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The problem of antimicrobial

resistance

Copyright © 2020 The Open University

Contents
Introduction 3
1 Life before antibiotics 4
1.1 Medicine in the 1800s 4
1.2 Discoveries in modern medicine 5
2 The golden age of medicine 9
2.1 What bacteria are 9
2.2 What are antibiotics? 12
2.3 What antibiotics do 13
2.4 Role of antibiotics in modern medicine 14
2.5 The role of antibiotics in food production 15
3 The problem of antibiotic resistance 17
3.1 Definition of resistance 17
3.2 Consequences of resistance 18
3.3 Scale of resistance 21
4 How resistance develops 25
4.1 Development of resistance 25
4.2 Spread of resistance in bacteria and the environment 25
4.3 Drivers of resistance 27
5 The global response to fight AMR 30
5.1 What can we do to address the problem of AMR? 30
5.2 One Health 31
5.3 International efforts 32
6 End-of-module quiz 36
7 Summary 37
8 Your experience of this module 39
References 39
Acknowledgements 40

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Introduction

Introduction
Welcome to The problem of antimicrobial resistance, an introductory module aimed at all
learners. Many basic concepts are introduced in this module and will be discussed in
more detail in other modules.
The problem of antimicrobial resistance will take you back in time to gain insight into our
understanding of prevention and treatment of infectious diseases. You will learn about
hygiene theory, germ theory and the discovery of antibiotics. You will gain an
understanding of the importance of antibiotics in modern medicine and other aspects of
modern life. Unfortunately, the antibiotics that we have today are becoming less effective
in the treatment of infections due to antimicrobial resistance. This is a very big threat to
global health. You will learn how resistance develops in bacteria and what the drivers are.
In the final section you will learn about ongoing global efforts to tackle the problem of
antimicrobial resistance (AMR), and finally reflect on what you can do to bring about
change.
By the end of this module, you should be able to:

● define the term ‘antibiotic’ and describe the importance of antibiotics in modern
society
● explain how the overuse and misuse of antibiotics contribute to bacterial resistance
● describe the scale and nature of antibiotic resistance worldwide, and discuss the
consequences of a future without antibiotics
● explain why the problem of AMR needs a One Health approach
● reflect on your own role and those of your colleagues in tackling the AMR crisis.

Activity 1: Assessing your skills and knowledge

Now use the interactive tool to rate your confidence in these areas using the following
scale:

5 Very confident
4 Confident
3 Neither confident nor not confident
2 Not very confident
1 Not at all confident

This is for you to reflect on your own knowledge and skills you already have.

Interactive content is not available in this format.

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1 Life before antibiotics

1 Life before antibiotics

The problem of antimicrobial resistance (AMR) is a universal issue that we could all be
directly or indirectly impacted by. AMR was responsible for an estimated 700,000 deaths
worldwide in 2016; if we don’t act now, this number is likely to increase in the future.
This section provides an historic perspective on important developments that have
shaped modern medicine and provides insights to understanding the problem of AMR that
we face today.
After completing this section you will:

● understand how concepts related to the prevention, causes and treatment of

infectious diseases developed over time
● understand the importance of good hygiene measures in preventing infections
● understand the importance of antibiotics in modern medicine and modern life
● appreciate that the pre-antibiotic era is not that long ago.

1.1 Medicine in the 1800s

In order to better understand some key aspects of modern medicine, we first go back to a
time when we did not know much about infectious diseases; a time when an infection that
can now be easily treated and cured could kill you.

Activity 2: Living and dying in the 18th century

Watch Video 1, about the death of George Washington in 1799. As you watch, keep
the following questions in mind:

● What did doctors think caused the disease?

● What treatment was given to George Washington?
● What might have caused this disease?
● What kind of treatments are available today?

Video content is not available in this format.

Video 1

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1 Life before antibiotics

Answer
● What did doctors think caused the disease?
○ His humours were unbalanced, or perhaps he breathed in miasma (foul air).
● What treatment was given to George Washington?
○ They drained his blood (blood-letting).
○ They applied ground-up green beetle on his throat.
● What do we now know about what might have caused this disease?
○ Microscopic organisms can cause infectious diseases, such as the one
that attacked George Washington’s throat. Other examples of diseases
caused by microbes are bubonic plague, tuberculosis and gangrene.
● What kind of treatments are available today for management of infections caused
by microbes?
○ We now know that infections are caused by microscopic organisms
(microbes), including bacteria. Antibiotics are used to treat infections caused
by bacteria. (You will learn more about antibiotics in the next section.)

1.2 Discoveries in modern medicine

A lot has changed since the 1800s: our understanding of the causes, treatment and
prevention of infectious diseases has considerably improved. In this section you will learn

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how our knowledge developed, who contributed to developing new insights and why this
new approach was so revolutionary at the time.

Activity 3: Development of hygiene theory

Watch Video 2 on the discoveries of Ignaz Semmelweis, a physician working in Vienna
in the mid-19th century, and answer the question that follows.

View at: youtube:toTWSmb-krw

Video 2

What did Ignaz Semmelweis discover?

Answer
He discovered that doctors could save lives by simply washing their hands.

Semmelweis was not the first person to see the connection between hygiene and the
spread of puerperal fever (childbirth fever); Alexander Gordon had made a similar
observation about 50 years earlier. He discovered that puerperal fever was spread from
patient to patient by the attending midwife or doctor. To limit the spread of the disease, he
recommended fumigating clothing and burning bedlinen used by women with puerperal
fever. He also recommended the cleanliness of the attending doctors and midwives.
At the time that Gordon and later Semmelweis made their discoveries on the importance
of hygiene in the spread of disease, they did not know what actually caused infections.
That discovery was made a few years later by the collective efforts of Louis Pasteur and
Robert Koch, whose discovered that diseases were caused by microscopic organisms –
which they called ‘germs’.

Activity 4: Definitions of microbes

‘Germs are microbes.’ True or false?
¡ True
¡ False
Discussion
When germ theory was developed, the organisms that were identified as the cause of
the disease were called germs. They are now commonly referred to as microbes –
another term for microscopic organism.

‘All microbes cause diseases.’ True or false?

¡ True
¡ False
Discussion
Microbes are microscopic organisms that exist as a single cell or as a colony of cells.
Some microbes cause diseases; these microbes are called pathogens (they are
pathogenic). However, many types of microbes do not cause disease and are in fact
very helpful to us. In your gut, for example, there are a lot of microbes that help with

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digesting food. Other microbes are completely harmless to us but can cause disease
in animals or plants.

‘Bacteria are microbes.’ True or false?

¡ True
¡ False
Discussion
Microbes are microscopic organisms that exist as a single cell or as a colony of cells.
Bacteria are cellular micro-organisms. Some bacteria cause diseases and are referred
to as pathogenic bacteria. Most species of bacteria, however, are not harmful to us.
You will learn more about bacteria in Section 2.1.

‘All single-celled microbes are bacteria.’ True or false?

¡ True
¡ False
Discussion
Yeasts, and single-celled animals such as amoebae, are also classed as microbes.
They may or may not be pathogenic.

Discovery of antibiotics
After germ theory was established, people knew what caused infectious diseases. The
search for a cure for these diseases had begun.
In 1928, Alexander Fleming discovered which penicillin killed bacteria. Florey and Chain
played an important role in making penicillin widely available.

