We have hit a new era of antimicrobial resistance, where the last successful antibiotic family had been found all the way in 1987. From this I believe that it has become time to change our gears and start initiating our focus on the research of vaccines, a possible effective alternative, in slowing and avoiding resistant bacteria. However we can’t simply just divert research into a new field that quickly, therefore I believe and support the World Health Organization and the Centres for Disease Control and Prevention on enforcing proper antimicrobial stewardship programs in hospitals around the world, especially in developing countries. This will help influence and educate the general public, and hopefully put an end to misuse and overuse of antimicrobials. While these organizations have promoted these programs in hospitals and nursing homes (to avoid spread of resistant nosocomial infections), I believe that it is just as important establishing them at farms, and getting input from veterinary doctors and people that work in the animal and agricultural industry. We need to increase our attention towards animal and plant health, as well as promoting proper hygiene in these sectors. From what I have learned from this project, and some of my own ideas, in the future I would like to research the role of vaccines in the community, and put a stop to anti-vaccination. If I were to make changes on this project I definitely believe I can put more emphasis on the animal and agricultural side of antimicrobial resistance. Small changes in my daily routine, and motivating others to do the same, can save modern medicine from AMR.

Citations

Citations

Research

About resistance. (n.d.). Retrieved March 16, 2021, from https://apua.org/about-resistance

Antibiotics. (n.d.). Retrieved March 16, 2021, from https://www.hopkinsmedicine.org/health/wellness-and-prevention/antibiotics

Antibiotics: Are you misusing them? (2020, February 15). Retrieved March 16, 2021, from https://www.mayoclinic.org/healthy-lifestyle/consumer-health/in-depth/antibiotics/art-20045720

Canada, P. (2014, November 13). Government of Canada. Retrieved March 16, 2021, from https://www.canada.ca/en/public-health/services/antibiotic-antimicrobial-resistance/antimicrobial-resistance-use-canada-federal-framework-action.html

Core elements of hospital antibiotic STEWARDSHIP PROGRAMS. (2020, November 16). Retrieved March 16, 2021, from https://www.cdc.gov/antibiotic-use/core-elements/hospital.html

D'Accolti, M., Soffritti, I., Mazzacane, S., & Caselli, E. (2019, March 27). Fighting AMR in the Healthcare Environment: Microbiome-based SANITATION approaches and monitoring tools. Retrieved March 16, 2021, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6479322/

Haque, M., Rahman, N., McKimm, J., Kibria, G., Majumder, M., Haque, S., . . . Othman, N. (2019, May 17). [Full TEXT] self-medication of Antibiotics: INVESTIGATING practice Among University: Idr. Retrieved March 16, 2021, from https://www.dovepress.com/self-medication-of-antibiotics-investigating-practice-among-university-peer-reviewed-fulltext-article-IDR#:~:text=Self%2Dmedication%20of%20antibiotics%20(SMA)%20has%20been%20recognized%20as,medication%20is%20considered%20as%20irrational.&text=Globally%2C%20the%20non%2Dprescription%20consumption,for%20antimicrobial%20resistance%20(AMR).

One health. (n.d.). Retrieved March 16, 2021, from https://www.who.int/news-room/q-a-detail/one-health

Stop overuse and misuse of antibiotics: Combat resistance. (n.d.). Retrieved March 16, 2021, from https://www.who.int/westernpacific/news/detail/10-11-2017-stop-overuse-and-misuse-of-antibiotics-combat-resistance

Study examines clinical and economic impact of antimicrobial resistance at acute care facilities. (n.d.). Retrieved March 16, 2021, from https://www.oha.com/news/study-examines-clinical-and-economic-impact-of-antimicrobial-resistance-at-acute-care-facilities#:~:text=With%20increasing%20resistance%2C%20the%20growing,trillion%20to%20the%20world%20economy.

