REVIEW

published: 28 June 2023

doi: 10.3389/bjbs.2023.11387

Antimicrobial Resistance (AMR)

Ka Wah Kelly Tang 1, Beverley C. Millar 1,2 and John E. Moore 1,2*
1
School of Biomedical Sciences, Ulster University, Coleraine, United Kingdom, 2Laboratory for Disinfection and Pathogen
Elimination Studies, Northern Ireland Public Health Laboratory, Belfast City Hospital, Belfast, United Kingdom

Antimicrobial resistance (AMR) has now emerged as a chronic public health problem
globally, with the forecast of 10 million deaths per year globally by 2050. AMR occurs
when viruses, bacteria, fungi and parasites do not respond to antimicrobial treatments in
humans and animals, thus allowing the survival of the microorganism within the host. The
prominent cause contributing to the current crisis remains to be the overuse and misuse
of antimicrobials, particularly the inappropriate usage of antibiotics, increasing the global
burden of antimicrobial resistance. The global consumption and usage of antibiotics are
therefore closely monitored at all times. This review provides a current overview of the
implications of strategies used by international governmental organisations, including the
UN’s 17 Sustainable Development Goals (SDGs), to address the problem of antibiotic
resistance, as well as the “One Health Approach,” a system incorporating a
multidisciplinary effort to achieve the best possible health outcome by acknowledging
the clear connections between humans, animals and their shared environment. The
importance of public awareness and health literacy of lay audiences still needs to be
further emphasised as part of global and local action plans. Antimicrobial resistance
continues to be a major global public health dilemma of the 21st century. Already this
topic is receiving substantial political input from the G7 countries and continues to be on
the agenda of numerous political conferences. The consequences of failure to
adequately address AMR are profound, with estimations of a return to the pre-
antibiotic era, where everyday infections relating to childbirth, surgery and open
fractured limbs could be potentially life-threatening. AMR itself represents a
microcosm of factors, including social anthropology, civil unrest/war, diasporas,
*Correspondence: ethnic displacement, political systems, healthcare, economics, societal behaviour
John E. Moore
both at a population and individual level, health literacy, geoclimatic events, global
[email protected]
travel and pharmaceutical innovation and investment, thus finding a solution that
Received: 22 March 2023 adequately addresses AMR and which helps stem further AMR emergence is
Accepted: 16 June 2023 complicated. Success will involve individuals, communities and nations all working
Published: 28 June 2023
together to ensure that the world continues to possess a sufficient armamentarium of
Citation:
Tang KWK, Millar BC and Moore JE effective antimicrobials that will sustain human and animal health, both now and in the
(2023) Antimicrobial Resistance (AMR). future.
Br J Biomed Sci 80:11387.
doi: 10.3389/bjbs.2023.11387 Keywords: infection, AMR, antibiotic resistance, antimicrobial resistance, one health

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Tang et al. Antimicrobial Resistance

