Lessons From a Decade of Antimicrobial Resistance Policy
When antimicrobial agents become less effective, it becomes more difficult—and more costly—to treat infections and control the spread of disease. Over the last decade, as the battle to respond to and combat antimicrobial resistance (AMR) has continued to shift, both U.S. and global policy have evolved with it. How has the view of the public health threat of AMR changed through a policy lens in the last 10 years, and what’s next?
AMR Has No Borders
Source: ASMThe World Health Organization (WHO) identified AMR as 1 of the top 10 global public health threats, estimating 10 million deaths related to AMR globally, every year, by 2050. It is unlikely that a new, broad-spectrum antibiotic like penicillin, which has been a reliable cornerstone of infection treatment for decades, will be discovered—so a key strategy for battling AMR is following best practices to prevent AMR transmission from the outset and reduce the need for more powerful antimicrobials. Issues that contribute to the challenge of addressing AMR include:
• Over-prescription of antimicrobials.
• Patients not completing prescribed antimicrobial courses.
• Antimicrobial overuse in livestock, fish and crop farming.
• Limited discovery of new antimicrobials.
Though domestic policy relating to AMR has been part of the legislative discussion for a long time, it is increasingly apparent that international collaboration and development of global policy is needed to adequately combat AMR.
A Decade of AMR Policy
In the U.S., Congress and federal agencies have been aware of AMR for years, but even though action has been taken, the goalposts are constantly shifting. In 2013, the U.S. Centers for Disease Control and Prevention (CDC) released a report on antibiotic resistant threats in the U.S. This report identified 3 bacteria with a threat level of “urgent” at that time: Clostridium difficile, Carbapenem-resistant Enterobacteriaceae and drug-resistant Neisseria gonorrhoeae. The CDC released an updated report in 2019 in which those bacteria remained on the list of urgent-level threats, and 2 more had been added: Candida auris and Carbapenem-resistant Acinetobacter.
Note: In 2016 the genus name for C. difficile was updated to Clostridioides, and in 2020 Enterobacteriaceae was updated to a family within the order of Enterobacterales. The above are listed as they were written in the reports at the time of publication.
Within the 6 years between publication of the first and second reports, the White House released the National Action Plan for Combating Antibiotic-Resistant Bacteria (March 2015) with the following goals:
- Slow the emergence of resistant bacteria and prevent the spread of resistant infections.
- Strengthen One Health surveillance efforts to combat resistance.
- Advance the use and development of rapid and innovative diagnostic tests for identifying and characterizing resistant bacteria.
- Accelerate basic and applied research and development for new antibiotics, vaccines and other therapeutics.
- Improve international collaboration and capacity for antibiotic resistance prevention, surveillance, control and antibiotic research and development.
The U.S. government also contributed to the global action plan on AMR endorsed by the WHO World Health Assembly in May 2015, with focus on the following 5 objectives:
- Improving awareness and understanding of AMR.
- Strengthening the knowledge and evidence base.
- Optimizing the use of antimicrobials in human and animal health.
- Using effective sanitation and hygiene measures to prevent infection.
- Developing an economic case for investment that accounts for global needs—increasing investment in new medicines, diagnostic tools and vaccines.
Domestic and global policy, as well as government agency efforts, to address AMR quickly ramped up as it became evident that the threat of AMR was rapidly evolving. In 2019, Congress passed the Pandemic and All Hazards Preparedness and Advancing Innovation Act. The bill contained language championed by ASM, which codified the Presidential Advisory Council on Combating Antibiotic-Resistant Bacteria (PACCARB), an advisory committee of outside experts that had originally been established in 2014 by Executive Order 13676.
The National Action Plan for Combating Antibiotic-Resistant Bacteria was updated in October 2020, building on the framework from 2015 to prioritize infection prevention and control and reduce the need for antibiotic use. The updated plan supported expanding activities that were shown to slow the spread of AMR, such as improving antibiotic stewardship in hospital and outpatient settings and engaging the animal health and crop protection communities to advance strategies for fostering responsible use of medically important antibiotics. The plan emphasized the interconnected threat of AMR to humans, animals and the environment. It also underscored that AMR is not an issue that can be addressed simply through domestic action in the U.S. but requires international and multisectoral collaboration between public and private entities.
Progress Interrupted: COVID-19
That same year would bring unprecedented challenges and impacts on the fight against AMR due to the COVID-19 pandemic. The 2019 antibiotic resistance threat report from the CDC highlighted prevention as the most crucial tool to protect against and prevent the spread of antimicrobial resistant infections. However, as health care facilities, health departments and communities grappled with the challenges of COVID-19, there was an increased use of antimicrobials and lower adherence to best practices for infection prevention and control. Moreover, public health resources had to shift from tracking antimicrobial resistance to tracking COVID-19. The CDC later released a report in 2022 analyzing the impacts and setbacks that the COVID-19 pandemic made to the fight against AMR, including increased prescription of antimicrobials that weren’t necessary for treatment and lapses in antimicrobial resistance tracking. The report underlined the imperative need to recover from those setbacks to continue to protect human and animal health.
Where Are We Now?
The work to fight AMR continues, with the convening of the 118th Congress on Jan. 3, 2023. Key pieces of legislation on AMR include the Pioneering Antimicrobial Subscriptions to End Upsurging Resistance (PASTEUR) Act, reintroduced to Congress in May 2023 by Sen. Sherrod Brown, which would promote new antibiotic development and appropriate use of existing antibiotics to limit the increase and spread of AMR. The Strategies to Address Antibiotic Resistance (STAAR) Act, which has yet to be reintroduced, would strengthen the country’s capability to address AMR outbreaks quickly, while bolstering antibiotic stewardship models to preserve their effectiveness against existing pathogen threats.
ASM released a report of policy recommendations in July 2023, Policy Pathways to Combat the Global Crisis of AMR, that underlined the need for a multidimensional approach to facing a problem like AMR and the crucial position of microbiologists as part of the solution. The recommendations assert the need for proper antimicrobial stewardship, harmonization of new domestic antimicrobials and antimicrobial alternatives, such as phage therapy, microbiome therapeutics and vaccines.
ASM is a leader in advocating for science and evidence-based policy and recognizes the essential role of microbiology in addressing public health issues, including AMR. ASM members and staff spent an entire day on Capitol Hill in September 2023, meeting with 50 Congressional offices to discuss the global public health threat of AMR.
"The expertise of microbiologists is crucial to the development of policy surrounding the mounting threat of antimicrobial resistance,” said ASM past president Robin Patel, M.D., who participated in ASM’s Hill Day in September. “Meeting our members of Congress face to face, and bringing expertise directly to them to show the impact that policy has on the fight against AMR, is important to ensure the health of all people living in the United States."
When microbiologists meet with legislators, they can explain how legislation directly impacts their research and work and contribute their first-hand scientific experience to the development of sound policy. ASM is actively tracking and contributing to the policy development surrounding AMR and continues to work with members of Congress and their staff members, government agencies and ASM members to develop key public policies that address the challenges of AMR.
In This Issue:
- Lessons From a Decade of Antimicrobial Resistance Policy
- Growing Resistance: How Plant Agriculture Contributes to AMR
- Understanding the Risks of Antifungal Resistance
- Experts in East Africa Propose Equitable AMR Interventions
- Wastewater As a Key Driver of AMR
- Exploring a One Health Approach to AMR in Pakistan
- Federally Qualified Health Centers Lead AMR Stewardship
- Updating Breakpoints in Antimicrobial Susceptibility Testing
- Hunting for Antibiotics in Unusual and Unculturable Microbes
- What's Hot in the Microbial Sciences