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THE ROLE OF DIAGNOSTICS IN THE

ANTIMICROBIAL RESISTANCE RESPONSE


LONDON SCHOOL OF
HYGIENE & TROPICAL MEDICINE

WEEK 1 INTRODUCTION TO THE ROLE OF DIAGNOSTICS IN THE RESPONSE TO


AMR
STEP 1.9 WHAT IS THE GLOBAL AMR CRISIS AND WHAT CAN BE DONE ABOUT
IT?

SALLY DAVIES: So people are beginning to realise that drug resistant infections
are here and killing people, but most people see the underlying cause, anti-
microbial resistance, AMR, as a problem particularly of the future. That doesn't
recognise the reality that already in the States, at least 23,000 people are
dying every year of drug resistant infections, at least 25,000 in the European
Union, and if you look at India, then nearly 60,000 babies are dying every year
of sepsis due to drug resistant infections. So AMR is here in a big way, and we
need to focus people on that. We've got some focus on that. We've got high
level political support through G20, G7, the United Nations.

Part of the problem is the complexity, that people find it difficult to understand
we have a problem of drug resistant infections in humans that extend hospital
admissions, double the cost of a hospital admission, double the mortality of
that infection.

If we don't act urgently on AMR, then the current 700,000 deaths a year across
the world will go up to probably about 10 million a year in 2050. Thinking
about that, that's more than we have dying of cancer at the moment, which is
about 8 million deaths a year. And the impact on people's economies is
dramatic. It's going to take out of the global economy the equivalent of the UK
economy. It will push an extra 28.3 million people into poverty if we don't act
on drug resistant infections now. So we've got to take action in a lot of areas.
We've got to start by making sure that people get the drugs that they need,
and access is a big issue.

And there's this tension between access and excess because we know more
people are dying at the moment because they're not getting antibiotics, but
overuse drives AMR and drug resistant infections. And that means we have to
take action on getting new antibiotics, using the antibiotics we've got better,
stopping growth promotion use in animals, stopping their use in agriculture

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except to treat serious infections, and importantly using rapid diagnostics so
that people know when it's a bacterial infection, ideally, what the infection is
so the antibiotics are targeted.

Without diagnostics, we are blind. So the old fashioned diagnostics-- we take a


blood sample or a swab from the back of the throat. It takes a couple of days
to grow the infection, and then you look at the resistance pattern. That is the
underpinning diagnostic. We need that because we may start with broad
spectrum antibiotics and then see if we can stop them entirely, or we have to
swap our treatments to the right treatment. Even better, a rapid diagnostic, so
you can take a decision at the time. And C reactive protein is one of those
which is very helpful in distinguishing bacterial and viral infections, but we
have to be careful how we use these.

And we really have to have high quality surveillance so we know in a hospital,


in a community, in a region, in a nation, what is the pattern of resistance that
we're seeing to guide our use of antibiotics, our guidelines for antibiotics and
other treatments going forward, and to modify what we do and how we do it.

We have to focus on all causes of drug resistant infections. So when I talk


about AMR, I mean bacteria with resistant genes, which are killing people. But
I'm also concerned about TB. Drug resistant TB is killing more people than any
other form of drug resistance at the moment. HIV, malaria, both have a
resistance issue, so we all have to work together hand-in-hand, but we've had
least focus to date on the bacteria. So a lot of people, when they talk about
AMR, think only of bacteria. We must think broader. We need rapid diagnostics
for all of that. We need to move the whole area forwards.

To sort AMR in the human field, we've got to kind of put AMR into the whole
area of health care at its broadest level. It underpins a lot of delivery of
sustainable development goals. We won't get there and then eliminate poverty
if we don't sort AMR. AMR is a key part of universal health coverage. It's a key
part of infection prevention and control. We need really to think about AMR as
we look at every lens for health care.

JEREMY FARRAR: The world is-- I don't use this word often-- but the world
really is facing a crisis with drug resistance. We've had 60 or 70 years of being
able to treat most infections, prevent most infections, and as a result, all sorts
of things in medicine have been made possible. Surgery is now possible
because we can control infections. Childbirth is now relatively safe around the
world because we control infections. Cancer therapies are possible because we
can control infections. Treatment of diabetes is possible. People are much more
prone to infection with diabetes. So the whole of modern medicine rests on the
ability to control infection.

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If we lose that ability, if drug resistance spreads as it is doing, and we don't
address it, then it's not just infectious diseases that are affected. It's the whole
of modern medicine, and that's a devastating scenario. So this is urgent. From
where we are today to having solutions is going to take years, and if we don't
start this work academically, in the commercial sector, changing behaviours in
society, if we don't start that work now, in a few years time, we will face this
apocalyptic scenario where surgery becomes impossible, childbirth becomes a
much higher risk, and children and adults will die of drug resistant infections.
That is the future, but actually that's already happening now.

So we've been a privileged position for 70 years, which we've abused, which is
that we haven't really needed to define the infection that's happening because
we have these wonderful broad spectrum antibiotics that would treat almost
everything. We're losing that ability now, and we have to become much more
specific at this infection requires this antibiotic. And in order to do that, you
have to define and diagnose that infection, and we need diagnostics to tell us
what the pathogen is, what the infection is.

And we need diagnostic to tell us which antibiotic to use, and we need to


combine those so that there are of use to a doctor in real time rather than
something that will be a result in a week's time when it's too late. The patient
has either died, or they've recovered. So we need diagnostics which are
sensitive, specific, and which are available to a practicing clinician in the time
frame that he or she needs it to treat the patient in front of them.

So diagnostics have been the Cinderella of medicine in a way, and it's because
we've become so good at medicine that, often, we felt that we didn't need it.
We could treat patients. We could conduct public health work with a sense of
what the diagnosis was without having to have the specific. I think what drug
resistance does is change that dynamic. We need to incentivize the academic
sector, the scientific sector, and it won't just be from biomedicine.

How to motivate a community actually is the biggest challenge because, first, I


think we need to make the case. And in my view, it's a little bit like climate
change. We need to make sure that we are getting across to the public the
importance of this issue and not that this is something that may affect them in
100 years time, but that actually this is affecting them, their children, their
parents, their grandparents across the world. Doesn't matter whether you're in
London, or Beijing, or Lagos, this is an issue for today.

And I think until you galvanise the public support for an appreciation this is
affecting people's lives today, then it's difficult to galvanise them to change
behaviour, to support the advances in diagnostics. So I think we need to make
the case that there is an urgency to this. This is not something that will only
happen 20 or 30 years from now. This is happening today, and things that

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we've all taken for granted-- hip operations, cancer therapies, diabetes-- would
all be affected if we lose these remarkable class of drugs.

1Then, I think we need to persuade the political masters to actually invest in


this space to provide incentives that would encourage the academic sector to
work, to provide incentives for industry to invest in this space. That could be
pull mechanisms. It could be prizes. It could be vouchers. It could be
preferential access to markets. All sorts of things could be tried economically
and politically, which would change this equation because if we don't, then
modern medicine will stop as we currently know it.

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