London School of Hygiene & Tropical Medicine

This week, I was a panelist at an event about ‘How to prevent the next pandemic’ and it made me think again about what we can learn from COVID-19 for antimicrobial resistance control but also how very different it is.

One problem is language – antimicrobial resistance (AMR) is more of an aspect of disease than a disease in itself. We get power from this in terms of cross-pathogen learning but we also lose some of the subtlety. Instead of thinking of AMR as the “next pandemic”- I wonder if previous literature is closer in stating that it is an “endemic problem” with raising levels threatening many aspects of healthcare, and something that, as we have seen with COVID-19, will “compound pandemics” (MacIntyre, 2017). Whilst I’m not sure that “pandemic” is the right word, I agree with recent opinions on one critical point: it is definitely not ‘silent’.

Getting the language right is something that we need to do better at within the general AMR field. It is so important as it allows us to define the problem and hence, hopefully, solutions. Which brings us back to the question of what do we need to do to prevent the next pandemic? I think for AMR, the more relevant question is what do we need to do to prevent and monitor AMR during the next pandemic? To which my answer would be that we need to improve diagnostic capability within resilient health systems which would improve health right now, and during an acute pandemic time.

Something that also really struck me during COVID-19 was the timescales. Due to the acute nature of infection with SARS-CoV-2, you really could be infected and then clear within a matter of weeks. For many people bacterial colonisation can be long term and for some bacteria it is hard to imagine how de-colonisation would happen. Once present, is a sub-population with a resistant gene ever lost from a microbiome? Moreover, for many worrying resistant bacteria, we are thinking about resistance creep over years.

One aspect of the idea of a “pandemic” does fit AMR – transmission and spread of resistance units, be that genes or bacteria, are now happening globally. For AMR, we are concerned about cross-species sharing of units of resistance as well as long term persistence of small resistant sub-populations that later get selected for by antibiotic use. This persistence represents a kind of endemicity of AMR. Surveillance of these, that continues during pandemics, with feedback loops to support better evidence-based decisions for those that perform the routine data analysis, is vital.

“He who would do good to another must do it in Minute Particulars" - William Blake.

Another theme that came from the debate was the importance of retained memory and context which Dr. Luisa Enria emphasised for Ebola and Prof. Jo Lines for malarial control. This memory aspect is pertinent for AMR – what can we learn about how resistance arose to previous antibiotics to protect new ones? Luisa also raised that there shouldn’t be a dichotomy between context specific and general tools – we don’t need to develop new surveillance capabilities or methods every time for each setting, but they need to be flexible and applied with context in mind. Indeed, thanks to Jo for this quote, relevant to AMR researchers from microbiologists to social scientists:

“He who would do good to another must do it in Minute Particulars" - William Blake.