INTRODUCTION and its derivatives (cephalosporins, carbepenems) are the major

class of antibiotics still employed today, in treating human and
Antimicrobial Resistance (AMR) results when microorganisms animal infections. Over 150 new antibiotics have been developed
including bacteria, fungi, parasites and viruses evolve to the since then and their widespread usage and overusage has led to
extent that they eventually become resistant to the the development of higher resistance and even multiresistant
antimicrobial medications, such as antibiotics, which are used forms of the so-called “superbugs.” These have increased
to treat such conditions [1]. AMR has now emerged to be one of mortality rates due to a lack of clinical effectiveness, resulting
the greatest global concerns in the 21st century due to the rapid from antibiotic use/misuse [11]. AMR is the term given to this
growth of AMR infections rate and the lack of new antimicrobial resistance, which has been discovered in viruses, parasites, fungi,
medications being introduced to combat this issue [2]. One of the and bacteria. However, with regards to AMR, bacterial antibiotic
main causes of the current issue could be the consequences of resistance is particularly problematic due to its rapid rate of
overuse or irresponsible use of antibiotics in various situations, developing resistance to many new antibiotics, which are used to
primarily in clinical treatment along with agricultural usage, treat bacterial infections (Figure 1) [2].
animal healthcare and the food system [3]. AMR is widely
referred to as the “Silent Pandemic” and is a problem where
urgent action is needed immediately and should be managed EPIDEMIOLOGY OF AMR
more effectively and not be considered as a future situation [4].
Without preventative measures, it is estimated that by 2050, Previous research has shown that one of the main causes of AMR
AMR could potentially become the world’s primary cause of is the inappropriate and excessive use of antibiotics, both in
death [5]. According to estimates provided globally, the number humans, as well as in animals. Since the 1950s, when the “golden
of deaths directly linked to AMR has risen to more than era” of antibiotics began, Alexander Fleming had expressed
1.2 million in 2019 and this is forecast to increase to concerns about the potential emergence of resistance if
approximately 10 million deaths per year by 2050, if treatment is used for an inadequate amount of time [13].
insufficient action is taken to control AMR [5]. “Since then, there has been an increasing demand for new and
In response to AMR, several global health organisations and novel antibiotics, in order to combat highly resistant strains that
governments have taken action to combat this issue. The “One have been emerging.”
Health Approach” was introduced which requires a global As a result, the use of antibiotics in treating infectious diseases
collaborative effort to involve a number of different and other conditions has become widespread in modern
disciplines: the Food and Agriculture Organization of the medicine. Nevertheless, the misuse and even over-prescription
United Nations (FAO) and the World Organization of Animal of these antimicrobials has fast outpaced their efficacy as AMR
Health (OIE), to ensure that each agency works within its has grown markedly [10].
speciality and with other agencies to minimise the potential A series of recent studies have indicated antimicrobial
effects of AMR [6]. In addition, the World Health involvement in agriculture and food systems may have a
Organization (WHO) has established the Global Action Plan significant impact on driving AMR [14]. According to estimates,
for managing AMR (GAP-AMR) followed by launching the in the US, 70% of antibiotics used to treat humans are available for
Global Antimicrobial Resistance and Use Surveillance System use in veterinary medicine [15]. In recognising such high usage in
(GLASS) to continuously close the existing knowledge gaps in global agriculture, several organisations, including the World Health
order to achieve the goals of GAP-AMR programme [7]. Organization (WHO), the United Nations (UN) and the European
Within most of these newly proposed measures, one of the Union (EU) have taken steps towards reducing and restricting the
most effective approaches is to increase public awareness of the use of antimicrobials in animals, through the legislative banning of
AMR pandemic as a preventative strategy, thereby requiring good using certain antibiotics in agrifood systems for growth promotion,
communication with all stakeholders [8]. In this review, the aim is as well as promoting antimicrobial stewardship initiatives in treating
to examine the various current global AMR management food animals, as well as in small domestic companion animals. Such
strategies, to aid its control. controls may be difficult to implement particularly in developing
The creation of antimicrobials is one of the most effective drug countries where the demands for food animals continue to rise
treatments in medical history. The introduction of antimicrobials annually [16].
has helped to manage and greatly reduce death rates caused by In addition, zoonosis also poses a serious transmission factor of
infectious diseases, previously the leading cause of death in AMR, where antibiotic-resistant bacteria are spread between animals
humans [9]. Human life expectancy has increased on average and humans, through either direct or indirect interaction, as well as
by 23 years, since the first antibiotic was introduced in 1910 [10]. through foodborne or waterborne events [17, 18].
With regard to that, the discovery of the antibiotic penicillin, by A study conducted in China has reported that mediated
Sir Alexander Fleming was one of the greatest medical colistin resistance (MCR-1) poses a high risk to AMR due to
advancements of the 20th century which initiated the “golden zoonosis transmission from animal to human [19]. According to
era” of antibiotics [10]. However, shortly after, the production of this study, MCR-1 was detected in E. coli isolates from animal and
penicillinase by antibiotic-resistant strains was reported, which commercial meat sources and MCR-1 is believed to have been
led to inactivation of the antibiotic molecule, thereby rendering it widely transmitted in food-producing animals in south China. In
clinically ineffective [11]. This is important to note, as penicillin contrast, relatively low MCR-1 was detected from human origin,

