Antimicrobial resistance: a global threat

Antimicrobials – antibiotics, antivirals, antifungals and antiparasitics – are substances widely used to prevent and treat infections in humans, aquaculture, livestock and crop production. Their effectiveness is now in jeopardy because a number of antimicrobial treatments that once worked no longer do so because microorganisms have become resistant to them. Microorganisms that develop resistance to commonly used antimicrobials are referred to as superbugs. UNEP released in 2023 the flagship report Bracing for Superbugs: Strengthening environmental action in the ‘One Health’ response to antimicrobial resistance.

What is antimicrobial resistance (AMR)?

AMR occurs when microorganisms such as bacteria, viruses, parasites or fungi become resistant to antimicrobial treatments to which they were previously susceptible.

Increased use and misuse of antimicrobials and other microbial stressors, such as pollution, create favourable conditions for microorganisms to develop resistance both in humans and the environment. Bacteria in water, soil and air, for example, can acquire resistance following contact with resistant microorganisms. Human exposure to AMR in the environment can occur through contact with polluted waters, contaminated food, inhalation of fungal spores, and other pathways that contain antimicrobial resistant microorganisms.

What is the impact of AMR?

The World Health Organization (WHO) lists AMR among the top 10 threats for global health.

Antimicrobial resistance threatens human and animal health and welfare, the environment, food and nutrition security and safety, economic development and equity within societies.

Predicted AMR mortality in 2050 — *Predicted mortality from AMR compared to common causes of death today (adapted from O’Neill 2016; Murray et al. 2022)*

According to recent estimates, in 2019, 1.27 million deaths were directly attributed to drug-resistant infections globally. By 2050, up to 10 million deaths could occur annually.

If unchecked, AMR could shave US $3.4 trillion off GDP annually and push 24 million more people into extreme poverty in the next decade.

Antimicrobial resistance in mycobacterium tuberculosis, malaria parasites, viruses and HIV is becoming a reality that could increase human suffering. It could also deal a huge blow to the world economy, due to productivity losses, increased healthcare costs and a rise in poverty. Even if it is a global crisis, poverty, lack of sanitation and poor hygiene make AMR worse. Also, AMR disproportionately impacts Low-Income Countries and Lower-Middle-Income Countries. AMR is thus an equity issue too.

Management and response to AMR

Environment plays a key role in development, transmission and spread of AMR. Therefore, the response must be based on a One Health approach, recognizing that humans, animals, plants and environment are interconnected and indivisible, at the global, regional and local levels, from all sectors, stakeholders and institutions. Prevention is at the core of the action needed to halt the emergence of AMR and environment is a key part of the solution.

One health approach to fight AMR — *One Health definition developed by the One Health High-Level Expert Panel (WHO 2021b)*

“AMR challenges cannot be understood or addressed separately from the triple planetary crisis – the crisis of climate change, the crisis of nature and biodiversity loss, and the crisis of pollution and waste, all of which are driven by unsustainable consumption and production patterns,” said UNEP Executive Director Inger Andersen.

Three economic sector value chains profoundly influence the development and spread of AMR:

*Type of environmental AMR pollution sources*

Pharmaceuticals and other chemicals manufacturing.

Agriculture and food including terrestrial animal production, aquaculture, food crops.

Healthcare delivery in hospitals, medical facilities, community healthcare facilities and in pharmacies where a range of chemicals and disinfectants are used.

In addition, poor sanitation, wastewater and related waste effluent in human and animal waste systems, such as municipal wastewater is an important source of AMR.

Management options to address releases, effluent and waste, such as:

Pharmaceutical manufacturing:

Ensure adequate waste and wastewater containment and treatment, and incorporate waste management into standard operating procedures used in the production of antimicrobials with a lifecycle approach.
Promote sustainable procurement and reimbursement systems for manufacturers.

Food and agriculture:

Limit use and reduce discharges to protect water sources from pollutants, resistant microorganisms, and antimicrobial residue contamination.
Apply infection control and prevention measures.

*Environmental complexities in transmission and spread of AMR*

Healthcare:

Install hospital-specific wastewater treatment systems, especially in locations without modern community wastewater treatment plants.

Leverage hospital stewardship and infection prevention control programmes to limit environmental contamination by AMR pollutants.

Municipals:

Increase waste containment and optimize wastewater treatment and sludge management processes.

Innovate and adapt wastewater treatment options, including technologies for different resource settings.

It is imperative to tackle the environmental dimensions of AMR to maintain progress towards the Sustainable Development Goals.

*Sustainable production and consumption of antimicrobials can impact many other SDGs*

Joining forces to accelerate the fight against AMR

Four lead organizations working in the multilateral system on human, animal, plant and environmental health, the UN Environment Programme (UNEP), Food and Agriculture Organization of the United Nations (FAO), World Health Organization (WHO) and World Organization for Animal Health (WOAH) joined forces to advance international co-operation for a One Health response on AMR.

The four organizations developed a joint strategic framework for collaboration on AMR and a common work plan sets out how the organizations will collaborate to deliver the vision of the Framework, defining workstreams implemented by the four organizations collaboratively over the next years.

In 2022, they signed an agreement to strengthen their co-operation and fully integrate environmental considerations into One Health efforts, including those related to AMR. They also developed the One Health Joint Plan of Action, with AMR as one of the six action tracks. The Quadripartite consolidated their Joint Secretariat to lead and coordinate global efforts across the One Health spectrum by consolidating cooperation.

Collaborating globally

Collaborating to fight AMR The AMR Multi-Stakeholder Partnership Platform launched in November 2022 is an inclusive, international and multi-stakeholder venue bringing together a diverse range of actors at all levels across the One Health spectrum. It is a voluntary, collaborative coordination mechanism established by the Quadripartite to catalyze a global movement for action against AMR and contribute to the implementation of the Global Action Plan on AMR and country National Action Plans.

Measuring progress

Measuring progress against AMR Countries agreed to have a National Antimicrobial Resistance Action Plans (NAP) consistent with the Global Action Plan, and to implement relevant policies and plans to prevent, control and monitor AMR. As of November 2022, 170 countries have finalized their NAP. An annual Tracking AMR Country Self-assessment Survey (TrACSS) jointly administered by FAO, UNEP, WHO and WOAH monitors country progress in the implementation of their NAP. View the results of the current and previous six amrcountryprogress.org

Advocating at the highest level

GLG advocating for AMR fight The Global Leaders Group on Antimicrobial Resistance consists of world leaders and experts from across sectors working together to accelerate political action on antimicrobial resistance. The group performs an independent global advisory and advocacy role. The GLG collaborates globally with governments, agencies, civil society and the private sector to prioritize political actions for the mitigation of drug resistant infections through responsible and sustainable access to and use of antimicrobials.

Financing action

AMR Trust Fund The AMR Multi-Partner Trust Fund (AMR MPTF) supports countries in the implementation of the AMR national actions plans through a One Health approach. The fund finances catalytical, coordinated policy advice, technical assistance and capacity-strengthening programmes.

Political action

On 25 November 2022, the Third Global High-Level Ministerial Conference on Antimicrobial Resistance, agreed on the Muscat Ministerial Manifesto. The three globally-agreed targets will be key to protecting the efficacy of antimicrobials and curbing the development of AMR worldwide, as well as reducing environmental pollution, which, in turn, will lower the spread of AMR.

Antimicrobial resistance: a global threat

What is antimicrobial resistance (AMR)?

What is the impact of AMR?

Management and response to AMR

Joining forces to accelerate the fight against AMR

Political action

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