Winning the fight against antimicrobial resistance

Singapore launched its National Strategic Action Plan on antimicrobial resistance (AMR) last week.

In a reflection of the complex nature of the problem, the workgroup that developed the plan included representatives from four government agencies – the Ministry of Health, Agri-Food and Veterinary Authority of Singapore, National Environment Agency and PUB.

The 24-page document broadly follows the World Health Organization’s Global Action Plan on AMR that was launched in 2015.

There are five core strategies aimed at limiting the spread of antimicrobial-resistant microbes and the hard to treat drug-resistant infections that they can cause.

These are education, surveillance, research, prevention of infection, and optimisation of antibiotic use.

The plan also outlines existing initiatives – largely driven by the four government agencies independently – and the gaps in each area.

But there are few details available at this point, as this is a “living document” and many of the proposed programmes are still work in progress.

The challenges posed by AMR are manifold and intricate.

The issue itself is invisible to and poorly understood by the majority of people.

Fundamentally, the ability of a microbe (bacteria, viruses, fungi and parasites) to develop or acquire resistance to the drugs used to kill them is a natural evolutionary phenomenon.

Many antibiotics are developed from natural occurring compounds used by microbes against each other – penicillin, famously, was isolated from a fungus – and thus the building blocks for resistance to these drugs already exist in the environment.

The widespread use of antibiotics in humans and agriculture artificially accelerates the process of resistance development.

Human activities, including delivery of complex healthcare to older and sicker patients, global travel and the industrial food production chain, facilitate the spread of antibiotic-resistant bacteria.

There is no “safe level” of antibiotic use below which AMR does not develop.

Yet, antibiotics are crucial to human and animal health, and excessive restriction of antibiotic use can potentially harm people - especially in the short term - even more than overuse of antibiotics in the long term.

Most people. including many health professionals, believe that hospitals and other healthcare institutions are the main generators and amplifiers of AMR.

This is a misconception. Antibiotic use in primary care has been shown to drive the development and spread of antibiotic-resistant bacteria in the community.

The volume of antibiotic use in agriculture and animal husbandry far exceeds that in humans. Antibiotic-resistant bacteria in the food chain as a result of such practices have caused infections and outbreaks in humans, either directly or through sharing of antibiotic resistance genes with human bacteria.

COMPETING INTERESTS

Perhaps surprising for a small and otherwise efficient country, we have an incomplete grasp of the scale of the problem of AMR in Singapore. The amount of antibiotics prescribed in private hospitals and collectively among general practitioners is not known, as is the prevalence of antibiotic-resistant bacteria in both private hospitals and community.

Traditionally, meat and other foodstuffs are not tested for the presence of antibiotic-resistant bacteria, but rather for antibiotic and other chemical residues in addition to specific bacteria that cause foodborne outbreaks, such as Salmonella species.

The socioeconomic impact of AMR specific to Singapore is also not well defined. Such knowledge is important for the calibration and future sustainability of intervention programmes.

Efforts at controlling the spread of antibiotic-resistant bacteria often run up against competing interests quickly. To name but a few:

1.      When hospitals are full, separation of patients infected by antibiotic-resistant bacteria and implementation of infection prevention measures become challenging.

2.      The use of rapid diagnostic tests for screening of inpatients for antibiotic-resistant bacteria incurs additional costs, and it is unclear at present who should bear them.

3.      Prescribing is not separated from dispensing in Singapore. That is, doctors and vets can both prescribe drugs and sell them directly from their clinics. It is the professionalism of doctors and vets that is the primary barrier to profiteering from inappropriate antibiotic prescription. But patients and pet owners who demand antibiotics can chip away at this barrier.

4.      The cost of meat obtained from animals raised without antibiotic growth promoters is higher, at least in this part of the world, and it is unclear if many people would willingly accept a cost difference of at least 20 per cent. It would also be difficult to officially verify claims that the animals were indeed raised “antibiotic growth promoter-free”. Or even truly “antibiotic-free”.

What will success in Singapore in our efforts to control antibiotic resistance look like?

Because microbes constantly evolve and new antibiotic-resistant bacteria will continue to emerge, there must always be effective, safe and relatively cheap antibiotics for infections in both humans and animals.

Many of the gains in cancer chemotherapy, transplant and other surgeries came about because of effective antibiotics that were available to treat patients with weakened immune systems.

AMR should not be allowed to significantly impact healthcare delivery or food safety. Whether we can slow the current trend towards increasing AMR is questionable, given the open nature of Singapore and dependence on global food production.

But Singapore cannot give up without trying, and it should do so in partnership with the region and internationally, as success in Singapore will depend on our neighbours being able to control AMR too.

The primary merit of Singapore’s national action plan, besides being a public declaration of resolve, is to highlight the interconnectedness of human and animal health and practices in the issue of AMR, and to focus the efforts of all stakeholder government agencies on this issue.

A long-term sustained effort is also explicitly spelled out. Bottom-up efforts from the various communities in human and animal health to promote education and awareness of antibiotics and AMR, research for better understanding of the issue, and private-public partnerships on interventions to control AMR will be necessary to match the top-down initiative that led to the development of the plan.

ABOUT THE AUTHORS:
Associate Professor Hsu Li Yang, who leads the Antimicrobial Resistance Programme at the NUS Saw Swee Hock School of Public Health, was a member of the workgroup that developed the National Strategic Action Plan. Professor Paul Ananth Tambyah is an infectious diseases physician and professor of medicine at the Yong Loo Lin School of Medicine.