Resisting Resistance:

Thinking Strategically about Antimicrobial Resistance

Richard D. Smith and Joanna Coast

Not long ago, it appeared as if the great twentieth-century battle against infectious disease had been won by the "magic bullet" of antibiotics. Unfortunately, celebrations have proved premature, and we begin the twenty-first century in retreat, as our once powerful antibiotics appear to be no match for the ingenuity of infectious "superbugs."

It has been observed as a natural biological phenomenon that micro-organisms can develop resistance against the antibiotics used to treat them. Although the development and spread of resistance is a complex process that depends on many factors, genetic transformation of micro-organisms into resistant strains is accelerated by the use of antibiotics.

These superbugs now present an ever greater challenge to public health. Diseases, ranging from mild ear-infection and strep throat to malaria and tuberculosis, are all increasingly demonstrating resistance to the antibiotics used against them. For example, in 1991 almost half of the 4,000 tuberculosis patients arriving at New York hospitals were suffering from resistant strains, and one such strain proved resistant to eleven different drug treatments. By 1993, physicians were regularly trying six or more drugs in attempts to treat tuberculosis. Doctors in New York have even died from drug-resistant tuberculosis; a situation that is being replicated in cities across the United States, other Western countries, and especially in the developing world.

Resistance creates serious health and economic repercussions. Patients infected with a particularly resistant strain are less likely to recover after the first antibiotic treatment. Such patients may require further examinations and treatments, and for some, a cascade of other drugs will be tried before the infection is eradicated. This generally means longer hospital stays, longer absences from work, and undoubtedly higher medical costs than for non-resistant infections. In the mid-1990s, estimates suggested that the health care costs associated with the treatment of antimicrobial resistance (AMR) in the Unites States were approximately $4-7 billion annually, or approximately 0.5-1% of total U.S. health care costs. Beyond increased health costs, patients with extreme cases of resistant infection face a greater likelihood of premature death.

This is understandably causing professional, government, and public concern. Indeed, the United States considers the potentially destabilizing economic and social effects of antimicrobial resistance, as well as its potential in biological warfare (especially in light of recent anthrax scares), sufficient to classify antibiotic resistance as a national security risk.…

Richard D. Smith is Senior Lecturer in Health Economics at the School of Medicine, Health Policy and Practice at the University of East Anglia.

Joanna Coast is Senior Lecturer in Health Economics at the University of Bristol.