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Dealing with the evolving threat of antimicrobial resistance

Every November since 2013, the World Health Organisation (WHO) and member states have commemorated World Antibiotic Awareness Week, an annual observance to improve antibiotic usage and to increase public awareness of the health risks posed by antimicrobial resistance.

Every November since 2013, the World Health Organisation (WHO) and member states have commemorated World Antibiotic Awareness Week, an annual observance to improve antibiotic usage and to increase public awareness of the health risks posed by antimicrobial resistance.

Antimicrobial resistance is a slow but implacable evolutionary process that has been sped up by human activity in multiple sectors, particularly healthcare and agriculture.

It results in drug-resistant infections that are harder to treat, with attendant increased deaths and socioeconomic costs.

The threat of a “doomsday scenario” of a post-antibiotic era – where common infections or minor injuries can result in death – has been raised by many experts and organisations, including the WHO.

This is an exaggerated worst case future projection designed to generate headlines and increase awareness (and support) of the issue via fear – a tactic that has similarly been adopted for many causes.

The reality is that we will never end up in such an apocalyptic future.

This is not to deny the seriousness of the problem, however.

In low-income countries and regions, the failure of common oral antibiotics to treat common infections such as pneumonia or urinary tract infections is a matter of disability and death.

In high-income countries such as Singapore, much of the modern medicine we benefit from today – including the “miracles” of complex surgery, organ transplantation and cancer therapy – are developed on the premise that infections can largely be prevented and treated.

This premise is eroded by antimicrobial resistance.

So clearly, a worsening of the problem of antimicrobial resistance will have implications for countries both rich and poor.

Since the call for action and political declaration on antimicrobial resistance at the United Nations General Assembly in September 2016, WHO has worked with partner agencies to develop a global framework to combat antimicrobial resistance.

The framework covers the entire chain of antibiotics’ life cycle from research & development to prescribing and appropriate use by the end users (both humans and animals) and even includes aspects such as investment and capacity building in vaccination programmes, infection prevention and good animal husbandry.

This is a necessary and ambitious goal, requiring the support of member states for a chance of success. However, not all aspects of this framework will be applicable for every country, and each will have to set individualised national plans and targets to address the issue of antimicrobial resistance.

Singapore launched its National Strategic Action Plan on Antimicrobial Resistance in November last year.

The coordinating agencies — the Ministry of Health, Agri-Food & Veterinary Authority of Singapore, National Environment Agency and water agency PUB — have worked behind the scenes to begin implementing that plan.

Perhaps the most visible aspect of it has been the Health Promotion Board’s various messages and campaigns, particularly the “boxer antibiotic pill” that can be seen at bus stops as well as videos in Health Hub.

It is noteworthy that many aspects of the National Strategic Action Plan involve enhancement and coordination of existing activities, particularly in the areas of human health, and in hospital practice.

Many healthcare workers in Singapore hospitals (and this is also true for Asian hospitals in general) have to manage patients with drug-resistant infections on a daily basis, such that the majority have become familiar with, and inured to, the alphabet soup of antibiotic-resistant bacteria terminology.

These include MRSA (methicillin-resistant Staphylococcus aureus), VRE (vancomycin-resistant enterococci), and CRE (carbapenem-resistant Enterobacteriaceae).

A healthcare worker in Singapore would have to travel out of the country to visit or work in a hospital in, say, Amsterdam or Perth where drug-resistant infection rates are more than 10 times lower than Singapore’s, to understand that the norm here with regards to drug-resistant infections is neither global nor necessarily future destiny.

Considerable effort and resources have already been spent over the past decade in Singapore to collect data on rates of various drug-resistant infections in hospitals – of which perhaps MRSA is best known to the public – and to improve the appropriateness of prescription of antibiotics in public sector hospitals via the formation of antibiotic stewardship teams comprising trained pharmacists and physicians.

Compared to 2008, the resources and manpower available for hospital infection prevention have also increased substantially.

Collectively, these efforts have made a dent in the rates of several different drug-resistant infections, especially in the case of MRSA.

Improvements can potentially be made on several fronts in the local hospital setting.

In addition to increased efforts and innovation in improving antibiotic prescription or infection prevention, hospitals can also better communicate to patients and their relatives what it means to be colonised or to have been infected by antibiotic-resistant bacteria.

Unfortunately, this is an issue often skirted around by hospital staff even as other areas of patient communications have improved, perhaps because the issue is complex and opens up questions on liability.

Conversely, patients and/or their relatives can also be more active in determining how best to care for themselves or their loved one in order to minimise the risk of a hospital-acquired infection.

Separately, none of the collected data on drug-resistant infection rates or antibiotic prescriptions are publicly available, unlike several other countries including Australia and the United Kingdom.

To have serial data on MRSA rates available online, for example, in the same way that one could view data on other communicable diseases such as dengue, would create a sense of accountability and may facilitate public understanding of the scale of the problem of antimicrobial resistance.

In conclusion, antimicrobial resistance is a constant evolving threat to human health.

Awareness of the issue among healthcare workers and policymakers has increased significantly over the past decade, and this is also beginning to enter the public consciousness.

Singapore has put together a comprehensive national plan to combat antimicrobial resistance, enhancing and bringing together previous disparate efforts by different agencies.

Control of drug-resistant infections in our hospitals has continuously improved relative to a decade ago, but will require constant effort and innovation even as the microbes also continue to evolve.



Associate Professor Hsu Li Yang leads the Infectious Diseases Programme at the National University of Singapore’s Saw Swee Hock School of Public Health.

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