Views from the London School of Hygiene & Tropical Medicine

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Evidence gaps in drug resistant infection need plugging to eliminate superbugs

By Clare Chandler, Co-Director of the Antimicrobial Resistance Centre and Susannah Woodd, Research Fellow Epidemiology at the London School of Hygiene & Tropical Medicine.

Global leaders at the United Nations General Assembly have signed a declaration that their 193 countries will take steps to rid the world of antimicrobial resistance (AMR). It is only the fourth time in the history of the UN that a health topic has been on the General Assembly agenda.

AMR has been increasing since we began the mass production and use of these medicines in the 1930s-40s. The scale of the problem therefore is unsurprising, however the lack of detailed knowledge about how to successfully address it is.

There are three broad areas of commitment that countries are signing up to. Each has potential for impact on drug resistant infection, but gaps in scientific evidence could undermine implementing them in a timely and cost-effective way.

First, countries around the world are agreeing to reduce the use of antimicrobial medicines. Reducing the opportunities for microbes to meet antimicrobial substances should diminish the populations of bacteria resistant to these medicines. But when more people still die from lack of antibiotics than antimicrobial resistance, this presents a dilemma.

We still don’t know where this reduction in use is most important: community versus hospital, veterinary versus clinical, prescribed antibiotics versus self-medication bought direct from a pharmacy or shop, local hotspots such as care homes or geographical locations such as slums or farming communities? And reducing use not only requires decreasing demand from patients but a change in doctors’ reliance on medicines as a symbol of care. Understanding this requires bringing scientists together with expertise in pharmacology, microbiology, sewerage, economics, social science and beyond.

Second, countries are committing to reducing the occurrence of drug resistant infections. To a large extent, this mirrors the ongoing challenge of controlling infectious disease. In settings with high risks of infection transmission, such as hospitals, methods to stop bugs being spread are established. However, simple hand washing is still not performed at crucial moments to prevent transmission, mainly because over a third of healthcare facilities in LMICs don’t even have access to improved water.

Infrastructural changes are required to reduce transmission of resistant microbes – but evidence is lacking as to which will have the greatest impact. Is it hand washing or environmental cleaning? The layout of hospitals or locations for care? Again, to understand these challenges and match up solutions that will be locally relevant, an approach that brings together scientists with different expertise and allows for area specific needs is required.

Third, there is a major push to develop new antimicrobials, following the observation of a ‘dried up’ pipeline. In some cases multi-drug resistant organisms warrant additional antimicrobials, but clearly these too will lead to resistance. Novel alternatives to anti-microbial drugs are therefore important to develop.

Working in different ways with our immune systems to develop responses presents new lines of action. For example, disarming, disabling or inhibiting microbes rather than killing them? Phage therapy? Faecal transplants? Vaccinations? A longer time in bed? Each may differ for different drug-bug combinations. Each have various consequences for the medical, political and economic status quo of our societies. Once again, the science for such policy options requires collaboration across disciplines and countries.

To address these gaps in scientific knowledge, the London School of Hygiene & Tropical Medicine is starting a new Antimicrobial Resistance Centre. This is a unique collaboration amongst scientists with truly diverse expertise. We aim to inspire innovative AMR research through interdisciplinary and international engagements.

The generalities of declarations for action have been accomplished. Now is the time for specifics guided by a strong evidence base. Urgent high quality science is required to support a coordinated approach to address the global AMR problem.

 

 

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