This report summarises current understanding of antibiotic resistance, the scope of the problem, and the methods available for detecting and preventing it. It highlights unique challenges faced by developing countries including poor research infrastructure and counterfeit antibiotics.

The authors highlight the need to build laboratory capacity, improve diagnostic tools, establish surveillance programs and implement tighter controls on antibiotic use in these countries.

This article examines the rising rate of antibiotic resistance, and proposes action to reverse the trend. The authors call for leadership at international and national levels, a change in the behaviour of consumers and providers, and the development of antibacterial agents to match existing public health needs.

They suggest that international bodies such as the WHO should provide coordination and resources for generating key information on the burden of antibiotic resistance, and call for individual governments to set up multidisciplinary action programmes. They also examine the methods needed to better inform the public and discuss alternative approaches to developing new antibacterials, including product development partnerships and gap analyses.

A mix of factsheets, opinion pieces and case studies on antibiotic resistance in developed and developing countries, the publication looks at the history of antibiotics, the development of resistance and possible ways of combating it. Some of the pieces look at how medical staff cope with resistance, particularly MRSA, in hospitals. The editorial emphasises the need for consumers to play their part, and urges people not to take the benefits of antibiotics for granted. The issue of antimicrobials in animals is covered because of growing evidence that resistant bacteria can spread from animals to humans.

This background piece to understanding antibiotic resistance in Africa is written in accessible language. It outlines the scale of the problem in Africa (bacterial infections cause 45 per cent of deaths) and the commonest types of infections — tuberculosis, respiratory illnesses and sexually transmitted infections.

It addresses problems of antibiotic resistance specific to African populations: the heavy burden of community-acquired infections; the limited range of first-line antibiotics and varying availability of second-line drugs (often vital against resistant bacteria); the hidden costs from longer hospital admission times and more expensive drugs needed to treat resistant pathogens.

The AIDS epidemic is linked to the problem – the HIV virus weakens people’s immune systems making them more susceptible to bacterial infection. In addition, antibiotics used prophylactically in AIDS patients to prevent opportunistic infections are also used for a wide range of bacterial infections, making it more likely that the pathogens will develop resistance.

Another problem is the sale of antibiotics by unsanctioned providers, who might give incorrect information about how to take the drugs. They frequently sell poor-quality or even counterfeit drugs that don’t cure the patient but encourage bacterial resistance.

Consumers need to be made aware of their own responsibilities, says the article, but ultimate responsibility lies with the healthcare providers in instituting and maintaining treatment programmes.

The factsheet outlines the problem of antibiotic resistance detailing the causes, consequences and factors that encourage the spread of resistance. It is ideal for people wanting a snapshot of the problem from WHO's perspective, although for more detailed information see the WHO global strategy for containment of antimicrobial resistance.

Researchers looked at global patterns of antibiotic resistance to assess how best to tackle the problem. They looked at three geographically separated, and culturally and economically distinct countries — China, Kuwait and the US: the theory was that if these very different countries had different patterns of resistance, a country-specific approach could still work: if the patterns were similar, a coordinated international response would be needed.

China had the fastest growing rate of increasing resistance, followed by Kuwait and then the US. The authors note that surveillance data are urgently needed to clarify the scope of the problem. Despite the paucity of data, preliminary data show China is doing worst — resistance of SPN (Streptococcus pneumoniae) to erythromycin is 73 per cent, compared with 23 per cent in Kuwait, and its MRSA levels are at 90 per cent

The authors say that although these countries have different trends at the moment, increasing globalisation means this might not last long. Also needed are better methods of data aggregation and analysis of how resistance is transmitted across national boundaries.

The first of this two-part series looks in detail at how antibiotic resistance affects the treatment of different types of illnesses — those that attack the gut (such as salmonella or cholera) and respiratory system (such as the tuberculosis bacterium), and the bacterium that causes gonorrhoea.  Treating these diseases in developing countries is increasingly difficult because the cheap antibiotics that were once effective are growing to be useful against bacteria that have developed resistance. These changes are pushing up treatment costs in developing countries. Drug-resistant tuberculosis, for example, is more expensive to treat than the non-drug-resistant type.

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The second half of this series focuses on action needed to contain antimicrobial resistance. It outlines the risk factors that can lead to resistance emerging and spreading, particularly in developing countries: using poor-quality drugs or inadequate infection control in hospitals, for example. The article outlines strategies to stop the problem getting worse but points out that developing countries differ widely in the state of their healthcare systems and their resources, so a one-size-fits-all model is not useful.

The authors emphasise the importance of education of the public and of medical practitioners because otherwise the only information available to most healthcare professionals is from pharmaceutical companies that may not fit government or local priorities. In developing countries, unsanctioned providers are a particular problem because they might give people counterfeit or substandard antibiotics that can fuel resistance.

