A social perspective on antimicrobial resistance

 A social perspective on antimicrobial resistance

To best answer antimicrobial resistance a historical perspective is necessary. Antimicrobials themselves are byproducts of rapid scientific and social changes that took place in the 19th and early 20th centuries. Infections have been known to mankind for a long time. The Roman physician Galen writes about the localisation of infection through the formation of pus, and Rome itself is said to have suffered from many outbreaks of the plague. That being said, two distinct processes in history are related to antibiotics. The first is large scale industrialisation and the rise of urban centres, following the industrial revolution in Europe which led to crowding and rapid disease transmission in the new cities. The second is the European Enlightenment that emphasised rationality and reason over belief. With the European powers colonising the world, European methods and outlook soon dominated the world stage. 

The rapid spread of infections associated with rising populations, owing to industrialisation and colonisation, necessitated counter measures. Public health measures such as improved city planning were implemented by the regional authorities; but advances in science provided a more immediate solution. Ehrlich worked on the antimicrobial properties of dyes, and soon introduced salvarsan for the treatment of syphilis. Florey and Chain isolated penicillin, following Fleming's discovery that bread mould inhibits bacterial growth. In the following decades, developments in public health and pharmacology meant that a variety of antimicrobial agents were readily available. 

The problem of microbial pathogens, by the popular expectation, should have had a conclusive ending. However, history is ironic. The problem in this case is Darwinian - organisms, under the stress of external pressures, get ‘naturally’ selected. Random mutations, in the genome of microbes, as well in the plasmids, conferred small amounts of resistance to microbial populations, and eventually those properties became abundant. Plasmids also allowed for ‘horizontal’ transmission of infection. The issue is thus self perpetuating, the more antimicrobials are used, the more resistance there will be. 

Society’s response, however, was one of defiance. Newer, and more powerful antimicrobials such as linezolid and teicoplanin were introduced. The result is a large list of ‘man made’ organisms - such MRSA (methicillin resistant Staphylococcus aureus) and its successor VRSA vancomycin resistant (Staphylococcus aureus). There are also drugs such as clavulanic acid, whose explicit purpose is to address the mechanisms of antimicrobial resistance, instead of the organisms themselves.

The author’s view is that this cycle is vicious and potentially never ending, and that there might be scientific solutions, these should be introduced in the context of sound social understanding of infection. Infectious disease is as much a social problem as it is a medical one - pathogens breed in the background of poor sanitation, crowding and poverty. That infectious diseases preferentially affect those of affluence is no coincidence. The multi pronged nature of infectious disease cycles, allows multi pronged prevention of infection and hence antibiotic abuse.. For instance, improving living conditions, health equity and labour laws, with a special focus on the socially disadvantaged and the poor will arrest infectious disease transmission and hence drug resistance. Control of wet markets and antimicrobial use in the animal industry will prevent resistance in zoonotic organisms. 

A change in clinical mindset too is of essence - doctors should follow microbiological reports and protocols while prescribing antibiotics and prescribe empirically, only on extreme need. This is particularly true in the perioperative period. Patient counselling to explain why antimicrobials aren't always necessary is prime. Science too can be harnessed for microbial prophylaxis. Ignaz Semmelweis noted that the rates of puerperal sepsis dropped with sanitation of hands between deliveries. By introducing proper sanitation protocols, hospital associated infections, which are often polymicrobial resistant, can be prevented. Indeed, during the COVID-19 pandemic, owing to the focus on sanitation, rates of nosocomial infections dropped. The scientific caveat is that due to different mechanisms of action, microbes seldom develop resistance to antiseptics. Finally, changes in government policy and crack down on over-the-counter prescribing of antimicrobials is of the essence.