Excerpt: Two global trends are on a collision course to upend decades of medical progress and health outcomes: Antimicrobial resistance, or AMR, and our rapidly aging society.
Two global trends are on a collision course to upend decades of medical progress and health outcomes: Antimicrobial resistance, or AMR, and our rapidly aging society.
The current trajectory for AMR is bleak: AMR pathogens are estimated to kill 700,000 people globally each year, and the United Nations forecasts that AMR could kill up to 10 million people annually by 2050 and push 24 million people into poverty by 2030. Meanwhile, our antibiotic innovation pipeline is bare, and we are losing the ability to treat infections daily.
On the other hand, the UN recently announced the Decade of Healthy Ageing (2021–2030) as the global framework for transforming the 20th century miracle of longevity to our 21st century’s era of healthy longevity. While AMR presents a significant global health problem of the first order, its effects are disproportionately burdened on older adults, a group that is rapidly increasing in proportion to other sectors of the population.
As is, antibiotics have added an estimated average of 20 years to the human lifespan, but if the incidence of multi-drug resistant pathogens continues to increase, the drugs that have unlocked this longevity miracle will no longer be effective. This is already the case in long-term care facilities, which have been called “reservoirs of resistance.”
As discussed in Health Affairs this year, AMR not only impacts the usage of antibiotics; it can also turn presently treatable ailments deadly. The availability and effectiveness of independence-promoting procedures—like hip and knee replacements, heart valve replacements, and even chemotherapy—all stand to change drastically. A procedure as simple as a catheter insertion may even find itself deadly to a given patient. If left unaddressed, AMR will undoubtedly have a profound effect on our ability to achieve healthy aging goals, while also shifting the world back to what experts have called “a pre-antibiotic era.”
Often, clinicians are the most responsible for decisions related to AMR, but there’s a wide gap between their acknowledgement of AMR as a critical health issue and their understanding of how to incorporate understanding it into their day-to-day medical interventions. A previous study of inpatient physicians demonstrates that they largely recognize that antibiotics are overused, but many admitted to prescribing antibiotics even when the clinical evidence of infection was uncertain—thereby contributing to the rising problem of AMR. And a different study by the World Society of Emergency Surgery found that almost all participants considered AMR an important worldwide problem, but nearly 46 percent underrated the problem in their own hospitals.
Most concerning, of course, is the possibility that patients may not be receiving treatments and interventions due to risk of antimicrobial-resistant infection—and clinicians’ concerns about that elevated risk. While the current literature is only now investigating if the risk of antimicrobial resistance has significantly impacted providers’ decision-making, it is clear there is reason for concern about AMR disproportionately impacting the world’s growing aging population. One study showed that of deaths in the U.S. due to infection with the most common AMR pathogens, approximately 40 percent occur in people aged 65 and older, but this age group only accounts for 15 percent of Americans. Further, older adults disproportionately suffer from diseases where AMR-resistant strains already exist, such as pneumonia and urinary tract infections.
AMR is already a top 10 global public health threat according to the WHO, but its silent or unrecognized effects on treatments could lead to even further issues during the Decade of Healthy Ageing: cancers undiagnosed, diabetes untreated, cardiovascular disease undetected. We saw this phenomenon during Covid, where risk of exposure to a doctor’s office or hospital led to clinical actions needed but not taken; the same is increasingly true for AMR risk in a world without effective antibiotic treatment. The untreated may soon be the crisis we missed.
There are four solutions:
First, we simply need new drugs—innovation is not working. Right now, there are no clear incentives to take on the high costs of developing these drugs, which would need to be held in reserve rather than sold and used at scale. Consider that in the UK only one new antibiotic was approved in the 15 years between 1999 and 2014, and fewer than 150 researchers are working on the problem in the industry, predominantly in small-to-medium-sized biotech companies.
But we are beginning to develop solutions. In the U.S., the PASTEUR Act would jumpstart our domestic antibiotic discovery. Notably, the bill would create a subscription financing model, which provides an upfront payment for new antibiotics instead of reimbursement for the total volume of drug sales. This approach delinks revenue from volume, which is needed to encourage judicious use of antibiotics to maintain their impact.
Second, there must be greater education and awareness building of appropriate use as a mitigating tool against AMR itself. Greater investment to promote public understanding is the first strategic objective of the WHO Global Action Plan on AMR. The Global Coalition on Aging’s AMR Preparedness Index found that increased media coverage contributed to higher levels of awareness in Germany, for example. In the UK, the British Society for Antimicrobial Chemotherapy is currently seeking to formally incorporate AMR into all pre-service training, demonstrating how others can build this resource into today’s medical education so that our newly minted healthcare professionals will be able to practice medicine differently. And for those practitioners already in the field, like today’s caregivers on the front lines of elder care, more can be done to develop standards around training and quality in support of national governments efforts or even in the WHO’s Guidelines on Integrated Care for Older People (ICOPE). Many factors lead to over-prescription and misuse of antimicrobials, but governments can do more to enhance sanitation infrastructure, accelerate vaccine programs, and strengthen surveillance and monitoring. A recent CDC report shows that many such programs in the U.S. have been strained during the pandemic, as members of stewardship teams were reassigned to emergency COVID response roles or outright furloughed.
Fortunately, here in the U.S., the PASTEUR Act—if passed—would also provide an opportunity to establish a grant system for hospital antibiotic stewardship, helping to fight AMR now and also establish the human infrastructure to take on the next pandemic. By extending the life-saving value of the antibiotics we already have, we can buy the time necessary to produce new ones.
Third, we need more research into the unintended and hidden decisions resulting from the fear of AMR. Despite growing recognition of AMR as a problem, there have been relatively few recent qualitative studies examining the perspectives of clinicians towards AMR. With the support of Pfizer Global Medical Grants, the Global Coalition on Aging recently conducted a series of surveys and qualitative interviews with more than 1,500 clinicians from various specialties across the globe to understand if and how AMR has affected their practice and clinical decision-making. While this research has elucidated the attitudes and general sentiments of clinicians towards AMR, more research is needed to better understand the nuances around this issue and track their evolution over time.
Finally, the risk-benefit analysis must shift to reflect the reality of our aging era, where functional ability as we age is as much a public health goal as the absence of disease. The forgone knee or hip implant due to greater concern about the deadly impact of infection without innovative, or effective, antibiotics can have a huge impact on the quality of life as measured by functional ability for 60-, 70-, 80- and 90-year-olds. These are not small things in a world where there are more old than young – by 2050, we’ll have more than 2 billion people over 60 on the planet.
The antibiotic revolution barely a century ago inspired and fueled the miracle of longevity that the 20th century bequeathed to our current era. Now, we need antibiotic innovation to not only continue the drive for longevity, but also extend it to create healthy and functional longevity.
The author’s work in this article was supported by funding from Pfizer Global Medical Grants. The views presented in this article are those of the author.