Policy-makers play a key role in tackling the emerging public health problem of antibiotic resistance. Antibiotics are important life-saving drugs used for the treatment of bacterial infections, but these drugs are now threatening to become ineffective because bacteria are developing resistance against them. This is a result of the misuse, and especially the overuse, of antibiotics. The use of antibiotics has to be balanced, meaning that they should be used only when they are needed and justified for therapeutic reasons, and not otherwise.

In many European countries, people can buy antibiotics over the counter without a prescription, and the pharmaceutical industry brings heavy pressure to bear on doctors and pharmacists to sell their drugs. In order to combat antibiotic resistance, a wide intersectoral approach and strong national commitment are needed. Without action now, we will see a situation in the future where common bacterial infections can no longer be treated and where routine, minimally invasive diagnostic procedures may become threatened by resistant bacterial infections. The tremendous health gains we have seen in the past 70 years may be under threat if the emergence and spread of antibiotic resistance cannot be contained.
Why is it important to invest in this now?

Antibiotic resistance leads to excess morbidity and deaths. The problem is urgent. In the European Union, Norway and Iceland, more than 25 000 people die each year from common resistant bacterial infections. These countries, however, make up only about half of the 53 Member States in the WHO European Region. Owing to variable diagnostic capacity and a lack of data in countries, the number for the whole Region is not known. Resistant bacteria are a serious problem both in health care facilities and in the community, causing infections such as urinary tract infections, pneumonia and food-borne illness. In addition, the WHO European Region has 15 out of the 27 countries with the highest burden in the world of multidrug-resistant tuberculosis (MDR-TB).

Antibiotic resistance increases health care costs. Longer durations of illness and more complex treatment increase health care costs and hence the financial burden on families and societies. The estimated total cost to society of antibiotic resistance in the European Union alone is estimated to be € 1.5 billion.

Multidrug-resistant tuberculosis. Treatment of MDR-TB is significantly more expensive than that of drug-susceptible TB. Many countries in the Region have reported extensively drug-resistant TB (XDR-TB) which is a form of MDR-TB resistant to the most important second-line drugs. MDR-TB and XDR-TB are the result of inadequate treatment of tuberculosis and complete cures are far more difficult to achieve.

Antibiotic resistance spreads. Because of the misuse, and especially the overuse, of antibiotics, “selective pressure” is put on bacterial populations: antibiotic-sensitive bacteria may be replaced by resistant bacteria when antibiotics are used. Resistant bacteria or genes that carry this information can spread easily. Poor infection control programmes in health care facilities further contribute to the spread of bacteria, including resistant bacteria and resistant tuberculosis.

The use of antibiotics in animals sometimes outweighs their use in humans. Although the use of antibiotics as a growth promoter in food animals is banned in the European Union, this is not the case in many other countries of the Region. Giving antibiotics to healthy animals, especially in low doses, increases the risk of selecting resistant bacteria which can easily spread along the food chain. Integrated surveillance systems should allow for the detection of resistant bacteria that are also important to humans.

Antibiotic resistance could take us back to the pre-antibiotic era. Resistant pathogens are emerging and spreading rapidly. Currently, there are not enough new antibiotics in the development “pipeline”. Without new and efficient antibiotics, but with increasing resistance, society could return to the conditions of the pre-antibiotic era. Without effective antibiotics for care and prevention, success rates for treatments such as organ transplantation, cancer chemotherapy and major surgery (not to mention other, usually easy to treat bacterial infections) would be far lower.
What can be done?

The complexity of the problem and the large number of sectors involved require strong national coordination, surveillance systems, national guidelines and sector-wide action plans. Good practices already exist: in many countries, the sale of antibiotics has already been regulated to prescription-only status. In most European countries, no antibiotics are available for sale over the counter. Antibiotics as a growth promoter in healthy animals for food production are banned in many countries of the Region.