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Good prescribing practices are important in tackling antibiotic resistance, and diagnostics are key to ensuring good practice. Knowing who not to treat is as important as knowing who to treat. The article reports on analyses by the Global Health Diagnostic Forum of the Bill & Melinda Gates Foundation to assess how many lives could be saved by better diagnostics for six major illnesses, including malaria and tuberculosis. The researchers assessed the technical issues associated with implementing the diagnostic tests in developing countries for three classes of laboratory infrastructure — none, minimal, or moderate to advanced.

They found that for acute lower respiratory infections, syphilis, gonorrhoea, chlamydia and TB, outcomes could be much improved if tests were sent to sites with minimal or no laboratory infrastructure. In these types of settings, the practicality of obtaining a specimen is important. For example, obtaining a blood sample correctly to test HIV viral load is almost impossible where there are no laboratory facilities. Using sputum to test for TB has similar issues because of the impracticability of the sample medium. Thus, new biomarkers might be needed to test for diseases with specimens different from those currently used. Combination tests that look for a range of infectious organisms in one sample would be useful in resource-poor settings.

The researchers also highlight the importance of taking into account cultural and social sensitivities when designing interventions – blood sampling is not always accepted in some regions of the world, for example.

The report focuses on the lack of antibiotics in the pharmaceutical pipeline. Until now, it says, problems of resistance have been overcome by the development of new drugs. The older ones, to which bacteria or parasites have become resistant get phased out, and the new effective ones are brought in. But what happens when the cupboard is bare?

After a year's investigation of the problem, the authors say that while all stakeholders have a part to play in reducing the effect of resistance, pharmaceutical and biotechnology companies are best placed to take the lead in developing new drugs. The reason for the slump in production has been the high risk involved in investing large sums of money in drugs that might not yield a high return (especially if the drugs are most needed in poor countries).

Legislative and policy changes are needed to spur the pharmaceutical industry into action, says the report. Changes might include allowing companies to extend the exclusivity period on drug patents if they develop a priority antibiotic, tax incentives for R&D of priority antibiotics, or a guaranteed market (for example, by a government or donor agreeing to buy large quantities of drugs).

The problem of antibiotic resistance is not easy to solve. In an attempt to tackle the issue, policies are being implemented with some successes. But the successes, however encouraging, will not be enough to stop the spread of resistance, say the authors. Advice to restrict the use of antibiotics so that they are prescribed only when necessary (e.g. not for viral infections just to placate a patient) is useful, say the authors, but, they say, we might need to go further. They make the controversial argument that antibiotic resistance might be stopped only by putting society before the individual, perhaps by banning antibiotic treatment for mild bacterial infections, or using them only for life-threatening illnesses. Everyone has the right to treatment, and acting against the patient's interest is not usually considered ethical. In some situations, however, what is good for an individual patient may not be good for the health of society as a whole, say the authors – drastic problems sometimes necessitate drastic solutions.

At WHO's behest, the Alliance for the Prudent Use of Antibiotics (APUA) undertook a review of 25 key reports on antibiotic resistance to identify areas of consensus in expert recommendations and to suggest ways of translating the advice into action.

The reports were chosen because they were highly cited in medical literature and had input from a wide variety of expert policy groups. The review authors separated their comments into five areas: surveillance; education of patients and providers; prevention; R&D; and antibiotic use in animals.

Education, says the review, needs to happen in medical schools and among the general public. Surveillance of antibiotic resistance occurs but is fragmented – coordinated local surveillance networks could do much to tackle resistance before it spreads. Healthcare institutions need committees to assess antibiotic use data and enforce infection control measures. In terms of use in animals, the review recommends that farmers prevent infection with good hygiene and not just antimicrobials, and calls for the reduced use of antibiotics as growth promoters.

Antibiotics are used to prevent or treat disease or to encourage growth in animals intended for human consumption. Opinion is divided over the potential of the practice to cause health problems in people. This forum presents different perspectives from human and animal medicine experts.

The remarkable variation of views indicates the complexity of the debate. For some, there is no doubt that antibiotic use in animals causes resistance in people; for others, the link is present but unclear; and for the rest, not nearly enough is known to start taking action, and they suggest monitoring the situation. All agree, though, that whether in animals or people, antibiotics should be used with caution.

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In this report, the World Health Organization (WHO) warns that vigilance is needed to prevent drug-resistant malaria arising from the widescale introduction of artemisin combination therapies (ACTs) for malaria. More than 50 countries have now adopted ACTs, and they must closely monitor the effectiveness of these drugs and check for the emergence of resistance, the report concludes. Patients should receive only WHO-approved high-quality medicines to minimise the risk of resistance emerging, and should be encouraged to complete their treatment courses. The report outlines the WHO's commitment to helping establish stardardised laboratory procedures, and strengthening resistance monitoring networks.