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SECTION FOUR: Conclusions

SECTION FOUR: Conclusions 

Antimicrobial resistance recognizes no national boundaries. Unless antibiotic resistance is detected and contained, the world could be faced with diseases that once more will become untreatable (Centers for Disease Control and Prevention 2010). Development of resistant microorganisms is a concern whenever antimicrobial agents are used. Careless use of antibiotics, lack of adherence to prescribed treatment regimens, poor environmental hygiene, antibiotic use in agriculture, and contamination of the food supply chain further exacerbate the situation and accelerate the spread of resistance to antibiotics. The increase in high-risk populations, including immunocompromised patients, those undergoing invasive medical interventions, those with implanted medical devices, and patients with chronic debilitating diseases, has increased the problem. Food-producing animals are frequently given antibiotic drugs for therapeutic, disease prevention, or production reasons. However, these drugs can cause microbes to become resistant to drugs used to treat human illness, ultimately making some human sicknesses harder to treat. 

The global increase in resistance to antimicrobial drugs, including the emergence of bacterial strains resistant to all available antibacterial agents, has created a public health problem of crisis proportions with significant economic and human implications. Increasing antimicrobial resistance presents a major threat to public health by reducing the effectiveness of antimicrobial agents; leading to increased morbidity, mortality, and healthcare expenditure. Salmonella spp and other food-borne pathogens resistant to antimicrobial drugs continue to spread globally (Teuber 1999; Smith and Coast 2002). In 1995, the cost of containing an outbreak of infection caused by MRSA in a district general hospital in the United Kingdom was estimated to exceed US $560,000, while the annual healthcare cost associated with the treatment of resistant infections in the United States was estimated at more than US $4 billion in 2002, an amount recently revised to more than US $7 billion (Smith and Coast 2002). Antimicrobial resistance is a cause of professional, governmental, and public concern and has been classified as a national security risk in the United States (Smith and Coast 2002). 

Globalization increases the vulnerability of all nations to imported diseases, and today infectious diseases travel faster and farther than ever before. During the 1990s, a resistant Pneumococcus spp first identified in Spain rapidly spread to Argentina, Brazil, Chile, Taiwan, Columbia, Malaysia, Mexico, the Philippines, Republic of Korea, South Africa, Thailand, United States, and Uruguay. No country acting on its own can adequately protect the health of its population against AMDR. International collective action is essential, yet responsibility for health remains predominantly a national responsibility. Consequently, there is a potentially significant disparity between the problems and solutions associated with AMDR, healthcare institutions, and the systems available to deal with them (Centers for Disease Control and Prevention 2010). Morbidity and mortality increases with delayed diagnosis and initiation of effective treatment (World Health Organization 2005). Physicians in developing countries may have to use older antimicrobial drugs that are becoming increasingly ineffective, resulting in higher rates of treatment failure (Howard et al. 2003). Most developing countries lack drug susceptibility testing, a key element that guides delivery of effective antimicrobial therapy. Countries of market economy should consider political and policy solutions such as redefining AMDR as a complex humanitarian crisis and provide appropriate tools and knowledge management to developing countries to handle this emerging global security threat.

Vaccines are needed to prevent infection, and transmission of resistant organisms (Interagency Task Force on Antimicrobial Resistance 2001). Further, vaccines are needed to prevent common bacterial infections, thus reducing antibacterial use. The development of novel vaccines occurs over a continuum, beginning with basic research, extensive clinical research, and trials and moving to product education, marketing, and distribution. An understanding at the molecular level of the mechanisms of resistance, policy, and political support for extensive evaluation of intervention strategies, as well as capital investment and product development capability, are required to successfully bring new vaccines into mass availability.

In 2009, the United States and the European Union signed a collaborative agreement to address the global AMDR health crisis. Although microbial resistance is a serious concern in countries of market economy, it is potentially devastating in developing countries. The global cost of AMDR morbidity and mortality now outstrips the total antibiotic market. All healthcare providers should have access to tools such as patient testing for AMDR, timely training to enhance knowledge, modification of attitudes, and improvement in the standards of clinical practices. Proactive polices to fight AMDR should be implemented by all national Ministries of Health. 

In conclusion, preventing transmission of infections should be priority in all healthcare settings and should include as a minimum: 

  • Hand washing or alcohol-based rinses by staff between patients and before undertaking invasive procedures such as injections
  • Use of barrier precautions, eg, wearing gloves and gowns for procedures that might result in transmission of pathogens
  • Adequate sterilization and disinfection of all supplies and equipment
  • Use of sterile techniques, together with protocols, for medical and nursing procedures capable of bridging skin or mucosal membrane integrity such as: bladder catheterization, administration of injections, insertion of intravenous cannulas, use of respirators, sterilization of equipment, and other surgical interventions
  • Maintenance of appropriate disinfection and sanitary control of the hospital environment, including:
    • Adequate ventilation
    • Cleaning of wards, operating theater, laundry, and other objects used by patients
    • Provision of adequate water supply and sanitation
    • Safe food handling
    • Safe disposal of infectious equipment, eg, dirty needles, body fluids, and other suspected contaminated materials
  • Isolation of infected patients from noninfected patients, eg, separation of suspected and proven sputum-positive TB cases (particularly from HIV-positive patients)
  • Visiting policies, such as preventing visitors with infections from visiting patients who may be immunocompromised (for example, patients with AIDS or leukemia or premature babies)
  • Training of healthcare staff in appropriate sterile techniques and infection control procedures

 Additional AMDR Resources (Pagani et al. 2009; Centers for Disease Control and Prevention 2010): 

  1. The Centers for Disease Control and Prevention —
  2. National Healthcare Safety Network (NHSN) —
  3. The World Health Organization —;;
  4. Cochrane Library —
  5. Ovid Medlines® —
  6. European Center for Disease Prevention and Control —

Table of Contents

SECTION ONE: The global threat of AMDR
SECTION TWO: Understanding AMDR
    1. Etiology and Epidemiology
    2. Incidence and Prevalence of Microbial Resistance
    3. Major AMDR Pathogens
       a. Acinetobacter baumanii
       b. Clostridium difficile
       c. Escherichia coli
       d. HIV/AIDS and Sexually Transmitted Infection
       e. Influenza virus
       f. Malaria (Plasmodium)
       g. Methicillin-resistant Staphylococcus aureus (MRSA)
       h. Streptococcus pneumoniae
       i. Tuberculosis and MDR-TB
       j. Vancomycin-Resistant Enterococcus (VRE)
SECTION THREE: Control and Prevention of AMDR
    1. Implications of Microbial Resistance
    2. Infections and Chronic Diseases
    3. Policies and Best Practices
       a. Antimicrobial Drug Stewardship
       b. Surveillance
       c. Environmental Decontamination
       d. Infection Control
       e. Patient Education
    4. Antibiotic Development Pipeline
SECTION FOUR: Conclusions
Test Questions
Program Evaluation
Self Assessment

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