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Tang et al. Antimicrobial Resistance

FIGURE 1 | Timeline showing some of the key antibiotic discoveries and reports of the emergence of antibiotic resistance strains [12].

this difference in the prevalence of MCR-1 between animals and 61,946 patients recorded in 2018 [24]. In comparison, the
humans is likely to be a form of zoonotic transmission from European Centre for Disease Prevention and Control (ECDC)
animals to humans [19]. has reported in the EU alone, the infection rate of AMR has
Colistin is regarded as a “last resort” antibiotic that is reached over 670,000 cases annually [25]. According to data
increasingly being utilised to treat patients with multiresistant analysis from a prior study, there were 4.95 million deaths
bacteria, although it is still effective it was not typically used to worldwide in 2019 that were linked to bacterial AMR, and
treat common infections due to its potentially adverse side effects. 1.27 million of those deaths were directly caused by bacterial
However, if colistin resistance evolves rapidly, these bacterial AMR [26]. In a well-known review, it was previously reported
infections may be more difficult-to-treat [20]. that the annual death rate directly caused by AMR is predicted to
The lack of knowledge of antimicrobials is also a major rise to 10 million by 2050. With the highest estimated deaths of
contributing factor to AMR. Public Health England conducted this being in Asia followed by Africa, mainly due large
a UK survey in 2017 to find out public knowledge on antibiotics populations and lack of regulation associated with AMR
[21]. Eighty three percent of participants admitted that antibiotics prevention [5]. According to previous research, Sub-Saharan
could be used to treat bacteria and 35% of participants believed Africa has the highest all-age mortality rate in the Global
that antibiotics could be used to treat viral infections. These Burden of Diseases (GBD) region that is directly linked to or
results have improved since the survey that was conducted in related to AMR, in contrast to Australasia which had the lowest
2014, which indicates that the public in the UK has become more rate of AMR-related mortality in 2019 [26].
informed and educated about antibiotics [21]. In comparison to a
survey conducted in India, it was found that 49% of the
respondents stated that antibiotics could treat viral infections RISK FACTORS CONTRIBUTING TO AMR
and 45% of respondents use antibiotics for treating colds [22]. As IN SPECIFIC POPULATIONS
a consequence, India was reported as having one of the highest
rates of infectious disease, including those caused by multi- Previous literature focusing on the different national responses to
resistant pathogens [23]. These studies indicate that there is a antibiotic resistance highlighted the key risk factors contributing
relationship between AMR and public awareness. to AMR between developing and developed countries and how
each lead to AMR in a different manner. Several AMR
contributing factors were found in developing countries which
GLOBAL BURDEN OF AMR include, poor regulation control of antimicrobial drugs,
insufficient monitoring of the emergence of AMR,
With AMR emerging at a rapid rate, the infection and death rates inappropriate use of antibiotics in clinical settings and the
of AMR are closely monitored at all times. In the inadequate quality check for antibiotics supplied [27].
United Kingdom, the estimated AMR infection rate was Recent studies on the accessibility of antibiotics in low- and
65,162 people diagnosed in 2019, which increased from middle-income countries found that Vietnam and Bangladesh

