Antimicrobial Resistance: A Major Threat to the Promise of Healthy Aging

Introduction

 

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 to complete its sustainable development goals and become 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. For example, a study showed that of deaths in the U.S. due to infection with the most common AMR pathogens, approximately 40% occur in people aged 65 and older, but this age group only accounts for 15% of Americans. Further, older adults disproportionately suffer from diseases where AMR-resistant strains already exist, such as pneumonia and urinary tract infections.

 

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. Additionally, the availability and effectiveness of independence-promoting procedures – like hip and knee replacements, heart valve replacements, and even chemotherapy – all stand to change drastically as we know it. A procedure as simple as a catheter insertion may find itself deadly to a given patient because of the risk of infection without an effective antibiotic treatment. If left unaddressed, AMR will undoubtedly have a profound effect on our ability to achieve healthy aging goals, while also putting our newborns at risks unseen since a century ago.

 

 

Methodology

 

Over the first half of 2022, we conducted a series of surveys and qualitative interviews with more than 1,500 clinicians across the globe – including in the U.S., Japan, and Europe – and from various specialties to understand if and how AMR has affected their practice and clinical decision-making. Further, we wished to elucidate the attitudes and general sentiments of clinicians towards AMR.

 

Healthcare providers: the frontline of antimicrobial stewardship

 

Often, clinicians are the most responsible for decisions that will impact or be impacted by AMR because they must weigh the risks of AMR-related infections against the benefits of important interventions like heart valve and knee replacements, or even stays in hospitals. However, there have been relatively few recent qualitative studies examining the perspectives of clinicians towards AMR. Those that exist show that the wider, population-based implications of AMR may not be given appropriate consideration when treating an individual and consequently, prescriptions for antibiotics are commonly given unnecessarily. Further research has also shown that clinicians often appreciate that AMR is a significant issue, but do not apply that macro view in how they conduct their own medical practice, and that knowledge, attitude, and practice regarding AMR remains a fundamental challenge in antimicrobial stewardship.

 

Here are some of the insights we gathered:

 

There’s a wide gap between acknowledgement of the issue and understanding of the issue.

 

This trend of “not in my clinic” has been demonstrated before in the literature – a previous study in the United States found that 94% of survey respondents agreed AMR was an issue in the United States, but only 55% agreed that it was in their own practice. In our study, only about 20% of health professionals surveyed indicated that they had a “fair amount” of knowledge about drug resistance issues and the ways in which it affected their decisions. Interestingly, those surveyed tended to rank their own knowledge and awareness of AMR highly and tended to rank their colleagues’ lower.

 

Several respondents indicated that they placed the needs of their individual patients above the risk of widespread AMR. One physician in palliative care noted “These infections unfortunately happen and are devastating when they do. But I’m not aware of anyone prospectively forgoing needed surgery because of them. We may not recommend [a surgery] due to fragility, comorbidities, etc., with the exception of someone already chronically infected (with an AMR or other pathogen).”

 

Another physician working in infectious disease acknowledged the significance of AMR, but noted that the needs of the individual patient were always put first. “The risk of AMR leads me to think carefully about providing the narrowest possible antimicrobial coverage that still adequately treats a patient’s infection. In general, I do not prescribe less aggressive treatment or forgo procedures if they are necessary for the patient’s care because of the risk of AMR.”

 

For the majority, the consideration from the clinical standpoint seemed to be against the risk of widespread AMR, and not within a given patient. In older adults and the medically fragile, groups who are more prone to infection with AMR pathogens, the growing AMR crisis will increasingly necessitate some form of risk consideration for a given procedure at the individual patient level.

Patients may not be receiving treatments and interventions due to risk of infection.

 

There is a risk that the proliferation of AMR will lead to non-essential, but life-quality improving procedures not being available, such as elective knee surgery to increase or maintain mobility, because the risk of infection with an AMR pathogen is too great. Our survey responses indicated that this phenomenon may already be occurring: approximately 27% of clinicians said they had recommended more conservative treatment or withheld necessary procedures from a patient due directly or indirectly to the risk of infection with drug-resistant organisms in the past five years, and about ¼ indicated that their colleagues had done so.

 

The survey responses, however, seemed to trend more heavily towards more conservative care decisions that reflect greater antimicrobial stewardship efforts rather those that reflect withheld procedures due to fear of untreatable infection. More research is needed in this area, but our preliminary research further suggested that AMR stewardship measures were oftentimes viewed among clinicians as public health imperatives misaligned or even in direct opposition to the needs of the individual patient.

 

Depending on medical specialty, levels of concern and consideration of AMR vary.

 

In our survey, we found differing levels of AMR consideration by specialty. Interviews with several clinicians revealed the presence of an unspoken “hierarchy” of which specialists and what procedures merited consideration of AMR. One interviewee, a hepatologist in California, gave little indication of implicating AMR into their clinical decisions. Although not explicitly stated, the impression given was that AMR was perhaps something for others to worry about. On the other hand, more than half (55%) of cardiologists and internal medicine specialists (51%) report impact on treatment.

 

If indicative of a wider trend, this mindset may jeopardize access to treatments and procedures that may improve quality of life, but are not considered essential, in favor of those that very much are. This sort of triage would be incredibly difficult to coordinate at a large scale and would likely lead to differing access to medical care at a national and global level, where those poorest in society or in low or middle-income countries have access to far fewer “non-essential” treatments. This also has potential implications for healthy aging: while a hip replacement may not be an immediately life-or-death situation, it is a procedure that can drastically improve mobility, overall quality of life, and therefore, longevity.

