Antibiotic resistance is concerning due to the possibility of further rapid progression. Antibiotic resistance is a global threat as antibiotic resistance patterns spread from country to country. The WHO estimates that the worldwide annual deaths from antibiotic-resistant bacteria will increase from 700,000 to 10 million by 2050. Due to the global nature of antibiotic resistance, partnership with the WHO is needed to help keep antibiotic resistance at bay in the United States. Stringent prescribing requirements are already in place regarding antibiotic prescribing in the United States. However, we know that efforts to improve antibiotic stewardship in the United States have not resolved the problem or growth of antibiotic resistance in the United States. An example of antibiotic prescribing requirements in the United States is the requirement of CMS-funded long-term care facilities to maintain an antibiotic stewardship program. The antibiotic stewardship program must include protocols for antibiotic prescribing and a surveillance system. Best practices in antibiotic stewardship include only prescribing antibiotics to treat a confirmed or suspected bacterial infection. Additionally, antibiotics may be appropriate in some high-risk and immunocompromised patients. Continued treatment with antibiotics should be monitored over time for ongoing necessity and limited to the shortest duration needed to reduce the incidence of antibiotic side effects. For prolonged antibiotic courses, once the source of infection is identified, the choice for definitive antibiotic treatment should be the narrowest spectrum antibiotic available to limit the development of new antibiotic resistance in other bacterial in the gastrointestinal and other microflora (commensal bacterial). In low-income countries, antibiotic prescribing practices and regulations are often more relaxed. And overprescribing and inappropriate prescribing of antibiotics are considered the primary cause of antibiotic resistance in low-income countries. Additionally, bacterial infections are more likely to be neglected and not receive treatment resulting in higher infectious loads of bacterial in low-income countries, which increase the bacteria's chances of expressing phenotypic antibiotic resistance through mutations (point mutations and horizontal gene transfer). Some of the factors that promote antibiotic resistance of commensal E. coli in low-income countries are overcrowding, poverty, bacterial contamination of water and foods, high bacterial concentrations in wastewater re-introduced to the environment, and lack of disease surveillance systems. The WHO lists the following bacteria as the highest priority regarding antibiotic resistance: Enterobacteriaceae, E. coli, Pseudomonas aeruginosa, and Acinetobacter baumanii. There is evidence that certain antibiotic patterns are more prevalent in low-income countries than higher-income countries. However, antibiotic resistance data in low-income countries are mainly from hospitals. And globally, antibiotic resistance evidence is primarily limited to the healthcare setting—the WHO has commented that evidence regarding antibiotic resistance in low-income countries is missing. Improving data collection of antibiotics in the community setting worldwide would shine a light on the extent of the problem globally. Paying attention to social determinants of health such as income and education level and improving the environmental health engineering of low-income countries is vital. 

References:

1 Nji, E., Kazibwe, J., Hambridge, T. et al. High prevalence of antibiotic resistance in commensal Escherichia coli from healthy human sources in community settings. Sci Rep 11, 3372 (2021). https://doi.org/10.1038/s41598-021-82693-4

2 Beaudoin A, Norton LE. Antibiotic Resistance and Stewardship. In: Boulton ML, Wallace RB. eds. Maxcy-Rosenau-Last Public Health & Preventive Medicine, 16e. McGraw Hill; 2022.

3 Rousham Emily K., Unicomb Leanne and Islam Mohammad Aminul 2018Human, animal and environmental contributors to antibiotic resistance in low-resource settings: integrating behavioural, epidemiological and One Health approaches. Proc. R. Soc. B.2852018033220180332 http://doi.org/10.1098/rspb.2018.0332