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had the highest proportion of unlicensed locations where Despite that, critics have also argued that this is not the only
antibiotics are administered, with relevant antibiotics problem but an addition to issues of increased “last line
frequently found in typical drug stores for mild illnesses, antimicrobials” consumption. According to recent research,
where they are widely available to the general public [28]. last-line antibiotics such as polymyxin consumption in
Since those communities have such easy access to antibiotics, humans has increased by 67% in the EU/EEA and these last-
maintaining this attitude would lead to a number of issues, such line antibiotics are typically prescribed in hospital settings to treat
as improper use of antibiotics due to a general lack of knowledge patients suffering from serious infections as a last resort to
on antibiotics and awareness of AMR and with lack of combat multidrug-resistant bacteria [32]. As a result, the
consideration of the quality of the antibiotics distributed. All increased consumption of such antimicrobials could eventually
such factors may contribute to the emergence of AMR. induce resistance and paradoxically make serious infectious
On the contrary, in developed countries, the risk factors diseases more difficult-to-treat.
that exist in developing countries may not necessarily apply. This ongoing pattern has presented a strong correlation
These include the excessive use of antimicrobials in between AMR and antibiotic consumption. Several studies
agricultural use and over-prescription in clinical settings have supported this view, including a longitudinal study which
[27]. Research on this issue presents conflicting findings as reported a significant strong association between the use of
a more recent study reported that China, as a developing antibiotics, particularly carbapenems and carbapenem
country, became the top consumer of veterinary resistance [33]. Similarly, this trend was supported by another
antimicrobials in 2017, accounting for up to 45% of global study which also identified a strong correlation between the
consumption and is estimated to remain the biggest user in antibiotic consumed and the prevalence of carbapenem
2030. In addition, with evidence that developed countries have resistance in Gram-negative bacteria [34].
reduced their total antimicrobial sales, for example, the UK However, issues of the debate are a concern as previous studies
had a 39.2% decrease from 2015 to 2017 [29]. These results have argued that a direct correlation may not be present between
suggested that risk variables in emerging countries are now antibiotic consumption and AMR since other factors were
beginning to overlap with those in developed countries. ignored during the research. Many of these correlation studies
were conducted in hospitals where patients are presented with
underlying problems, the results of the correlation may be
GLOBAL CONSUMPTION OF ANTIBIOTICS overstated [35]. Further research would be needed to be
conducted in this area with a study being more inclusive and
There is now a growing body of research that investigates global not restricted to a specific sector.
antibiotic consumption. The Global Research on Antimicrobial Antibiotic usage also influenced AMR in relation to the difference
Resistance (GRAM) Project, conducted the first known long-term between LMICs and High Income Countries (HICs), resistance maps
study to estimate the global consumption of antibiotics, which of global usage of antibiotics were collected worldwide from the years
covered 204 nations from years 2000–2018. According to this 2000–2015 (Figures 2A, B). A distinct pattern was observed, as seen
estimation of the average daily dose, a significant increase of 46% in Figure 2A, when in 2000, the more developed continents
in the global antibiotic consumption rate was observed including North America, Europe, and Australia were shown to
throughout this period of time [30]. have the highest overall antibiotics usage. However, compared to
This seminal study through employment of a spatial disparities/ Figure 2B with data from 2015, it was observed that usage of
geostatistical model, identified large national and subnational antibiotic remains high in Europe, with a slight decrease in North
variations of antibiotic usage in Low- and Middle-income America, in contrast, parts of Africa and Asia have been reported to
countries (LMICs), with the lowest levels in sub-Saharan Africa have increased antibiotic use since 2000 [36].
and the highest in eastern Europe and central Asia [30]. The study Since there is evidence of a correlation between the overuse of
also showed a global antibiotic consumption rate of 14.3 (95% antibiotics and the development of AMR, reducing antibiotics
uncertainty interval 13.2–15.6) defined daily doses (DDD) per usage could be a beneficial goal in HICs, with over usage of
1,000 population per day in 2018 (40.2 [37.2–43.7] billion DDD), antimicrobials. In contrast, increasing the accessibility of such
an increase of 46% from 9.8 (9.2–10.5) DDD per 1,000 per day in antimicrobial medication remains a goal for many LMICs, as the
2000 [30]. There were large increases in the consumption of death rate remains high caused by infectious diseases in many
fluoroquinolones and third-generation cephalosporins in North LMICs due to the lack of effective antimicrobials access to those
Africa and Middle East and south Asia [30]. Carbapenem in need [37]. In a study with children in Haiti, Kenya, Malawi,
consumption was highest in the high-income region, where it Namibia, Nepal, Senegal, Tanzania, and Uganda between May
increased from 0.05 to 0.09 DDD per 1,000 per day from 2006 and December 2016, antibiotics were prescribed to 80.5%
2000 to 2018 [30]. The surge in the misuse of antibiotics has of children diagnosed with respiratory illness, 50.1% with
remained the main factor in causing this trend and the diarrhoea, and 28.3% with malaria, where the mean number
emergence of AMR. The characteristic of inappropriate use of of antibiotic prescriptions issued to children between birth and
antibiotics includes using antibiotic for an insufficient amount of age 5 years across the eight countries was 24.5 (95% CI
time than specified, treating conditions other than bacterial infection 22.6–26.7), ranging from 7.1 (6.3–7.9) in Senegal to 59.1
using antibiotics, as well incorrect administration methods and (54.1–64.6) in Uganda [38]. The authors indicated that with
dosage taken [31]. such high prescription rates for antibiotics, that there was over-