Video content is not available in this format.

Video 3

In Section 2.2 you will learn more about what antibiotics are, and in Section 2.3 you will
learn more about what antibiotics do.

Timeline
The following timeline summarises important moments in history that shaped our
understanding of the prevention, causes and treatment of infectious diseases:
Before 1800: The general understanding was that diseases were caused by bad gases,
which were called miasmas, or by an imbalance of fluids in the body. The treatment for

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diseases at that time included blood-letting and treatments that are now regarded as
quackery.
1795: Alexander Gordon observed that puerperal fever was spread between patients by
attending midwives and doctors. He recommended cleanliness of the attending medical
staff as a measure to prevent disease from spreading, but his recommendations were
largely ignored.
1847: Ignaz Semmelweis discovered hygiene theory – that is, the importance of
handwashing in preventing puerperal fever. He was also largely ignored.
1854: John Snow traced an outbreak of cholera to a single contaminated water pump in
London, and thus discovered the link between contaminated water and this disease. He is
considered to be one of the founding fathers of the discipline of epidemiology.
1850–1880: Collective efforts by Louis Pasteur and Robert Koch led to the discovery that
diseases are caused by micro-organisms (germ theory).
1928: Alexander Fleming discovered that a substance produced by a mould – which he
called penicillin – could kill bacteria. Florey and Chain later played an important role in
making the antibiotic penicillin widely available. Fleming, Florey and Chain were awarded
the 1945 Nobel Prize for Medicine for their achievements.

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2 The golden age of medicine

2 The golden age of medicine

In this section you will learn about antibiotics: what they are, how they work and the
important role they play in modern medicine but also modern life. Here, you will be
introduced to the basic concepts that will be explained in more detail in other modules in
this course.
After this section you will be able to:

● define the term ‘antibiotic’ and give examples

● describe how antibiotics work
● describe the role of antibiotics in modern medicine and modern life.

2.1 What bacteria are

Figure 1 Bacteria: they get everywhere!

Bacteria are the most numerous organisms living on Earth. They live all around us: in our
gut, in the soil and in water. Bacteria are pretty much all over the place.

Activity 5: Bacterial growth

The secret of the success of bacteria – why there are so many of them – is that they
can reproduce rapidly. Under the right conditions, some types of bacteria can replicate
every 20 minutes. Take a look at Video 4 to see what this looks like, and answer the
question that follows.

Video content is not available in this format.

Video 4

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The video mentions that a bacterial infection can take hold so quickly because bacteria
can double their numbers in such a short time. What are the three options mentioned
in the video that help to stop the growth and replication cycle of bacteria?

Answer
The three options are:

● handwashing with soap

● vaccination to boost the immune system
● antibacterial drugs.

Most bacteria do not cause us any harm. However, a small group of bacteria – about 500
species – can cause diseases in humans, animals and/or plants. These bacteria are
called pathogenic, and they are capable of causing an infection by evading the host’s
normal defences and invading cells or tissues. They may also produce harmful toxins
(poisons).
Many bacteria are opportunistic pathogens, meaning that they can cause an infection
when the defence mechanisms of the host – which could be a human, animal or plant –
are weakened.

Activity 6: Diseases caused by bacteria in humans, animals and plants

Think about examples of diseases in humans, plants and animals that are caused by
bacteria.

Answer
Diseases caused by bacteria in humans:

● Tuberculosis (TB) is caused by Mycobacterium tuberculosis and mainly affects

the lungs. The classic symptom of active tuberculosis is a chronic cough with
bloodstained sputum, fever and weight loss. This disease can spread to other

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people through respiratory secretions when patients with active TB cough, spit up
their sputum or sneeze.
● Tetanus, also known as lockjaw, is characterised by muscle cramps and is
caused by Clostridium tetani. This bacterium is commonly found in soil, dusts and
manure. The bacteria can enter the body through a break in the skin and produce
toxins that cause the muscle contractions. This disease is not spread from human
to human.
● Typhoid fever is caused by Salmonella typhi serovar Typhi, sometimes
abbreviated as Salmonella Typhi. Patients infected with it may experience mild to
severe symptoms including fever, abdominal pain constipation and vomiting. This
disease is spread through contaminated water or food.
● Pneumonia is an infection of the lungs. Some bacterial strains that can cause
pneumonia include Streptococcus pneumoniae, Staphylococcus aureus and
Klebsiella pneumoniae. Bacteria are the most common cause of pneumonia;
viruses cause only about one third of cases of pneumonia in adults.

Diseases caused by bacteria in animals:

● Anthrax in cattle, sheep and goats is usually spread by contact with spores of
Bacillus anthracis in the soil or from pastures. Animals present with weakness,
staggering and bloody discharges, often rapidly leading to death – although
sometimes sudden death of livestock is the first sign of the disease. Anthrax is a
zoonotic disease, so it can also be passed from animals to humans.
● Salmonellosis in poultry, with Salmonella species causing disease in a wide range
of birds including chickens and turkeys. Different species and serovars present
differently, with common presentations being pullorum disease, fowl typhoid and
fowl paratyphoid. Some strains of Salmonella in poultry can be passed to humans
through the food chain.
● There are several species of Brucella which tend to present slightly differently in
different species. The most common sign of brucellosis in livestock is abortion
during the final trimester of pregnancy. Some species of Brucella are zoonotic.
● One of the most common aquatic diseases is Vibrio, which leads to massive
mortality of cultured shrimp, fish and shellfish. Vibriosis (Vibrio illness) can be
zoonotic, and Vibrio cholerae can cause cholera in humans.

Diseases caused by bacteria in plants:

● Bacterial leaf streak and black chaff are a major bacterial disease of wheat. The
bacteria (Xanthomonas translucens) are seed-borne. Typical symptoms on the
leaf consist of elongated, light brown lesions, several centimetres long, that are
initially distinct but later coalesce to cover larger solid areas. Yield losses can be
as high as 40%.
● Epidemics of rice bacterial blight caused by Xanthomonas oryzae have been
observed in Asia, the western coast of Africa, Australia and Latin America. The
early signs consist of streaks that spread from leaf tips and margins, eventually
oozing a milky substance that dries into yellow droplets. Later on, leaves will die;
infected seedlings die within a few weeks of infection.
● Bacterial canker mainly affects tomatoes (caused by the bacterium Clavibacter
michiganensis), present worldwide. Infections result in wilting, defoliation,

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desiccation, skin cankers, significantly reduced fruit yield and quality, and
ultimately plant death.

2.2 What are antibiotics?

Activity 7: What are antibiotics?

Watch Video 5, on antibiotics:

Video content is not available in this format.

Video 5

Now write down in your own words a definition of antibiotics.

Discussion
Compounds that are made by microbes to fight other microbes are naturally occurring
antibiotics. Scientists have copied and often modified these compounds to use to fight
bacteria in humans, animals and plants.

Activity 8: Study definitions

In this course you have already seen a few concepts, and you have read about
microbes, bacteria, antibiotics and antimicrobials. Take a few minutes to study the
definitions listed in the table below and then answer the questions that follow.

