Bacteria Knows No Borders: The Challenges of Global Antimicrobial Resistance

Image credits: Wikimedia Commons

By Tulsi Ankur Patel

Introduction

On a breezy fall evening in 1928, after a restful summer vacation, Alexander Fleming returned to a messy lab bench. Sorting through different petri dishes of Staphylococcus bacteria that he had forgotten to place in the incubator, he realized a moldy film had formed over his dishes, possibly contaminating the samples. But, as he went to throw them away, he realized something fascinating. On his dishes, the mold had killed the bacteria in concentric rings. Upon repeating the experiments, Fleming found that the mold naturally produced a groundbreaking antibiotic: penicillin. While our first antibiotic may have resulted from a fungus floating through a window and into a petri dish by chance, scientists and clinical researchers have since deliberately developed well over 100 antimicrobial agents (antibiotics, antivirals, antifungals and antiparasitics) which save millions of lives every year, treating everything from athlete’s foot to MRSA. A true foundation of modern medicine, it is difficult to imagine clinical care without antimicrobials prevalent in medical records and hospital pharmacies.

While many patients scoff at having to obtain a prescription for a simple antibiotic, this hurdle is necessary to prevent the new danger in antimicrobial usage: resistance. Patients must take antibiotics under medical guidance and for the entire duration of their prescription to prevent pathogenic bacteria from becoming immune to antimicrobial agents. Antimicrobial resistance has become a global public health issue. Overuse of antibiotics in farming, poor-quality development and uncontrolled access to antibiotics through gray markets have led to the rapid evolution of resistant bacteria. Moreover, current global conflicts are hastening the countdown to complete resistance. Effectively tackling the issue of antimicrobial resistance (AMR) will require a global effort that prioritizes education, medical diplomacy and strengthening surveillance to recognize that the negative effects will not be localized but will have catastrophic impacts on mortality worldwide. 

(Bacterial) Cultures of Misuse

Unauthorized antimicrobial use is highest in developing middle-income countries such as India and Brazil. Here, antibiotics are readily available from third-party vendors and taken without adequate medical guidance. As such, individuals may futilely take antibiotics for viral infections or may sporadically take medications without regard to their treatment timeline, allowing bacteria to develop resistance. There are many motivating factors for this underground network and dispersion of potent drugs. One of the most pressing issues is the burdensome high cost of medical consultations required for receiving antibiotics. Due to socioeconomic constraints, many individuals, even in developed countries, may opt to receive antimicrobials from community-based networks. Individuals living in low-resource rural communities may also not have access to a formal distribution system for antibiotics. The compliance penalties for these illegal distributions are weak, allowing local pharmacies and drug stores to sell antibiotics without a valid permit. The quality of these drugs is substandard, making them less effective at treating the chief complaint and, paired with haphazard usage, increases the likelihood that bacteria will develop resistance. 

Even within proper medical jurisdiction, amidst increasing demand and high patient volumes, medical institutions and hospitals have also become notorious for overprescribing antimicrobials as quick solutions. In limited primary care settings with few diagnostic screening tools, antibiotics are often used as a “catch-all” medication. Due to the lack of medical laboratories in low-resource settings, there may also be reduced access to microbiological testing to identify the correct pathogen. In Africa, over 50 percent of hospital patients are prescribed broad-spectrum antibiotics due to a poor patient-provider ratio and limited time for meaningful medical consultations. In Lebanon, one study found that 52 percent of physicians prescribed the wrong antibiotic dose, and 63.7 percent prescribed the wrong treatment duration. Human capital flight also worsens this trend as fewer medical providers practice and provide resources for emergent care.  By comparison, studies in the United States and Western Europe typically find inappropriate antibiotic prescribing rates in outpatient settings ranging from roughly 20 to 30 percent, with substantially lower rates of dosing and duration errors due to stronger stewardship protocols.

But AMR is not just confined to human-centric medical centers; it simmers under our own feet and in our food. The most recent realization in AMR has been through agriculture. Antimicrobials are used in massive quantities to prevent disease in livestock raised for mass consumption worldwide. Often, these medications are administered in concentrated animal feeding operations where bacterial infections run rampant, and antibiotic treatment is given without regard for the particular circumstances. As such, the waste matter and remains of such livestock end up contaminating soil and water supply. Resistant bacteria multiply and infect all agricultural products typically consumed by humans. Without proper action, the interconnected nature of the global food supply chain will become infected with bacteria resistant to current antibiotics. 

The Growing Offense

These trends capture key issues in proper medical education and providing resources to global areas of need. Antimicrobial resistance currently festers due to the aforementioned resource and time constraints, but has been exacerbated by global inequality in resource allocation and medical diplomacy. This dynamic is most evident with the fact that countries with the highest rates of antimicrobial resistance have the lowest access to antibiotics. Most antimicrobials are developed in high-resource countries, typically designed for their own populations, and often circulate immediately in wealthier countries. A patient in a country like Uganda may wait a decade before receiving a new antimicrobial while new strains of resistant bacteria multiply. As such, AMR becomes far more disastrous in these countries, as high-value drugs are initially withheld due to market-driven mechanisms that restrict launches and prioritize high-cost patented drugs rather than the most equitable or generic.