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FIGURE 2 | (A) Resistance Map showing the Global usage of antibiotics in 2000 [36]. (B) Resistance Map showing the Global usage of antibiotics in 2015 [36].

FIGURE 3 | Illustration representing the concept of One Health Approach.

prescribing of antibiotics that needs addressing to avoid the WHAT GLOBAL AND LOCAL ACTION IS
emergence of AMR [38]. BEING TAKEN TO ADDRESS AMR?
While there is ongoing research on new antimicrobial
treatments, there must be controls and management of the One Health Approach
antibiotics including standardisation of quality checks and AMR is an emerging issue where a unified global approach is
accessibility of antibiotics. Therefore, improving surveillance required. “One Health” embraces the concept that there is a clear
programs is urgently required in some LMICs to improve the connection between the health of both humans and animals and
current state of AMR. the shared surrounding environment as shown (Figure 3) [39]. It

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FIGURE 4 | The 17 sustainable development goals of the United Nations (Source [54]).

was evidenced that humans and animals can share the same the development of various antimicrobial stewardship
bacteria, diseases and more importantly, the sharing of the same programmes. RUMA (Responsible Use of Medicines in
antibiotics to treat infectious diseases in animals, as well as in Agriculture Alliance) encourages innovative and proactive
humans [40]. With all aspects considered, AMR has emerged as efforts to improve the responsible use of veterinary medicines
one of the most prominent “One Health” issues, since AMR has while ensuring optimum animal health and welfare [42].
the ability to spread rapidly across the population as well as in the Additionally, the idea of “One Health” emphasises the
food chain, healthcare settings and the environment, thereby interdependence of human and animal health [43, 44].
making it more challenging to manage many infectious diseases Therefore, guidelines on veterinary antimicrobials should
in both humans and animals [40]. be included to address the possible risk associated with the
The “One Health Concept” is a multisectoral approach, where use of these medications, including the development of AMR.
combined efforts from all stakeholders are required to successfully This information should not be restricted to providing
engage in this program. The WHO has worked in close human antimicrobials medications only [43]. This
collaboration with the Food and Agriculture Organization of approach will further raise people’s awareness of the
the United Nations (FAO) and the World Organization of current issue of AMR.
Animal Health (OIE) to ensure effective actions are taken from The implication of the “One Health Approach” on AMR is
all sectors in reducing the risks of AMR from this approach [1]. rather challenging to be successfully conducted in LMICs
A growing number of studies have shifted their attention from compared to HICs. LMICs still remain to be the most
human factors to more serious contributing AMR factors arising affected by AMR as to facing more serious challenges that do
from animal aspects. Earlier research indicated that 73% of all not apply in HICs such as poverty, corruption and healthcare
antibiotics used worldwide are used in farm animals, largely for systems leading to a more disease-prone environment such as
food production [14]. This would become a serious issue if lack of clean water access and sanitation issue and even the
continuously progressing without being controlled. Van accessibility of antimicrobials [45]. A previous study has also
Boeckel et al. have proposed user fees and regulatory caps on noted a further concern in the farming sectors of LMICs where
veterinary use of antimicrobials as a means to reduce animal the only option available to farmers to combat widespread
consumption of antimicrobials [41]. bacterial infection in an animal is by the use of antibiotics
Additionally, the agriculture sector is taking a proactive role due to lack of access to professional veterinarians and support
in ensuring the responsible use of veterinary medicines, through systems [46]. However, AMR is still most closely monitored in