Term Definition
Antibacterial Compounds that kill or inhibit the growth of bacteria.
Antibiotic Compounds that kill or inhibit the growth of microbes/micro-organisms. ‘An
antibiotic is an agent or substance that is produced by or derived from a
micro-organism that kills or inhibits the growth of another living micro-
organism. Antibiotic substances that are synthetic, semi-synthetic, or derived
from plants or animals are, strictly speaking, not antibiotics. However, for the
purposes of this module they are included. In this document “antibiotic” refers
to an antimicrobial agent with the ability to kill or inhibit bacterial growth.’
(WHO, 2019)
Antifungal Compounds that kill or inhibit the growth of fungi.
Antimicrobial Compounds that kill or inhibit the growth of microbes/micro-organisms. ‘An
antimicrobial is an agent or substance derived from any source (micro-

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organisms, plants, animals, synthetic or semi-synthetic) that acts against any

type of micro-organism, such as bacteria (antibacterial), mycobacteria (anti-
mycobacterial), fungi (antifungal), parasite (anti-parasitic) and viruses
(antiviral).’ (WHO, 2019)
Antiparasitic Compounds that kill or inhibit the growth of parasites.
Antiviral Compounds that kill or inhibit the growth of viruses.

‘All antibacterials are antimicrobials.’ True or false?

¡ True
¡ False

Answer
Antibacterials are a kind of antimicrobial.

‘All antimicrobials are antibacterial.’ True or false?

¡ True
¡ False

Answer
Antimicrobials also include antifungals, antivirals and antiparasitics.
Note: because this course mostly focuses on bacterial antimicrobial resistance, we will
generally use the terms ‘antibiotic’ and ‘antimicrobial’ to mean ‘antibacterial’.

2.3 What antibiotics do

Antibiotics that are used for medical treatment work through a mechanism of selective
toxicity: they attack the bacteria that cause the infection but they don’t kill the patient.
They often also attack bacteria that are not pathogenic.
That seems very obvious now, but let’s briefly go back in time again. Not even that long
ago – let’s say about 100 years …

■ Do you remember the year that antibiotics were discovered?

� 1928.

At that time there was some understanding about the importance of hygiene measures to
prevent spread of infectious disease. However, infections were difficult to treat, because
the treatments that were available not only killed the infection, but also often killed the
patient.
The discovery of antibiotics was the discovery of ‘magic bullets’: a treatment was now
available that only targeted microbes and therefore kept the patient alive.
Not all antibiotics attack bacteria in the same way: some attack the cell wall, some attack
bacterial protein syntheses and some attack the DNA-replicating mechanism of bacteria.
In all cases, they tackle structures or biochemical processes that are either not found in
human or animal cells, or don’t work in the same way. Antibiotics are classified based on
their chemical structure: those with a similar chemical structure tend to have similar
antibacterial activity. (You will learn more about this in Introducing antimicrobial
resistance.)

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Some classes of antibiotics target several bacterial species: these are called broad-
spectrum antibiotics. Antibiotics with a working mechanism that only attacks a small
group of bacterial species are called narrow-spectrum antibiotics.

Activity 9: The antibiotics quiz

Answer these two multiple-choice questions on antibiotics. Only one answer is correct
in each case. Don’t worry if you don’t know the answers to the questions; by the end of
this module you should be able to answer them all.
Antibiotics can be used to treat infections caused by:
¡ bacteria and viruses
¡ bacteria
¡ viruses
Discussion
The term ‘antibiotic’ describes an antimicrobial agent produced by a microbe to protect
it against other microbes, or a drug designed (often with a natural product as a
template) to target pathogenic/harmful organisms. However, the term ‘antibiotic’ is
widely used to mean ‘antibacterial’ (any compound used to kill, or inhibit the growth of,
bacteria).
Using this definition, antibiotics specifically target bacteria. They are not effective
against infections caused by viruses (such as influenza), or the viruses that cause the
common cold – although they may sometimes be used against secondary bacterial
infections that can follow viral infections. Indiscriminate use of antibiotics to treat viral
infections leads to unnecessary and inappropriate use of antibiotics and antimicrobial
resistance.

Antibiotics:
¡ do not cause side-effects
¡ are only active against pathogens
¡ can be used in a prophylactic manner to prevent bacterial infections
¡ stimulate the body’s immune system.
Discussion
Antibiotics can be used in a prophylactic manner to prevent bacterial infections. This
happens during some surgical procedures.
Antibiotics are not selective; they inhibit or kill ‘good’ bacteria along with ‘bad’ bacteria.
This can lead to common side-effects such as an upset stomach and antibiotic-
associated diarrhoea caused by Clostridium difficile or other gut microbes. Antibiotics
do not enhance the body’s immune response.

2.4 Role of antibiotics in modern medicine

In the previous sections you learned that:

● pathogenic bacteria can cause infection in humans, animals and plants

● antibiotics are used to treat bacterial infections.

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However, antibiotics can be used in other scenarios, beyond the treatment of infectious
diseases.

Activity 10: Antibiotics in modern medicine

Based on the understanding that you have now, reflect on the role that antibiotics play
in these different aspects of modern medicine:

● The use of antibiotics in cancer treatment.

Discussion
Cancer is a disease caused by cells that grow excessively, creating tumours and
potentially invading other tissues. Chemotherapy is one of the principal treatments for
cancer; a major-side effect is that the immune system is weakened. In Section 2.1 you
learned that opportunistic bacteria can take advantage of this situation and cause an
infection. Antibiotics are important to treat bacterial infections in patients with
extremely weakened immune systems due to chemotherapy.

● The use of antibiotics for surgical prophylaxis.

Discussion
Antibiotics are used before certain surgical procedures to prevent infection. For
example, for orthopaedic operations where implants are put in to replace joints (such
as a hip or knee), there is a possibility of micro-organisms infecting the prosthesis.
Nowadays, surgery is performed in aseptic conditions to minimise the risk of infection.
Without antibiotics, surgery would still be possible; however, the risk of an infection as
a result of the surgery would be bigger and more difficult to treat. Surgery was
performed before the discovery of antibiotics, but mortality rates were very high.

2.5 The role of antibiotics in food production

In the previous sections you learned that:

● pathogenic bacteria can cause infection in humans, animals and plants

● antibiotics are used to treat bacterial infections
● antibiotics are also used to prevent infections in patients with weakened immune
systems, for example in cancer patients

Activity 11: The role of antibiotics beyond human medicine

Based on the understanding that you have now, reflect on the role that antibiotics play
beyond human medicine.
What is the role of antibiotics in the production of crops?
Discussion
Bacteria and fungi cause significant plant disease and production losses worldwide.
Pesticides, including antimicrobial pesticides, play an important role in reducing losses
in crop production. Some of the same drugs that are used in human and veterinary

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medicine – for example, streptomycin, tetracyclines or triazoles – are also used to

control plant diseases (FAO, 2018).

What is the role of antibiotics in food-animal production and veterinary medicine?

