Evolution by natural selection is a law of nature and affects all species. The basis for evolution is that individuals that are better adapted to their environment will have more offspring. Over time, their genes will dominate the population. Microorganisms have very short generation times, and their genome is ”dynamic” because it is susceptible to mutations and horizontal gene transfers. Thus, resistance to antimicrobials may easily evolve. This capability is, however, usually so resource demanding that the resistant variants will die out. Only in an environment rich in antimicrobials will these resistant variants fare better and in time dominate. Thus, the use of antimicrobials is equivalent to breeding resistant microorganisms (1).
Antimicrobial resistance has grown into an important public health problem. It may lead to delay of effective treatment of infectious diseases because the initial antimicrobials do not work. Newer drugs with higher costs and more side effects may be needed. This, however, is only a temporary solution, because the microorganisms may develop resistance also to these new antimicrobials. In the worst case, some diseases may be impossible to cure because of resistance to all antimicrobials. This may soon be a true scenario case with some cases of tuberculosis, gonorrhoea and staphylococcal infections.
The challenge to public health posed by antimicrobial resistance has been increasingly recognised in the last decade. In 1998, European Union politicians, health administrators, pharmaceutical industry representatives, scientists and health care professionals met in Copenhagen to discuss the challenge. The conference resulted in the ”Copenhagen Recommendations” against antimicrobial resistance (2). Among these were recommendations to set up surveillance systems for resistant microorganisms and for consumption of antibiotics, to promote prudent use of antibiotics and to increase research into the problem.
In 2001, the EU Council turned the essence of the ”Copenhagen Recommendations” into an official recommendation to EU Member States, emphasising surveillance of resistant microorganisms, guidelines for prudent use of antibiotics, improved training of health care professionals, implementation of hygiene and infection control standards in health care institutions, extension of national immunisation programmes, and information to the public about the challenges posed by antimicrobial resistance (3).
In June this year, the EU Council noted that there remained numerous areas where member states had undertaken only limited action. The Council reiterated its previous recommendation.
The European Centre for Disease Prevention and Control (ECDC) has become an important instrument in the struggle against antimicrobial resistance in the EU. The ECDC has antimicrobial resistance as one of its priority working areas, and the Centre continues to run the European Antimicrobial Resistance Surveillance System (EARSS) (4) and the European Surveillance of Antimicrobial Consumption (ESAC) (5).
Meanwhile, the World Health Organisation also put antimicrobial resistance on the agenda. In 1998, the World Health Assembly passed a resolution urging member states to monitor antimicrobial resistance, develop educational programmes for professional staff and the lay public to encourage the appropriate and cost-effective use of antimicrobial agents and to improve practices to prevent the spread of infection and thereby the spread of resistant pathogens (6).
The resolution was followed in 2001 by the new WHO Global Strategy for Containment of Antimicrobial Resistance (7). The strategy highlights education of the public and health care professionals on the prudent use of antimicrobials and surveillance of antimicrobial resistance.
Now, more than ten years after the Copenhagen Recommendations and the World Health Assembly resolution, there seems to be a stable consensus on what needs to be done: surveillance of antimicrobial resistance and consumption of antimicrobials, promotion to the public and the health services of prudent use of antimicrobials, improved prevention of infectious diseases and research. Still, action is lacking in many countries, and the global situation is worsening.
Maps that illustrate the prevalence of resistance in important microorganisms (4) and maps that show the consumption of antimicrobials (5) in Europe indicate that there is an association between the level of consumption and the occurrence of resistance (8). Countries in the EpiNorth region, notably the Nordic countries, seem to have a favourable situation. These countries already follow the EU and WHO recommendations to a large extent. Thus, they may constitute examples for other countries.
On November 18, countries all over Europe will for the first time mark the annual European Antibiotic Awareness Day (9). This is an opportunity to raise public awareness about the risks associated with inappropriate use of antibiotics and how to take antibiotics responsibly. EpiNorth Journal is encouraging readers to support national activities this day. However, the struggle against antimicrobial resistance is not a one-day affair. It is long-lasting and hard work for everyone who is concerned with public health.
- Aavitsland P, Helland Å. The selected infectious agents. Tidsskr Nor Legeforen 2008; 2008; 128: 2304.
- The Copenhagen Recommendations. Copenhagen: Invitational EU Conference on The Microbial Threat, 1998. (http://www.sum.dk/publikationer/micro98/index.htm)
- Council Recommendation 2002/77/EC of 15 November 2001 on the prudent use of antimicrobial agents in human medicine. (http://antibiotic.ecdc.europa.eu/PDFs/l_03420020205en00130016.pdf)
- European Antimicrobial Resistance Surveillance System (http://www.rivm.nl/earss/)
- European Surveillance Antimicrobial Consumption. (http://www.esac.ua.ac.be)
- World Health Assembly (fifty-first). Emerging and other communicable diseases: antimicrobial resistance. Geneva: World Health Organization, 1998.
- WHO Global Strategy for Containment of Antimicrobial Resistance. Geneva: World Health Organisation, 2001. (http://www.who.int/drugresistance/WHO_Global_Strategy_English.pdf) (Russian: http://www.who.int/drugresistance/WHO_Global_Strategy_Russian.pdf)
- Bronzwaer SL, Cars O, Buchholz U, Mölstad S et al. A European study on the relationship between antimicrobial use and antimicrobial resistance. Emerg Infect Dis 2002; 8: 278-82.
- European Antibiotic Awareness Day. Stockholm: European Centre for Disease Prevention and Control, 2008. (http://antibiotic.ecdc.europa.eu/)