 

Pictures and Data

I) How Antimicrobial Resistance Works:  

http://modmedmicro.nsms.ox.ac.uk/wp-content/uploads/2018/06/amrdescription.png

II) The Cost of Misuse andOveruse:   https://lh4.googleusercontent.com/OODtw2ibll2j0pPlIgLEDvtVtsMNLqvvZana9LuiYnidoNs8yyZtSWND6dr271EXp6SBdrHoZUxUYqYlFa3se9C9RKYA4l_a_euf741moT8DCiwbSm_GSCxEL9gAsWniMaD3fY

III) The 3 Main Groups of Antimicrobials:

https://lh3.googleusercontent.com/iMW2Ij4Xx7CzsqVAhOeb1Mr_daPtkh8TCWJYhD245Y5NGaON68OD8UWNdZeHRTIqmHx-gHPcNlFe8fsAkId4EHrjVdYRMWsOhbWdjWii5eKXtcXsTNlSD5SVYieYFJ8nvqG4P8k

IV) The Spread of Antimicrobial Resistance in the Community:

https://lh3.googleusercontent.com/MbZ-VPsJUXzVu_89AtdDCd4bre4v-Vb9-II-s9K7XWml9ZEFCREcdWcW6faOuUm6nfq_JVKLZTrSXE7iwGQOn95taynWXPOdr3XbI5cYhgynfumV2O4KHUIejfETPqW8cj-ff_k

V) Nosocomial Infections: 

https://lh4.googleusercontent.com/yBRVL0PRopXOeQudbT1vfiwTEHkGeJQlWDXoc8YneATexr789vcXmMu7th_6yuu3PsmpWL3u4WwZCobV1yNQHGDsIAvDREend4yGWbLO8P8NOL5ag9LbvyYo8opIZAXLrE-u1I4

VI) Covid 19:

https://www.canada.ca/content/dam/phac-aspc/images/services/publications/diseases-conditions/reduce-spread-covid-19-wash-your-hands/eng-washthumb.jpg

VII) Elements for Creating Antimicrobial/Antibiotic Stewardship Programs:

https://lh6.googleusercontent.com/7F6syifozehIhYEHbdqXlEhMT7Mfs9Ys1O_fdueOQ7RHWE9Tmm9YUxStCFVrZST0v8LmtIWDT1A_sNHL5VhFDkDW4DoWR5tSHmOoFfeg3QjMmcNC965u6ljEkTwjUDN3Aqh_VU4

VIII) A One Health Approach: 

https://lh4.googleusercontent.com/hGirhYCGjFBSNOWmLiYvN6zxq4Sr1GmcsDbPw0KGAF4fxZDnZGdlWGc9lQwNLdNrGsWQK0ZcnUuL0d9Rjkjcp0s7zNNepzGr9hLNUqU5pM8DBrccXQzioSxUMR9t9ou9Fsde4EU

IX) Antibiotic Approvals:

https://lh5.googleusercontent.com/H_-EAvCK19CHkunjn1YpQwmPadUdJR_HF2VlmRZlPOj--3IDf-CM6nIP7AnzTjEwe-ayWTqjvk8Y1HptYtr2jDRQONsBp7YNb40gzQyj_apccOFhqjgwKmi77_0TvnWx9WBpLB8

X) DRI Scores:

https://lh3.googleusercontent.com/XnXsEHRG0m6N0a5fM2BrbMEQjWc5rejU1OQ3Cx_cpS60yVPE-0c2496UdDQbG7LtA62MtiExzz4DA6wvXcvBzeNsblO6oL4V2DVqNrBc6pVWmABPIH6xT_FRyX1bhgZ8dXc2XOc

XI) Effect on Global Economy:

https://lh6.googleusercontent.com/j1LAHKn0hyHS-lTD7eO2bO0-jrVC0wqN_o2GNUTQROrVHE9QlNUW2e1VL1TPnQY0NnjXz4j5PZlcnFaYB_otV333I7U3WFZk3Yzkk3Y0bxVQy4gGqiotIc82U3rztiT-XGoXp1w

XII) Spread of AMR:

https://lh5.googleusercontent.com/MmT6vRacAv6S7D8AdKg-j3n_Qi-V7x4OcRpU8_l5LK7_sTq1XFVGgZGr0_L4fYXKSZNem3mk5BIkZL65Sr0F9TWR-Kao_1BvBggPQ5HD6dKj27SgjP5zJu0j5c1IVQylm0bCY8I

XIII) Spread in Nursing Homes:

https://lh3.googleusercontent.com/wS-Cb2YclAuuRqz2EDfTRECFHl4nnd-slUoROiUJs05jo4T2RmBcb-eAvsQpoLf40DWXBZXkAoKc8c4wUS1nES36i2A4m0FdQ5rGLMkh3JYMOdGeyW3w5xyfj2Qhz_PzNGrKOWU

 

Acknowledgement

Acknowledgment

I would like to thank my sister, Aayushi, for helping me to edit and verify my project. I would also like to thank my science teacher Mrs. Shoults, for helping me through the science fair process.