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healthcare systems and AMR regulations which need to be

addressed.
Several approaches can strengthen this “One Health
Approach,” especially in LMICs, by possibly introducing
antimicrobial-sensitive intervention such as clean water access,
this approach would be more cost-effective and sustainable in
some resources limited LMICs.

Global Action Plan (GAP) and Global

Antimicrobial Resistance and Use
Surveillance System (GLASS)
In addition to the “One Health Approach,” in 2015, the WHO
launched an AMR-related management program known as the
Global Action Plan focusing on AMR (GAP-AMR). This plan
aims to ensure that infectious disease can always be successfully
treated and prevented by preserving antimicrobials in a responsible
manner with appropriate accessibility and quality checks [48].
Five main objectives were established to fulfil this goal, one of
which is to enhance the efficacy of antimicrobial medication use
for both human and animal health, this would require a good
regulatory system, respectively [48]. Some of the most
recognisable drug regulatory agencies such as the Food and
Drug Administration (FDA) in the United States, and the
Health Products Regulatory Authority (HPRA) in Ireland,
both of which regulate medicine for human and animal
health. In comparison, the UK has a separate system for
humans and animals, the Medicines and Healthcare products
Regulatory Agency (MHRA) for human health and the
Veterinary Medicines Directorate (VMD) for animal health.
It is expected that countries would introduce their national plans
in AMR in order to reach the goals of the overall Global Action Plan.
According to the WHO, 18 countries and territories have established
multi-stakeholder national action plans on AMR while six countries
are in the final stages of creating national action plans [49].
The other approach launched was the Global Antimicrobial
Resistance and Use Surveillance System (GLASS). The aim of this
program is to focus on promoting surveillance of AMR globally
and determining the causes of AMR. This would involve
providing advice and guidance to support nations to
implement remedial measures as necessary [50].

ANTIMICROBIAL RESISTANCE AND THE

COVID-19 PANDEMIC
The occurrence of the COVID-19 pandemic in 2020 created an
unprecedented scenario for the treatment of suspected or proven
bacterial infections with antibiotics. The changing dynamic in the
movement of patients within healthcare (community and hospital),
largely driven by the patients’ SARS CoV-2 status, combined with
FIGURE 5 | The seven United Nations Sustainable Development Goals
reduced diagnostic ability due to redeployment of laboratory staff to
(SDGs) affected by antimicrobial resistance.
SARS CoV-2 testing, resulted in a temporary redefining of “Best
Practice” antimicrobial stewardship programmes, due to pandemic-
HICs, despite the fact that many of the most modified resistant related constraints. A recent study investigating global antibiotic use
strains of bacteria are particularly transmitted in LMICs [47]. during the pandemic, through examination of pharmaceutical sales
This demonstrates a development gap in these nations’ data from 71 countries during the years, 2020–2022, showed that

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TABLE 1 | Antimicrobial Resistance (AMR) reduction strategies and related outcomes.

