The Forgotten Factors of Antimicrobial Resistance

Antimicrobial resistance is a complex problem. The issue stems from multiple industries and practices and there are myriad factors involved that facilitate the spread of resistant bacteria on a global scale. The challenges of constantly changing medical culture and spurring drug discovery can feel insurmountable, and now, the results of a new study indicate that factors like corruption may have a role to play in the spread of antimicrobial resistance.

Investigators pulled data from 3 separate sources—recent publications, the Resistance Map, and the World Health Organization 2014 report on antimicrobial resistance. From these data, they established 2 global indices that tracked antimicrobial resistance across 103 countries from 2008 to 2004. These country-level measure of antimicrobial resistance were 2 indices: Escherichia coli resistance to third-generation cephalosporins and fluoroquinolones and “aggregate resistance,” which includes resistance prevalence for multiple organisms and is “the combined average prevalence of E coli and Klebsiella spp resistant to third-generation cephalosporins, fluoroquinolones, and carbapenems, and methicillin-resistant Staphylococcus aureus.”

Data from the World Bank DataBank was used to evaluate governance, education, gross domestic product (GDP) per capita, health care spending, and community infrastructure, such as sanitation.

The team also evaluated the level of corruption within a country. Political stability and absence of violence, literacy, average climate temperature, access to electricity, internet penetration, and ration of public to private public health expenditure, are all points we do not necessarily discuss when it comes to combatting antimicrobial resistance; however, the team found that they play a role in the spread of antimicrobial resistance.

After analyzing associations between antimicrobial resistance and these factors through univariate regression, the investigators found that GDP per capita, education, infrastructure, public health-care spending, and antibiotic consumption were all inversely correlated with both of the aforementioned antimicrobial resistance indices. Meaning that as governance (ie, lower corruption, political stability, rule of law, and a lack of violence) and infrastructure (sanitation, safe water, internet accessibility, urbanization, and access to electricity) were stronger, there was a strong inverse correlation with antimicrobial resistance.

Although it’s not surprising that poorer infrastructure and governance would correlate to a higher level of antimicrobial resistance, it is helpful to have such data to support and initiate change. Moreover, higher temperatures, poorer governance, and the ratio of private to public health expenditure were also positively correlated with antimicrobial resistance. When the investigators performed a multivariate regression analysis for the 73 countries that had antibiotic consumption data available, they found that better infrastructure and governance were associated with lower antimicrobial resistance in both indices. Furthermore, antibiotic consumption was not statistically significant for an association with either antimicrobial resistant indices.

Additionally, higher education was significantly associated with higher levels of antimicrobial resistance. The authors note that this is likely due to the fact that affluent and better-educated individuals likely have better access to antibiotics.

Lastly, the investigators found that following univariate regression, the warmer the country, the higher its antimicrobial resistance levels were. “The correlation with temperature is an interesting finding,” the authors wrote, “[B]ut, whether this is a socioeconomic factor (poorer infrastructure in hotter areas) or has to do with temperature per se, remains unclear.”

Following this analysis, the investigators concluded that fighting antimicrobial resistance at a global level should not be focused solely on antibiotic consumption, but also the factors that contribute to the transmission of these infections. Antibiotic consumption and stewardship are wholly important to reducing antimicrobial resistance; however, we must not ignore the mechanisms that encourage its spread, as they appear to be dominating factors.

This is the first study of its kind and although additional analyses are needed, it gives considerable insight into more contributors of antimicrobial resistance on a global scale.