But most importantly, AMR has become insurmountable in conflict zones worldwide. With the current major conflicts in Ukraine and Gaza, AMR has found fertile ground among vulnerable communities. While most casualties in these zones are depicted as casualties of war, thousands are also dying due to incurable infections. Conflict zones face throngs of individuals living in refugee camps, and displacement tends to inflict illness on its voyagers due to densely packed living environments and limited sanitary administration. While many of these illnesses and bacterial infections are typically treatable with standard antibiotics, conflict zones are low-resource settings and, as mentioned, do not have the diagnostic or medical capacity to accurately assess or treat patients. Additionally, a new trend has emerged regarding cross-resistance and heavy metals. Due to ceaseless bombings and artillery being deposited in communities, many individuals are becoming exposed to toxic heavy metals such as cadmium, lead, and mercury, which enter the wounds of injured civilians and soldiers. As they are treated with antibiotics, both heavy metals and bacteria become resistant as they are located on the same genetic elements. Metal pollutants allow bacteria to evolve and, through cross and co-resistance, create selection pressures that make surviving bacteria more formidable. 

As such, conflict zones see high levels of multidrug resistance, in which all antibiotics for a given infection are rendered ineffective. The outlook for this is bleak in conflict zones where embargoes and high-density living camps make disease commonplace and all the more dangerous. In Ukraine, pan-drug-resistant bacteria have been discovered, unlike anything that medical experts have seen since the advent of antibiotics. Medical staff have treated soldiers and civilians who face infectious wounds with multiple antibiotics to no avail. Even last resort drugs have been rendered unsuccessful, leading to the transmission of superbugs and over 30,000 deaths directly attributable to AMR. In the previous conflict in Iraq, a whole new strain of bacteria, Acinetobacter baumannii, emerged as the signature drug-resistant foe and became known as the Iraqibacter. Even then, this bacterium was known to succumb to broad-spectrum and high-dose antibiotics in serious cases. However, even these antibiotics are developing resistant bacteria globally, and all it will take is another direct conflict to possibly make Iraqibacter undefeatable. 

Creeping Beyond the Agar Plate

While it may appear that the effects of AMR are localized, bacterial resistance is a global issue that continues to plague even the world’s best medical environments. The effects of AMR in developing countries will spread through travel, trade, supply chains and wastewater. The impacts of conflict are not contained to the battlefield; they reach into the depths of civilization, and it is only a matter of time until these resistant bacteria move beyond warzones. Global organizations have begun to take note. The United Nations held its first high-level meeting on AMR in 2016 and, most recently, convened in 2024 to make strides towards reducing AMR-related deaths by 10 percent before 2030. The meeting made key advancements by securing millions in funding to launch AMR action plans in 60 percent of countries, and by aiming to have 95 percent of countries report AMR surveillance data. The World Health Organization has aimed to generate a comprehensive surveillance report on new strains of resistant bacteria and which illnesses breed the broadest spectrum of resistance, using data from hundreds of countries. 

However, while these plans and data have been successful at generating committees in most countries, very few nations have secured the implementation agents to act upon these lofty goals. Moreover, global conflict zones continue to grow with the new conflict in Iran impacting multiple countries in the Middle East, while existing conflicts continue to press down on limited supply chains. An ethical question arises about the role of wealthy countries in exacerbating conflict while also controlling initial access to antibiotics and allowing AMR to grow out of hand. Moreover, recent shifts in international medical diplomacy, with countries such as the United States reducing medical aid, education and pharmaceuticals to low-resource countries, further create a culture that considers AMR an afterthought or even a contained issue. With the current antibiotic development pipeline “dried up,” wealthy countries play a dangerous game in which financial and military strength serve as cover for AMR to grow stronger and attack unexpectedly. These countries highlight neglect of responsibility, where the moral obligation to address these issues is ignored. This will certainly lead to a scenario where countries contributing heavily to conflict from afar will not face the immediate impacts of AMR; instead, they will only realize danger when the problem has seeped beyond borders and into the global community.

So what can be done to address this issue at the forefront of international affairs and public health? Other than aiming to reduce and end conflict, the most effective solution at the moment is global collaboration reinvigorating the antimicrobial pipeline. Medical diplomacy will require high-resource countries to develop new classes of drugs and to take responsibility for distributing them internationally without the initial lag time that exacerbates AMR. Global supply chains will have to be more cognizant of 1) how to develop drugs through means that are translatable even in low-income settings and 2) generating generic drugs that allow for faster distribution. Programs like One Health, which consider the interconnected nature of human, animal and environmental systems, also enjoy strong support from scientists and public health experts: by using genetic and AI-driven drug discovery, it may be possible to  find an alternative approach to AMR that is not just a ceaseless anthropogenic cycle of discovery and resistance. But this research does not occur in shielded labs; rather, it requires a multi-site clinical network. Global health security rests on countries’ ability to manage multi-pronged collaboration and stewardship. While current rhetoric has highlighted the recent destruction of international relations, the global spirit must recognize that, if left unaddressed, AMR will pay no mind to borders or sovereignty.