Antimicrobial Description Outcome

resistance theme

AMR Global/National WHO Framework of interventions to slow the emergence and reduce Many countries have now developed and published their national AMR
Action Plans the spread of AMR Action plans. Certain countries (e.g., Japan, Tanzania, China) have now
published their second national plan on AMR.

AMR Surveillance WHO Global Antimicrobial Resistance and Use Surveillance System The ongoing collection of antimicrobial susceptibility data on human
(GLASS) and veterinary pathogens.
Study for Monitoring Antimicrobial Resistance Trends (SMART) Surveillance data is available through reports in scientific and medical
journals, as well as freely available on hosts’ websites, e.g., EARS-net
(https://www.ecdc.europa.eu/en/about-us/networks/disease-
networks-and-laboratory-networks/ears-net-data)
U.S. National Antimicrobial Resistance Monitoring System (NARMS) AMR surveillance helps informs health policy.
European Antimicrobial Resistance Surveillance Network (EARS-Net) AMR surveillance data allows for examination of temporal and spatial
trends of AMR locally, nationally and internationally.

AMR Diagnostics Development of commercial laboratory diagnostic kits (phenotypic and Investment by biotechnology companies into developing commercially
molecular) to test for AMR bacteria or antimicrobial resistance markers/ available kits has allowed the widespread adoption of novel AMR
determinants in clinical, veterinary, food/water and environmental diagnostics for AMR detection either in realtime—for the clinical
isolates management of patients or for AMR surveillance purposes.

AMR Public Health World Antimicrobial Awareness Week (WAAW) WAAW is a global campaign that aims to raise awareness of
Messaging antimicrobial resistance worldwide and encourage best practices
among the general public, health workers and policymakers to slow the
development and spread of drug-resistant infections [60].
British Society for Antimicrobial Chemotherapy (BSAC) “Stop Superbugs” campaign to raise public awareness and support
antibiotic health literacy initiatives [61].
US Centers for Disease Control and Prevention “Combatting Antimicrobial Resistance.” A portfolio of guidance,
epidemiology and communication resources to support AMR public
awareness [62].

AMR Antimicrobial An organisational or healthcare-system-wide approach to promote Enhancement of the role of pharmacists to establish Antimicrobial
Stewardship and monitor the judicious use of antimicrobials to preserve their future Pharmacists, to support Antimicrobial Stewardship programmes
effectiveness [63]. Establishment of Antimicrobial Stewardship Committees in healthcare
institutions to develop local antimicrobial policies.
Establishment of Antimicrobial Stewardship policies in animal medicine
(National Office of Animal Health; NOAH) and RUMA (Responsible Use
of Medicines in Agriculture Alliance) [42]

sales of cephalosporins, penicillins, macrolides, and tetracyclines (SDGs) including many aspects of societal and human
decreased dramatically during April–May 2020, afterwhich there interactions, as illustrated in Figure 4 [53]. One SDG is
was a gradual rise to nearly pre-pandemic rates through May SDG3–“Good Health and Wellbeing.” Within this, AMR has a
2022 [51]. This study calculated that a 10% increase in monthly named specific inclusion, with indicator 3.d.2, namely,
COVID-19 cases was associated with 0.2%–0.3% higher sales of “Percentage of bloodstream infections due to selected
cephalosporins, 0.2%–0.3% higher sales of penicillins, 0.4%–0.6% antimicrobial-resistant organisms.” The WHO have indicated
higher sales of macrolides, and 0.3% higher sales of all four that AMR impacts seven of the 17 SDGs, as detailed in
antibiotics combined per 1,000 people. Geographically, a 10% Figure 5 and these are futher discussed by Jasovský et al. [55],
increase in monthly COVID-19 cases was associated with 0.8%, particularly in terms of environmental, social, and economic
1.3%, and 1.5% higher macrolides sales in Europe, North America, targets in the SDG framework.
and Africa, respectively. The U.S. Centers for Disease Control and
Prevention estimates that antibiotic resistance in the United States
increased 15% during 2019–2020, leading to 29,400 additional The Role of Biomedical Science in Helping
deaths, of which 40% were from hospital-acquired infections [52]. Combat AMR
The clinical microbiology laboratory, as well as biomedical
scientists, have an important role to play in combatting AMR,
ANTIMICROBIAL RESISTANCE AND THE both locally and internationally. Diagnostics play a vital role in
UNITED NATIONS SUSTAINABLE adding value in terms of 1) laboratory surveillance of AMR
epidemiology, through monitoring, 2) providing antimicrobial
DEVELOPMENT GOALS susceptibility results for clinically significant pathogens, to help
As part of the 2030 Agenda for Sustainable Development, the avoid empirical antibiotic prescribing, but rather evidence-led
United Nations has published 17 Sustainable Development Goals antibiotic selection, 3) helping to determine if the aetiology of