Discussion
In food-animal production, antibiotics are used to treat disease, prevent disease and
promote growth. The rising global demand for animal-sourced food has led to more
intensive, large-scale farming, with animals reared in confined spaces – often at a high
density. These production systems promote pathogen spread. In some countries and
production systems, prophylactic use of antibiotics to address disease problems in
intensive systems is common. In other countries, industries have worked particularly
hard on improving biosecurity to minimise or even completely eliminate the
prophylactic use of antibiotics in food-animal production.
The use of antibiotics to promote growth in food-producing animals was common
historically but is now considered inappropriate. Members of the World Organisation
for Animal Health (OIE) agreed in 2016 to ‘phasing out the use of antibiotics for growth
promotion in the absence of risk analysis’. The latest OIE Annual Report on
Antimicrobial Agents Intended for Use in Animals reported that 77% of the 118 nations
that submitted data on antimicrobial use in animals responded that antimicrobials were
not used for growth promotion in animals in their countries (OIE, 2020).
There is now a global consensus that the use of antibiotics for prophylaxis and growth
promotion in animals should be minimised and avoided where possible. However, like
humans, both food-producing and companion animals (e.g. cats, dogs and other pets)
suffer from bacterial diseases that can easily be treated with antibiotics. Therefore,
there will always be a role for treating individual animals therapeutically with
antimicrobials. Failing to treat these animals results in unnecessary suffering (and in
some cases, death), which threatens the livelihood of farmers and the welfare of
animals.
There is a series of principles that can help reduce the impact of the necessary
antibiotic use in animals on AMR in humans (e.g. avoiding the use of some antibiotics
in animals that should be reserved for treatment of some bacterial infections in
humans). These principles will be covered in the Antimicrobial stewardship in
veterinary practice module

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3 The problem of antibiotic resistance

3 The problem of antibiotic resistance

In this section you will learn about antibiotic resistance and reflect on its implications for
modern medicine and other aspects of our lives. In the previous section you learned about
the importance of antibiotics today. In this section you will reflect on what a future without
effective antibiotics would look like. You will also study figures and maps to get an
understanding of the global scale of the problem of antibiotic resistance.
After this section you will:

● be able to define the term antibiotic resistance

● understand the scale of the problem of antibiotic resistance
● be able to reflect on a future without functional antibiotics.

3.1 Definition of resistance

Activity 12: A recap on definitions

Recall the definitions of:

● antimicrobial
● antibiotic
● antibacterial.

Discussion
The definitions are as follows:

Term Definition
Antibacterial Compounds that kill or inhibit the growth of bacteria.
Antibiotic Compounds that kill or inhibit the growth of microbes/micro-organisms. ‘An
antibiotic is an agent or substance that is produced by or derived from a
micro-organism that kills or inhibits the growth of another living micro-
organism. Antibiotic substances that are synthetic, semi-synthetic, or derived
from plants or animals are, strictly speaking, not antibiotics. However, for the
purposes of this module they are included. In this document “antibiotic” refers
to an antimicrobial agent with the ability to kill or inhibit bacterial growth.’
(WHO, 2019)
Antimicrobial Compounds that kill or inhibit the growth of microbes/micro-organisms. ‘An
antimicrobial is an agent or substance derived from any source (micro-
organisms, plants, animals, synthetic or semi-synthetic) that acts against any
type of micro-organism, such as bacteria (antibacterial), mycobacteria (anti-
mycobacterial), fungi (antifungal), parasite (anti-parasitic) and viruses
(antiviral).’ (WHO, 2019)

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Activity 13: Understanding resistance

Watch the following video on antibiotic resistance, up to 2:38. Don’t worry if you hear
some terms in this video that you are unfamiliar with; it is important that you
understand the overall concept of resistance to antibiotics in bacteria.

View at: youtube:znnp-Ivj2ek

Video 6

In your own words, what is antibiotic resistance?

Discussion
Bacteria have developed ways to defend themselves against the antibiotics that other
microbes produce. When bacteria can withstand attack by the antibiotic, they are
termed resistant to that antibiotic.
Bacteria can be innately resistant or acquire resistance. (You will learn more about this
in the module Introducing antimicrobial resistance.) The first, innate resistance, is a
natural state of some bacteria. For example, some organisms may have innate
resistance because the antimicrobial cannot pass the bacterial cell wall. Examples of
innate resistance include Enterococci, which can withstand the effects of cephalos-
porins, and Klebsiella species that are not susceptible to penicillin V.
Resistance can also be acquired. The two major ways of developing acquired
resistance are through genetic mutation or through gene transfer. Bacteria mutate
with a high frequency: not all of these mutations lead to antimicrobial resistance, but
some do. Even the slightest selective advantage brought about by a mutation can
result in an organism out-competing its neighbours. Bacteria with a resistance gene
can transfer it to another bacterium, which then acquires resistance (gene transfer).
Remember: bacteria are the ones that get resistant to antibiotics – not people, animals
or plants.

The term ‘antimicrobial resistance (AMR) is used to describe this phenomenon.

Although it technically includes resistance to all microbes, in this course it will generally be
used to refer to antibacterial resistance.
In Section 4 we will look at the development and drivers of resistance in more detail, but
first let’s take a moment to think about what this means for modern medicine (human and
veterinary), and agriculture at the global scale.

3.2 Consequences of resistance

Activity 14: Consequences of resistance

In Sections 2.4 and 2.5 you learned about the role of antibiotics in modern medicine
(human and veterinary), and agriculture.

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3 The problem of antibiotic resistance

Due to development of resistance in some bacteria, the antibiotics that we have

available today are not always effective. Take a moment to reflect on what that
means for:

● treatment of infectious diseases caused by bacteria

● surgery
● crop production
● meat production.

Discussion
Treatment of infectious diseases caused by bacteria
Antibiotics are the ‘magic bullets’ that can attack bacterial infections without killing the
patients. That does not mean that the antibiotic treatment is completely harmless to
the patients: antibiotics disrupt the normal bacterial flora as they not only kill the
pathogenic organism, they also kill the normal flora (good bacteria). So antibiotics
must be used carefully, only where appropriate, and should not be prescribed
indiscriminately. For example, for a mild sore throat with no signs of fever, the infection
is likely to be caused by a virus. Warm saline gargles may be effective at relieving
symptoms, while antibiotics may have no effect at all. Similarly, in animals, small
wounds can be managed with proper wound dressings and care without the need to
prescribe antibiotics.
You have also learned that there are different classes of antibiotics that work in
different ways. So if a bacterium becomes resistant to one kind of antibiotic, there
might be another type of antibiotic with a different mechanism of action that is still
effective against that bacterial infection. However, what happens if the bacteria
become resistant to that one as well, and then to the next one and the next one? This
is already happening with some bacteria, which we call multi-drug-resistant bacteria.
If a strain of bacteria becomes resistant to the last class of antibiotics that is available
to treat it, we have no way to treat the infections that it causes. Methicillin-resistant
Staphylococcus aureus (MRSA) is an example of such a multi-drug-resistant
bacterium.

Surgery
Without effective antibiotics, surgery will become riskier because there will be no way
to treat bacterial infections that might happen as a complication of surgery. To prevent
the risk of infection, surgery should be performed in aseptic conditions. However, there
is still a possibility that bacteria on patients’ skin may enter the body during the course
of surgery. In Section 2.1 you saw that under the right conditions, bacteria can
replicate very quickly. Without antibiotics to treat the infection, the risk of complications
from the surgery is high.

Crop production
Bacteria and fungi cause significant plant disease and production losses worldwide.
We need antibiotics to treat crop diseases caused by bacterial pathogens to preserve
food security and livelihoods. Intensive agriculture often involves monocultures of
crops in which pathogens can spread easily. In a plot of land where plants are widely
spaced, plant diseases cannot spread as easily. The reality is that we are growing our
crops in conditions that favour spread of pathogens, so we need to be able to continue
to treat the diseases they cause.