 

Clinical practice curricula stand to benefit from more standardized and in-depth training on AMR concepts.

 

Not enough is known, and what we don’t know may be the most devastating. Our survey indicates that standardized guidance and clinical protocols surrounding treatments that may be impacted by AMR could be improved.

 

One hospitalist discussed that in their role, they went through various infectious disease trainings with some emphasis on AMR, but they were unsure if this was the case for all specialties and other organizations. This general lack of knowledge among providers further suggests large differences between hospitals and medical specialties with regards to consideration of AMR in clinical decision-making, furthering the case for standardized training.

 

How policymakers can begin to address healthcare workers’ attitudes towards AMR

 

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.

 

Incentivize care providers to consider the implications of clinical decisions on AMR by rewarding good behavior.

 

Our findings that clinicians see AMR as a problem for others and not themselves is in line with previous qualitative research on clinician sentiments towards AMR. This attitude of dissonance is dangerous and should be addressed through educational programs and increased AMR stewardship programs at the hospital level, which will require additional funding at the state, provincial, or federal level.

 

One potential avenue for this is to use push incentives to reward hospitals with additional funds for actively pursuing good AMR stewardship. This could take the form of additional funding for locations that have low levels of antibiotic over-prescription and conducting robust surveillance activities. The proposed Pasteur Act  in the United States includes similar strategies, with grant funding available for hospitals who are “judicious” in their AMR stewardship. Of course, such a program would require checks and balances to ensure that hospitals are not penalized for taking on patients at higher risk for infection with an AMR pathogen, such as older adults.

 

Incentives could also be targeted at the individual level. Physicians have noted that publishing AMR patterns at a localized level would be a strong way to incentivize AMR stewardship, which would enforce social norms and have the potential to shift physician attitudes towards AMR.

 

Incentives are already happening to some extent in select countries. One interviewee, a physician from Turkey, mentioned that hospitals in their area could be rewarded and penalized for their performance in AMR stewardship, and the NHS in England has required hospital trusts to submit yearly antibiotic consumption data, with additional payment for submission. There is broader political will for such an initiative: the Organisation for Economic Co-operation and Development (OECD) has advocated stronger economic incentives to promote better AMR stewardship, and in the May 2022 meeting communique of G7 Health Ministers, support for LMICs to develop national investment cases on AMR response was given.

Encourage medical accreditation bodies to require AMR training as part of their continuing medical education (CME) training or professional development.

 

A 2018 study found only 94 educational opportunities on AMR targeted at healthcare workers worldwide, very few of which were accredited for professional continuing education credits.  The same study referenced the need to improve education and uptake in AMR and antimicrobial stewardship, including at the medical school level. Administrative healthcare workers could also be encouraged to partake in professional development courses to help strengthen their ability to administer a robust AMR stewardship program at the hospital or clinic level.

 

We encourage medical education to highlight the disproportionate effects of AMR on older adults and the medically fragile, as well as the increased risk of infection faced by groups living in and out of long-term care homes.

 

Conduct more research into the unintended and hidden decisions resulting from the fear of AMR.

 

This research is a first step towards building a literature on the impact of AMR on clinical decision-making, and the attending enormous implications for patients, the practice of modern medicine worldwide, and the future of healthy aging itself. More research is needed to better understand nuances in this impact, track its evolution over time, and point to additional solutions both in policy and practice. Specifically, more extensive research on clinical decision-making, AMR incentives, and healthy aging is required to further understand this phenomenon and to shape comprehensive policy solutions that will provide the opportunity for change.

 

Conclusion

 

AMR is an increasingly catastrophic public health issue that threatens healthy and active aging worldwide and has the potential to increase disparate access to care. 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 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 – we’ll soon have more than 2 billion people over 60 on the planet.

 

Here, we give insight to the general sentiments that healthcare professionals hold towards the AMR crisis, and how clinical decision-making has been affected among our respondents. Additionally, we offer some potential strategies and solutions to approaching this progressively urgent issue from a communications, education, and awareness standpoint, and all of these efforts must be met with corresponding strategies to replenish our dwindling pipeline of new antibiotics.

 

The antibiotic revolution barely a century ago inspired and fueled the miracle of longevity that the 20th century bequeathed to our current century. Now, we need antibiotic innovation to not only continue the drive for longevity, but extend it to create healthy and functional longevity.

 

Authors’ Note:

 

The authors’ work in this article was supported by funding from Pfizer Global Medical Grants. The views presented in this article are those of the authors.

 

Michael W. Hodin, PhD, is CEO of the Global Coalition on Aging, Managing Partner at High Lantern Group, and a Fellow at Oxford University’s Harris Manchester College. He has spoken internationally on the topic of aging, including at G20, APEC, Davos, and the World Knowledge Forum (WKF). Hodin holds a BA, cum laude, Cornell University, MSc in International Relations from The London School of Economics and Political Science, and MPhil and PhD in Political Science from Columbia University.

 

Susan Wile Schwarz, MPH, is the Director of Communications for the Global Coalition on Aging and Senior Director at High Lantern Group. She holds a BA from Columbia University and an MPH from Emory University’s Rollins School of Public Health.

 

Olivia Canie has a BA from McGill University and is an MPH candidate at the Yale School of Public Health.

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