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clinical infections are viral or bacterial, thereby helping decide the and continues to be on the agenda of numerous political
potential value of intervening with antibiotics, 4) providing conferences. Adoption of mitigating strategies are beginning
innovative techniques to robustly allow more rapid turnaround to see positive results, with tangible outcomes (see Table 1).
times for reporting of antimicrobial susceptibility results to However, the consequences of failure to adequately address
antibiotic prescribers, so that good antimicrobial stewardship AMR are profound, with estimations of a return to the pre-
practices are promoted and 5) allowing the elucidation of novel antibiotic era, where everyday infections relating to childbirth,
mechanisms of antimicrobial resistance, through whole genome surgery and open fractured limbs could be potentially life-
sequencing techniques. Recent advances in biomedical science threatening. AMR itself represents a microcosm of factors,
innovative has allowed the development of total laboratory including social anthropology, civil unrest/war, diasporas,
automation for the rapid detection and identification of ethnic displacement, political systems, healthcare,
pathogens, as well as for the determination of their economics, societal behaviour both at a population and
antimicrobial susceptibility [56]. Additionally, IT capacity in individual level, health literacy, geoclimatic events, global
terms of having sufficient laboratory informatics capacity, travel and pharmaceutical innovation and investment, thus
including data management systems, is important for effective finding a solution that adequately addresses AMR and which
laboratory surveillance of AMR, as well as the interface to share helps stem further AMR emergence is complicated. Success
AMR susceptibility data, on a global basis [57]. will involve individuals, communities and nations all working
AMR places new challenges for the clinical diagnostic laboratory. together to ensure that the world continues to possess a
Our group recently reported that traditional microbiological agar sufficient armamentarium of effective antimicrobials that
formulations may become less efficient in their selective properties will sustain human and animal health, both now and in the
due to breakthrough of AMR organisms, where current future.
concentrations of antibiotics have become ineffective in
containing breakthrough from AMR organisms [58]. The
emergence of AMR now threatens the ability to detect pathogens AUTHOR CONTRIBUTIONS
using traditional selective microbiological media, without a radical
rethink and reformulation of many of these selective agars [58]. KT: formal analysis; methodology; roles/writing—original draft;
One example of this is the growing problem of highly resistant writing—review and editing. BM and JM: conceptualization;
organisms, especially Pseudomonas aeruginosa, overgrowing agar formal analysis; methodology; writing—review and editing. All
cultures designed for the detection of Mycobacterium authors contributed to the article and approved the submitted
tuberculosis [59]. version.

CONCLUSION CONFLICT OF INTEREST

Antimicrobial resistance continues to be a major global public The authors declare that the research was conducted in the
health dilemma of the 21st century. Already this topic is absence of any commercial or financial relationships that
receiving substantial political input from the G7 countries could be construed as a potential conflict of interest.

7. World Health Organization. Comprehensive Review of the WHO Global Action

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