In the 2013 Global Risks Report, a chapter entitled “The Dangers of Hubris on Human Health” warned about the growing risks associated with complacency towards antimicrobial resistance (AMR). It highlighted two underlying drivers: the overuse and misuse of antibiotics, in both human health systems and livestock management; and the fact that no new classes of antibiotics had been invented since the 1980s. The chapter noted newly emerging resistance to the strongest class of antibiotics, carbapenems. It cited estimates of 100,000 AMR-related deaths in US hospitals and 80,000 in China. The potential economic impact was put at 0.4% to 1.6% of GDP.

The risks posed by AMR have continued to intensify in the five years since the 2013 report. Numerous welcome initiatives have been launched, but concrete successes in addressing the two drivers identified above remain elusive. We still face two trends that spell potential disaster: new classes of drugs are not being invented and resistance to existing drugs continues to spread inexorably. The stakes are incredibly high—if resistance overtakes all our available antibiotics, it would spell the “the end of modern medicine”.¹ 

The costs are rising…

The latest economic impact assessments should be cause for alarm about the dangers of AMR to human health and the global economy. A study published by the World Bank in March 2017 estimated that AMR would exert a drag on global GDP of between 1.1 and 3.8 percentage points between now and 2050.² According to estimates from a report supported by the UK government and the Wellcome Trust, AMR could cost US$100 trillion between now and 2050, with the annual death toll reaching 10 million over that period.³ As in 2013, the patchiness of data continues to make a precise assessment of the AMR problem difficult. For example, a 2016 Reuters investigation in the United States determined that the accuracy of Centers for Disease Control and Prevention (CDC) estimates of AMR effects—2 million infections and 23,000 deaths per year—is undermined by problems such as AMR-related deaths being mis-recorded on death certificates.⁴ One of the most exhaustive official studies of AMR—a two-year review commissioned by the UK government—concluded in 2016 that, globally, 700,000 deaths each year can be attributed to AMR.⁵ The Center for Disease Dynamics, Economics & Policy (CDDEP) has been tracking antimicrobial resistance globally—the maps in Figure 4.1 illustrate their latest data, which show impacts broadly unchanged when compared with the European data for MRSA and Klebsiella pneumoniae we cited in 2013.⁶ In October 2017, a new four-year global project that aims to track the evolution of AMR in 195 countries since 1990 was announced.⁷ 

Figure 4.1: Selected AMR Rates 

Resistance of Staphylococcus aureus to Oxadcillin (MRSA), % Resistant (invasive isolates)

Resistance of Klebsiella pneumoniae to Cephalosporins (3rd gen), % Resistant (invasive isolates)

Source: Figure courtesy Center for Disease Dynamics, Economics and Policy. Used with permission via Creative Commons license. https://resistancemap.cddep.org/AntibioticResistance.php
Note: Countries in white indicate no data available.

…and resistance is spreading

Resistance to the strongest antibiotics continues to spread, even as their use increases to cope with still higher levels of resistance to weaker antibiotics. In 2014, the World Health Organization (WHO) reported that “K. pneumoniae resistant also to carbapenems has been identified in most of the countries that provided data, with proportions of resistance up to 54% reported.”⁸ In 2017, research demonstrated that bacteria resistant to colistin, the “antibiotic of last resort”, had spread around the world within 18 months of the resistance first emerging.⁹ 

Global plans are taking shape…

There are some encouraging signs of action to counter AMR, although most of them are still at the planning stage. In 2015 WHO’s five-point Global Action Plan on Antimicrobial Resistance was ratified, and it is being supplemented with accelerating completion of national action plans—important because the causes and consequences of AMR can differ widely across countries. As of April 2017, 67 countries had completed national action plans, according to WHO, with another 62 in the process of doing so.¹⁰ 

One key objective of these plans is to reduce excessive use of antibiotics, both in human health systems and in livestock and agriculture. The latter, in particular, is a growing problem.¹¹ In the United States, 62% of the antibiotics used in agriculture are medically important for humans.¹² And agricultural usage is rising sharply: the global use of antimicrobials in meat production is expected to grow by 67% between 2010 and 2030.¹³ 

Efforts to reduce the excessive use of antimicrobials need to also ensure access to affordable life-saving medications in the world’s poorest countries, as underscored in a declaration by the G20 leaders in 2017, as well as by UNICEF.¹⁴ UNICEF’s Chief of Health has recommended using an integrated community case management (ICCM) approach, which can help to achieve an appropriate balance between ensuring access and preventing misuse of antibiotics.¹⁵ 

…but the drugs pipeline is a cause for alarm

There is still a stark lack of new drugs in the development pipeline.¹⁶ According to a 2016 study by The Pew Charitable Trusts, every currently available antibiotic is derived from a class discovered by 1984.¹⁷ Efforts are, however, intensifying to steer research in the right direction, such as the first-ever priority list of antibiotic-resistant bacteria published by WHO in 2016.¹⁸ New incentives are helping to catalyse new work. For example, CARB-X is an international non-profit partnership launched in July 2016 to accelerate research that focuses on the AMR bacteria prioritized as the most urgent by WHO and the CDC.¹⁹ It has already funded 18 projects from six countries.²⁰ In the United Kingdom, the innovation foundation Nesta has offered a £10 million prize for the invention of a fast, accurate and affordable test for bacterial infections to help health professionals worldwide administer the appropriate antibiotics.²¹ As of October 2017, 250 entries had been submitted. Scientific advances are allowing researchers to study a greater number of potential new sources of antibiotics; one company undertaking this kind of research is NovoBiotic Pharmaceutical, which studies soil microbes that until recently could not be cultivated in a laboratory.²² More radical alternatives to traditional antibiotics are also being studied, including the potential use of CRISPR to trick harmful bacteria into destroying their own DNA.²³