Meat production

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Antimicrobials are used to treat infections in food-producing animals. Just like humans,
food-producing animals can be infected with bacterial pathogens. Because of the
pressure placed by human population growth on agricultural systems, food-producing
animals are often housed very close together in what’s referred to as intensive farming
systems. When animals are housed close together, bacterial infections occur more
frequently and spread more readily. Improving biosecurity in intensive farming systems
can reduce the incidence of bacterial diseases but many of these farming systems
may still require antimicrobials to control disease at some point so that animals do not
suffer, and farms remain economically viable.
A good example is the use of antimicrobials to treat mastitis in high-producing dairy
systems. In these systems, dairy cows are kept together in a large herd (possibly at
high density), and milked at least twice daily using machines that attach to the cows’
teats. Milking with shared machinery and close proximity with other members of the
herd can lead to infection of the mammary glands – mastitis, which is painful and
reduces milk quality and safety.
There are many ways to reduce and control the incidence of mastitis on a dairy farm,
such as making sure milking equipment is cleaned properly and that cows’ teats are
cleaned before and after milking. Despite this, most high-producing commercial farms
still need to treat mastitic cows with antimicrobials when necessary. If these
antimicrobials become ineffective, treatment of cows with mastitis will also be less
effective. This will likely lead to more euthanasia of infected cows and will impact the
quality, quantity and expense of milk production.

If we lose functioning antibiotics, will we go back to life as it was in the 1800s? (Use the
theory you learned in Section 1 of this module.)
Discussion
No. Because of the developments in hygiene theory and epidemiology (starting with
the work of John Snow), we know much more about the spread of disease in the
population and how to prevent it.
Take for example the way we prevent and treat cholera. Cholera is an infection of the
small intestine by a bacterium called Vibrio cholerae. The classic symptom is a watery
diarrhoea that quickly leads to severe dehydration and electrolyte imbalance. In 1854,
John Snow discovered the link between contaminated water and cholera, as you saw
in Section 1.2. He was able to convince the local council that the water well was the
source of the outbreak. The outbreak was controlled by removing the well pump’s
handle to disable it, thus preventing people from drinking the contaminated water.
Another important advance that has been made in cholera prevention is the
development of cholera vaccines. However, despite preventative measures, there are
still many people getting sick from this disease. Antibiotics are available to treat it, but
that is not the only possible treatment. Oral rehydration therapy is now recommended
as the first line of treatment for cholera, and this alone will successfully treat most
cases. The WHO recommends prescription of antibiotics only to those with the most
severe infections.

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3 The problem of antibiotic resistance

3.3 Scale of resistance

Although we would not go back to life as it was in the 19th century if we lost antibiotics, we
should definitely not underestimate the impact that losing them would have on global
health.
In 2016, the UN assembly gathered to discuss the problem of AMR and called it one of the
biggest threats to global health. This was only the fourth time in the history of the UN that
a health topic was discussed at its General Assembly – the other three were HIV,
noncommunicable diseases and Ebola (WHO, 2016).

Activity 15: Resistance of Acinetobacter baumannii to carbapenems

Now let’s look at the scale of resistance worldwide.
Acinetobacter baumannii is an opportunistic pathogen that can cause a range of
diseases, including pneumonia and bloodstream infections. Carbapenems are a class
of highly effective broad-spectrum antibiotics, usually reserved for treating multi-drug-
resistant infections. The fact that this species has developed resistance to such an
effective and important antibiotic class is particularly worrying.
In Figure 2 you see the resistance that Acinetobacter baumannii has developed
against a class of antibiotic known as carbapenems as documented by the Center for
Disease Dynamics, Economics & Policy (CDDEP). The percentage of resistant
isolates of Acinetobacter baumannii is indicated in blue; the darker the country, the
higher the percentage of resistance. There are no data available on the countries in
light grey.

Figure 2 Resistance of Acinetobacter baumannii to carbapenems.

Is data available from your country?
Which countries have the highest level of resistant isolates of Acinetobacter baumannii
against carbapenems?
Discussion
The darker blue the country, the higher the proportion of isolates that were found to be
resistant. High levels of resistance are found in Mexico, Venezuela, Argentina, South

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3 The problem of antibiotic resistance

Africa, Tunisia, Poland, Ukraine, Spain, Italy, Greece, Turkey, Saudi Arabia, Russia,
China, India and Pakistan.

Let’s zoom in to a few countries to see the percentage of Acinetobacter baumannii

isolates found to be resistant over time. Take a minute to look at the trends of
resistance in Russia, the United States and Venezuela (Figures 3–5).
The figures show the percentage of Acinetobacter baumannii isolates resistant to
carbapenems over time in Russia, Venezuela and the United States in different years
as documented by the CDDEP. Data are based on different data sources.
Different colours on the maps are assigned at random.

Figure 3 Antibiotic resistance of Acinetobacter baumannii in Russia. (Source: Central

Asian and Eastern European Surveillance of Antimicrobial Resistance (CAESAR))

Figure 4 Antibiotic resistance of Acinetobacter baumannii in Venezuela. (Source:

Venezuela: Programa Venezolano de Vigilancia de la Resistencia a los
Antimicrobianos (PROVENRA))

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3 The problem of antibiotic resistance

Figure 5 Antibiotic resistance of Acinetobacter baumannii in the USA. (Source: United

States: The Surveillance Network, USA/ResistanceMap Surveillance Network/
National Healthcare Safety Network, USA)
What is the trend that you can identify on the percentage of Acinetobacter baumannii
isolates resistant to carbapenems over time? What is different in the trend in the
United States?
Discussion
In Russia and Venezuela, the level of resistance has increased over time. It is not
increasing in a straight line, but the trend is going up. In the United States, the level of
resistance increased until 2009 but started decreasing after that year.

Why are the timelines of the graphs different?

Discussion
The timelines of the graphs are different due to the practical reasons of the availability
of information. In Section 5.3 you will learn about international efforts to standardise
data collection on the levels of resistance of different pathogens all over the world.

Unfortunately, Acinetobacter baumannii is not the only type of bacterium that shows
resistance to this class of antibiotics: several other types of bacteria have developed
resistance to carbapenems or other broad-spectrum antibiotics such as cephalosporins
and vancomycin. The WHO developed the priority pathogen list (see Table 1) for
development of new antibiotics. This list (adapted from WHO, 2017) ranks antibiotic-
resistant bacterial pathogens for which alternative treatments are urgently required, giving
each a priority rating. As you can see, the priority rating for Acinetobacter baumannii is
‘critical’.

Table 1 The WHO’s priority pathogen list.

Bacterium Type of antibiotic resistance Priority rating

Acinetobacter baumannii Carbapenem Critical

Pseudomonas aeruginosa Carbapenem Critical
Enterobacteriaceae Carbapenem, cephalosporins Critical

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3 The problem of antibiotic resistance

Enterococcus faecium Vancomycin High

Staphylococcus aureus Vancomycin, methicillin High
Helicobacter pylori Clarithromycin High
Campylobacter sp. Fluoroquinolone High
Salmonella sp. Fluoroquinolone High
Neisseria gonorrhoeae Cephalosporin, fluoroquinolone High
Streptococcus pneumoniae Penicillin Medium
Haemophilus influenzae Ampicillin Medium
Shigella sp. Fluroquinolone Medium

The WHO has also produced a list of priority pathogens for surveillance as part of its
Global Antimicrobial Resistance Surveillance (GLASS) programme. This is a list of
organisms in which high levels of resistance have been reported and are also some of the
most common causes of bacterial infections. The priority pathogens for the GLASS
surveillance (WHO, 2015) are:

● Acinetobacter baumannii
● Escherichia coli
● Klebsiella pneumoniae
● Neisseria gonorrhoeae
● Salmonella sp.
● Staphylococcus aureus
● Streptococcus pneumoniae.