There are also good examples of national coordination: in some north European countries, all-inclusive national coordinating committees (such as the Swedish Strategic Programme against Antibiotic Resistance – STRAMA, or the Dutch Working Party on Antibiotic Policy – SWAB) give advice on all matters regarding the prudent use of antibiotics and surveillance and prevention of antibiotic resistance. They provide guidelines on the use of antibiotics, steer awareness campaigns, advise on health professionals’ curriculum development and draw up national regulations.
Strategic action plan

As guidance for national policy-makers, the WHO Regional Office for Europe is developing a seven point strategic action plan that will be launched in Azerbaijan in September 2011, at the next session of the WHO Regional Committee for Europe.
I. Strengthen national multisectoral coordination for the containment of antibiotic resistance

The role of a coordinating committee would be to monitor the public health risks and impact of antibiotic resistance, recommend policy options and provide overall regulation and guidance concerning national strategies for containment of antibiotic resistance. All sectors and expertise should be included in these national coordination efforts and in the development of national action plans.
II. Strengthen national surveillance of antibiotic resistance

A system guided by international standards should be developed to collect, analyse and report priority data on the occurrence of and trends in resistance among relevant pathogens, including alerts about the identification of newly emerging resistance. Regional databases should be in place to ensure timely detection and response to geographical spread and trends.
III. Promote national strategies for the rational use of antibiotics and strengthen national surveillance of antibiotic consumption

A national government authority or agency should be in place to oversee this particular area, establish systems for monitoring drug consumption, develop national guidelines on the prudent use of antibiotics and draw up national regulations covering their implementation, as well to provide training.
IV. Strengthen infection control and surveillance of antibiotic resistance in health care settings

Prevention of hospital-acquired infections should be promoted through rigorous hospital infection control. Infection control committees should be installed to enhance antibiotic stewardship in health care settings, analyse resistance, and promote and monitor the prudent use of antibiotics.
V. Prevent and control the development and spread of antibiotic resistance in the food chain

National food safety authorities and veterinary services should play a central role in regulating and monitoring the use of antibiotics in food production and animal husbandry. The use of antibiotics as a growth promoter in healthy animals needs to be reviewed, as do integrated (between relevant sectors) surveillance systems, particularly for food-borne diseases.
VI. Promote innovation and research on new drugs and technology

Governments and academic networks need to play an active role in carrying out research into new antibiotics and making better use of available or older antibiotics, as well as of accessible technology, especially in the area of diagnostic sensitivity testing. Consideration should be given to “push” incentives for basic research and development, as well as to “pull” incentives to offset the risks of limited and volatile markets. The regulatory process for new tools should be a rapid one, and equitable access to such tools should be ensured when possible.
VII. Improve awareness, patient safety and partnership

The complex nature of antibiotic resistance and the use of antibiotics requires the involvement of a wide array of partners and alliances. National awareness campaigns are crucial to maintaining a high level of commitment. Patient safety groups can play an important part in addressing the prevention of infections and prudent use of antibiotics.
Definitions: antibiotics and antibiotic resistance

Antibiotics are a subclass of antimicrobial agents that are active only against bacteria. They can either be naturally derived from bacteria or moulds (fungi) or produced synthetically. Scientifically, “antibiotic” refers only to naturally produced antimicrobial agents, but this text uses the term to mean all drugs or agents against bacterial infections.

The emergence of resistance to antibiotics is a natural biological phenomenon that occurs when antibiotics are used. Antibiotic resistance results from the ability of bacteria to withstand attack by antibiotics, which can develop either through mutation or by acquiring resistance genes from other bacteria that are already resistant.

The main drivers of antibiotic resistance are the use of antibiotics, especially overuse (but also misuse and underuse) and the transmission and spread of already resistant bacterial strains or genes that carry the information on resistance.
For further information on antibiotic resistance, please contact:

Dr Bernardus Ganter
Senior Adviser, Antimicrobial Resistance, Division of Communicable Diseases, Health Security and Environment
WHO Regional Office for Europe
Scherfigsvej 8
DK-2100 Copenhagen Ø
Denmark
Tel.: +45 39 17 14 23
E-mail: bga@euro.who.int

For further information and interview requests, please contact:

Ms Viv Taylor Gee
Regional Adviser, Communications
WHO Regional Office for Europe
Scherfigsvej 8
DK-2100 Copenhagen Ø
Denmark
Tel.: + 45 39 17 12 31
E-mail: VGE@euro.who.int