As you may have noticed, there is a lot of overlap between the two lists.

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4 How resistance develops

4 How resistance develops

In the previous section you learned about the global scale and impact of AMR on modern
life. In this section you will learn about the causes that contribute to this problem –
specifically, the development and drivers of AMR.
After this section you will understand:

● that development of antibiotic resistance is a naturally occurring process that

protects bacteria
● that increased use of antibiotics has sped up the natural process of resistance
development
● how resistant bacteria spread in the environment
● that use of antimicrobials in different sectors is a driver for AMR.

4.1 Development of resistance

In Section 2.2 you learned that antibiotics occur naturally, although scientists have copied
and modified those compounds to produce synthetic antibiotics, and most antibiotics in
current use are not naturally produced. Just as the development of antibiotics is a
naturally occurring process, so too is the development of resistance to antibiotics.

Activity 16: Antibiotic resistance occurs in nature

Watch this video about bacteria living very remotely from humans in a resource-scarce
environment.

Video content is not available in this format.

Video 7

4.2 Spread of resistance in bacteria and the

environment
Earlier in this module you learned that bacteria are all around us. Some types of bacteria
are common to all living beings (humans, animals and plants). Remember from
Section 2.1 how fast bacteria replicate?

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4 How resistance develops

Consider a few Salmonella bacteria that have infected a chicken. The chicken is treated
with antibiotics, and one of the bacteria happens to be resistant to the antibiotic that is
given. All the other bacteria will be killed by the antibiotic, but the resistant bacterium will
survive, divide, multiply and pass the resistance to all offspring. In addition, bacteria can
pass on resistance between each other by other mechanisms called horizontal transfer,
which is explained in the module Introducing antibiotic resistance.

Activity 17: Spread of antibiotics in the environment

Study Figure 6 (from Berkner et al., 2014) on the different ways that antibiotics spread
in the environment and answer the question that follows. Just as antibiotics can spread
in the environment, so can some resistant bacteria.

Figure 6 The pathway of the spread of antibiotics in the environment.

Identify three ways that antibiotics can end up in the groundwater.
Discussion
Three ways that antibiotics can end up in the groundwater are through:

● waste deposits from humans that contain antibiotic-resistant bacteria

● run-off from fields that have been fertilised with manure that carries antibiotic-
resistant bacteria, or with sewage sludge from the sewage plant that carries
antibiotic-resistant bacteria
● excrement or droppings from animals that carry antibiotic-resistant bacteria.

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4 How resistance develops

4.3 Drivers of resistance

Activity 18: Resistance to newly discovered antibiotics

Listen to part of a TED talk (between 3:49 and 5:00 in Video 8) and pay particular
attention to the figure that appears onscreen at around 4:45, which summarises the
development of resistance against different classes of antibiotics.

View at: youtube:o3oDpCb7VqI

Video 8

The more antibiotics we use, the more we select for resistance. Any mutations (genetic
changes) in bacterial genes happen by chance; if the genetic mutation leads to the
bacteria becoming resistant to an antibiotic, and we continue to use the same molecule,
the bacteria that do not have this resistance are killed, but the ones that carry the mutation
survive. That is what we mean by ‘selecting for resistance’.
This process holds true for any newly discovered antibiotic. Evolution means that
resistance will inevitably emerge, but it will do so more rapidly if we do not use antibiotics
with care. Let’s look at some graphs on antimicrobial consumption (AMC) in the world.

Activity 19: Human antimicrobial consumption

Study Figure 7 and answer the questions that follow. It shows the percentage change
in antibiotic consumption per capita between 2000 and 2010. Percentage decrease is
indicated in blue while percentage increase is indicated in red. Lower percentage
changes are indicated by lighter colours. No data are available for the countries shown
in grey.

Figure 7 Country-specific human antibiotic consumption data, 2000–2010.

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1. Is human antibiotic consumption data available for the country that you live in?
2. What global trend(s) can you identify in human antibiotic consumption?

Discussion
In some countries the consumption of antibiotics by humans has decreased between
2000 and 2010, and in others it has increased. Decrease of antibiotic consumption is
seen in the Americas, most countries in Europe and in eastern Asian countries.
Increase in antibiotic consumption is seen in South America, Africa and Asia.
Generally, based on Figure 7, you can say that in high-income countries the antibiotic
consumption by humans has decreased between 2000 and 2010, whereas it has
increased in low- and middle-income countries. However, no information is provided
on the use of antibiotics, such as who they were given to and whether they were used
appropriately. Understanding how antibiotics are used is another important factor in
understanding the drivers of AMR.

Antibiotics are also used to keep animals healthy. This includes both companion animals
and food-producing animals. Use of antimicrobials in companion animals is likely to have
less impact on AMR than antimicrobial use in food-producing animals. Companion animal
medicine is usually based on therapeutic treatment of a small number of individual
animals, whereas antimicrobial use in food-producing animals sometimes occurs at a
larger scale and may include use for prophylaxis or growth promotion. In addition,
treatment of food-producing animals may result in resistant bacteria entering the food
chain.
The Food and Agriculture Organization (FAO) states that estimates of the total use of
antimicrobials in agriculture vary considerably. This is mainly due to a lack of systems in
place to collect information on use of antimicrobials in animals, although in Section 5.3
you will learn that global efforts are being made to address this data gap. Antimicrobial
use in livestock and in other food-producing animals such as aquatic animals is projected
to increase over the coming decades based on the increased demand for animal-sourced
food products (FAO).

Activity 20: AMR in aquaculture

Watch Video 9 (up to 0:50), which looks at AMR in aquaculture:

View at: youtube:1MlhG0FgeAI

Video 9

Why should we be concerned about using antimicrobials in (aquatic) animals? For

inspiration for your answer, look at the figure that you studied in Activity 17.

Provide your answer...

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4 How resistance develops

The link between use of antimicrobials in food-producing animals and AMR spread among
humans requires further study, because the link isn’t as clear as we think. There is some
evidence that use in animals contributes to AMR spread in people, but what isn’t clear is
how much it contributes compared to use in human health. Further studies are also
required to quantify the volumes of antibiotics used in companion animals compared to
food-producing animals. Although we might assume there are much higher volumes of
antimicrobials used in food-producing animals, there are limited data available on this
point, and even less on the reasons for use (treatment, prophylaxis, growth promotion).
This data gap is slowly changing as countries start to improve the ways they measure and
monitor the quantities of antibiotics and how they are used in different sectors.
In conclusion, global antibiotic consumption has increased since 2000 and is predicted to
continue increase in the future (WHO, 2015b). In some countries, antibiotic use in humans
and animals has decreased, but the opposite has happened in others. It is important to
remember that any encounter a bacterial population has with an antibiotic may select for
resistant bacteria. This is irrespective of whether bacteria are innately resistant or have
become resistant due to mutation or gene transfer. The antibiotics kill the non-resistant
bacteria, but the resistant bacteria survive. As described above, we don’t yet fully
understand the links between use in agriculture and resistance in human disease. There
are proven examples of resistant bacteria in animals transferring to humans through the
environment and/or the food chain; however, there is a poor understanding of the scale of
these events and their impact, and it is likely that, overall, AMR in humans is related to
antimicrobial use both in healthcare and in farming. All sectors, therefore, need to address
the issue of misuse of antibiotics to do their part in minimising the emergence and spread
of AMR.

Activity 21: Reflection on use of antimicrobials

Should we just stop using antibiotics?
Discussion
No, of course not. Antibiotics are very important to us. We just need to make sure we
use them responsibly in all sectors. Also, we should look at things that we can do to
limit the use of antibiotics wherever possible. There are many things we can all do, as
citizens and in our professional lives, to address the problem of AMR. In the next
section you will learn about this.

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5 The global response to fight AMR

5 The global response to fight AMR

In the previous section you learned about some of the underlying causes, the global scale
and the impact of the problem of AMR. This section introduces steps we can take to
address this problem, One Health and global efforts that are currently being made to
address the problem of AMR.
After this section you will be able to:

● explain why the problem of AMR needs a One Health approach

● know about ongoing global efforts to address the problem of AMR
● reflect on your own role and those of your colleagues in tackling the problem of AMR.

5.1 What can we do to address the problem

of AMR?
The problem of AMR is a universal issue; every one of us could be directly or indirectly
impacted by it. AMR already has a significant impact, being responsible for an estimated
700,000 deaths worldwide in 2014 (Review on Antimicrobial Resistance, 2014), and this
impact will become increasingly severe if action is not taken now.
In this section you will learn about steps we can and should take to fight the problem of
AMR. You will use your understanding of the underlying causes that have led to the global
scale of the problem of AMR to reflect on how all these steps are in themselves
contributing to fighting it.

Activity 22: Ten things we can do to reduce AMR

Watch Video 10, which shows ten things we can do to reduce AMR.

Video content is not available in this format.

Video 10

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5 The global response to fight AMR

Take a moment to reflect on these ten steps. Pick three steps and, use your
understanding of the underlying causes and drivers of the problem of AMR to write
down how each of these steps contributes to addressing the problem. If you have
difficulty thinking of things you can do, just watch the video again.

Provide your answer...

Activity 23: Self-reflection

The AMR crisis affects us all so we can all do something to fight it.

1. Think of three things you can do in your personal life that are important in
combatting the AMR crisis.
2. How can you contribute to combatting the AMR crisis in your professional life?

Provide your answer...

5.2 One Health

In AMR surveillance and you you were introduced to the concept of One Health and why
addressing the issue of AMR requires a One Health approach. One Health is defined as
‘the collaborative effort of multiple disciplines – working locally, nationally, and globally – to
attain optimal health for people, animals and our environment’ (One Health Initiative Task
Force, 2008).
In this module you have learned that antimicrobial-resistant bacteria can be found in
humans, animals and the environment. It makes sense, therefore, to take a One Health
approach to address the problem of AMR.

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5 The global response to fight AMR

Figure 8 Addressing AMR with a One Health approach

Activity 24: Self-reflection

1. Look at Figure 8. In which area does your professional expertise fall?
2. In which area(s) of Figure 8 do you lack professional expertise? Do you know
professionals in your network who have this expertise? If not, how would you get
in touch with professionals with this expertise?

Provide your answer...

5.3 International efforts

In Section 3.3 you learned that the UN General Assembly gathered in September 2016 to
discuss the problem of AMR.
The 193 member states committed to work collaboratively to take worldwide action to
control AMR by signing the UN Declaration on AMR. All the declaration signatories have
agreed that drug-resistant infections must be tackled as a priority and have committed to:

● developing surveillance and regulatory systems on the use and sales of antimicrobial
medicines for humans and animals

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● encouraging innovative ways to develop new antibiotics and improve rapid

diagnostics
● raising awareness among health professionals and the public on how to prevent
drug-resistant infections.

By taking this course and discussing what you have learnt with colleagues, friends and
family, you are already helping to raise awareness of AMR.

Figure 9 Guidance on how to respond to AMR.

AMR surveillance is critical to tackling AMR, and is the backbone of these efforts. In AMR
surveillance and you you learned that AMR surveillance is the ongoing collection,
analysis, interpretation and dissemination of data related to AMR.

● At a global level, AMR surveillance provides quantitative data about the spread of
resistant strains of bacteria, revealing trends and potentially identifying hotspots of
resistant infections.
● At a regional level, surveillance data informs intervention priorities and helps to
identify gaps in service delivery.
● At a national level, data guides planning and resource-allocation, and informs
policies and responses to patterns and trends.

AMR surveillance data are important to inform policy-makers and decision makers at all
levels.
Let’s look at two surveillance programs in the framework of the Global Action Plan on
AMR supported by the tripartite collaboration:

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5 The global response to fight AMR

Use of antimicrobials in animals

As you learned in Section 4.3, there is limited information available on use of
antimicrobials in animals. The World Organisation for Animal Health (OIE) has developed
a database on antimicrobial agents intended for use in animals. The progress on
developing the database and the findings have been published in annual reports; at the
time of writing, the most recent one is the fourth annual report published in 2020. These
reports present estimates of antimicrobial agents intended for use in animals adjusted for
animal biomass, based on quantitative data reported by countries to the OIE.
In the fourth round of data collection, 152 member states submitted complete reports, of
which 118 included quantitative data on animal use. However, based on challenges faced
by countries to collect quantitative data on antimicrobial use in animals, the OIE advises
caution in interpretation and use of quantitative data. Based on data reported to the OIE
from 92 countries, the global estimate of antimicrobial agents used in animals in 2016
adjusted by animal biomass was 144.39 mg/kg (Góchez, 2019; OIE, 2020).

GLASS, coordinated by the WHO

In 2015, the World Health Assembly (WHA), the decision-making body of the WHO,
endorsed a Global Action Plan (GAP) to tackle antimicrobial resistance. The goal of the
GAP is ‘to ensure, for as long as possible, continuity of successful treatment and
prevention of infectious diseases with effective and safe medicines that are quality-
assured, used in a responsible way, and accessible to all who need them’ (WHO, 2015b).
The Global Antimicrobial Resistance Surveillance System (GLASS) was launched in
October 2015 to support the GAP on antimicrobial resistance. GLASS encourages and
facilitates the establishment of national AMR surveillance systems that are capable of
monitoring AMR trends and producing reliable and comparable data. As of April 2020, 92
countries, territories and areas are enrolled in GLASS (WHO, 2020).

Activity 25: The Global Antimicrobial Resistance Surveillance System

(GLASS)
Take a look at Figure 10, taken from the 2020 GLASS report (WHO, 2020):

Figure 10 International enrolment in different data surveillance systems. (AMR =

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5 The global response to fight AMR

antimicrobial resistance, AMC = antimicrobial consumption)

1. Is your country enrolled in GLASS?

2. If so, is it enrolled for AMR or antimicrobial consumption surveillance, or both?

You will learn more about GLASS in the module An overview of national AMR
surveillance.

Provide your answer...

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6 End-of-module quiz

6 End-of-module quiz
Well done – you have reached the end of this module and can now do the quiz to test your
learning.
This quiz is an opportunity for you to reflect on what you have learned rather than a test,
and you can revisit it as many times as you like.

End-of-module quiz

Open the quiz in a new tab or window by holding down ‘Ctrl’ (or ‘Cmd’ on a Mac) when you
click on the link.

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7 Summary

7 Summary
Bacteria are micro-organisms that can cause diseases in humans, animals and plants.
Hygiene measures such as handwashing and water sanitation are important in the
prevention of bacterial infections. Antibiotics can be used to treat a bacterial infection.
Antibiotics are sometimes referred to as ‘magic bullets’ that kill the infection but keep the
patient alive. Antibiotics have played an important role in the treatment of bacterial
infections, but also have supported modern human and veterinary medicine in different
ways. For example, prophylactic use of antibiotics in surgery reduces the risk of infection.
Antibiotics also have a role in food production by keeping plants and food-producing
animals healthy.
However, due to resistance that develops in bacteria, antibiotics are becoming less
effective in treating bacterial infections. Development of resistance is a naturally occurring
process, but due to increased antimicrobial use in human and animal health, we have
selected for resistant bacteria. The resistant bacteria can spread directly between
humans, between animals and humans, and in some cases via the environment.
The increase in AMR is a serious threat to global health. The global response to fight the
problem of AMR includes several activities in the framework of the Global Action Plan on
AMR, which uses a One Health approach.
Now that you have completed this module, consider the following questions:

● What is the single most important lesson that you have taken away from this
module?
● How relevant is it to your work?
● Can you suggest ways in which this new knowledge can benefit your practice?

When you have reflected on these, go to your reflective blog and note down your
thoughts.

Activity 26: Reflecting on your progress

Do you remember at the beginning of this module you were asked to take a moment to
think about these learning outcomes and how confident you felt about your knowledge
and skills in these areas?
Now that you have completed this module, take some time to reflect on your progress
and use the interactive tool to rate your confidence in these areas using the following
scale:

5 Very confident
4 Confident
3 Neither confident nor not confident
2 Not very confident
1 Not at all confident

Try to use the full range of ratings shown above to rate yourself:

Interactive content is not available in this format.

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7 Summary

When you have reflected on your answers and your progress on this module, go to
your reflective blog and note down your thoughts.

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8 Your experience of this module

8 Your experience of this module

Now that you have completed this module, take a few moments to reflect on your
experience of working through it. Please complete a survey to tell us about your
reflections. Your responses will allow us to gauge how useful you have found this module
and how effectively you have engaged with the content. We will also use your feedback on
this pathway to better inform the design of future online experiences for our learners.
Many thanks for your help.
Now go to the survey.

References
Al Jazeera English [YouTube user] (2013) ‘The cure – unsung hero: Ignaz Semmelweis’,
YouTube, 20 August [online]. Available at
https://www.youtube.com/watch?v=toTWSmb-krw (accessed 3 December 2020).
Berkner, S., Konradi, S., Schönfeld, J. (2014) ‘Antibiotic resistance and the environment –
there and back again’, Science & Society series on Science and Drugs, EMBO Reports,
15(7), pp. 740–44.
Cornell University College of Agriculture & Life Sciences (n.d.) ‘Bacterial canker’ [online].
Available at https://www.vegetables.cornell.edu/crops/tomatoes/bacterial-canker/ (ac-
cessed 2 December 2020).
Center for Disease Dynamics, Economics & Policy (n.d.) ‘Antibiotic resistance’ [online].
Available at https://resistancemap.cddep.org/AntibioticResistance.php (accessed 2 De-
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Acknowledgements
This free course was collaboratively written by Clare Samson and Dorien Faber, and
reviewed by Priya Khanna, Hilary MacQueen, Rachel McMullan,Claire Gordon and
Natalie Moyen.

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Acknowledgements

Except for third party materials and otherwise stated (see terms and conditions), this
content is made available under a Creative Commons Attribution-NonCommercial-
ShareAlike 4.0 Licence.
The material acknowledged below is Proprietary and used under licence (not subject to
Creative Commons Licence). Grateful acknowledgement is made to the following sources
for permission to reproduce material in this free course:

Images
Course image: © Design Cells/iStock/Getty Images Plus.
Figure 1: © Natalie Dee 2002–2018. Courtesy of Natalie Dee.
Figure 2: Center for Disease Dynamics, Economics & Policy (cddep.org). © Natural Earth.
Figures 3–5: taken from https://resistancemap.cddep.org/AntibioticResistance.php.
Figure 7: from Gelband, H. et al. (2015) The State of the Worlds Antibiotics 2015,
https://www.cddep.org/publications/state_worlds_antibiotics_2015/. Source: Van Boeckel
et al., 2015 (adapted; based on IMS MIDAS).
Figure 8: United Nations Foundation (2017) ‘Sustaining global action on antimicrobial
resistance’, Wellcome Trust.
Figure 9: Fleming Fund (2017) ‘What you need to know about antimicrobial resistance’,
taken from
https://www.flemingfund.org/wp-content/uploads/LP1_AMR_A4Screen_FinalSignOff_-
Jan2017.pdf.
Figure 10: data, World Health Organization; map, Information Evidence and Research
(IER). © WHO 2019.

Videos

Video 1: from Pain, Pus and Poison: The Search for Modern Medicines, episode 2, TX 10
Oct 2013. © BBC.
Video 2: ‘The cure – unsung hero: Ignaz Semmelweis’, 20 August 2013.
Video 3: ‘Seven wonders of the microbe world’, The Open University; Alexander Fleming
in his laboratory: © Davies/Stringer/iStock/Getty Images Plus; image from Living Memory:
Ena Munroe/The Living Memory Association; image of bacteria-MRSA: Centers for
Disease Control and Prevention, USA (public domain); image of Penillium notatum : this
file is licensed under the Creative Commons Attribution-Share Alike licence,
http://creativecommons.org/licenses/by-sa/3.0/; image of William Stewart: public domain.
Video 4: BBC Learning Zone. © BBC.
Video 6: TED-Ed; this file is licensed under the Creative Commons Attribution-
Noncommercial licence (http://creativecommons.org/licenses/by-nc/3.0/).
Video 7: Michael Mosley vs The Superbugs, TX 17 May 2017. © BBC/Renegade Pictures.
Video 8: TED, 25 June 2015, https://creativecommons.org/licenses/by-nc-nd/4.0/.
Video 9: WorldFish; this file is licensed under the Creative Commons Attribution-
Noncommercial licence (http://creativecommons.org/licenses/by-nc/4.0/); text: Global
action plan on antimicrobial resistance.
https://apps.who.int/iris/bitstream/handle/10665/193736/9789241509763_eng.pdf: World
Health Organization; [n.d.]. Licence: CC BY-NC-SA 3.0 IGO.
Video 10: The Association of the British Pharmaceutical Industry, ‘10 steps to reducing
AMR – the Review on Antimicrobial Resistance’.

41 of 42 https://www.open.edu/openlearncreate/course/view.php?id=5023 Friday 9 July 2021

Acknowledgements

Every effort has been made to contact copyright owners. If any have been inadvertently
overlooked, the publishers will be pleased to make the necessary arrangements at the
first opportunity.

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