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As defined by World Health Organization (WHO),
“Antimicrobial resistance (AMR) occurs when
microorganisms such as bacteria, viruses, fungi and
parasites change in ways that render the
medications used to cure the infections they cause
1
ineffective.
AMR is a very serious threat of present time to the
human health security all over the world. It has been
reported against almost every anti microbial
discovered so far and in every country or community
on the surface of the globe. The antibiotic resistance
(ABR) shown by bacteria is more prevalent globally
and specially in low and middle income countries
resulting in devastating results. The WHO, in one of
the latest reports has described that globally 3.6% of
all new cases and 20.2 % of previously treated cases
of Tuberculosis (TB) are estimated to have multi drug
resistant TB (MDR‐TB) and on the average 9.7% of
these MDR‐TB cases are found to be extensively drug
resistant (XDR‐TB). Great concern has been aroused
by antibiotic resistance shown by particular bacteria
against specific antibiotic groups like methicillin
resistant Staphylococcus aureus (MRSA), the
extended spectrum beta lactamase (ESBL) producing
gram negative bacilli and cocci leading to resistance
against fluoroquinolones and 3rd generation
cephalosporins, carbapenemase producing
members of bacterial family enterobacteriaceae
becoming resistant to almost all antibiotics including
carbapenems, the last resort antibiotics for these
and NDM‐1 producing bacteria resistant to most
antibiotics except Polymyxin. The other emerging
threatening pathogens include 3rd generation
cephalosporin resistant Neisseria gonorrhoeae,
Vancomycin resistant Enterococci and Staphylococci,
multidrug resistant Salmonellae and Haemophilus
2
influenzae.
About 10‐17% of all new patients of HIV infection in
Australia, Europe Japan and USA are infected by virus
resistant to at least one antiretroviral drug.
Emergence of plasmodium falciparum resistant to
almost the last resort antimalarial named
Artemisinin is another dreadful threat. Similarly
antimicrobial resistance against antivirals like
adamantanes by influenza virus type A, and against
anti‐fungals like fluconazoles by candida is among all
2
types of antimicrobial resistances.
Out of the above mentioned list, almost every type of
antimicrobial resistance is present in Pakistan. But
the most devastating and alarming are MDR and XDR
Mycobacterium tuberculosis, Chloroquin and multi
resistant plasmodia, ESBL and carbapenemase
producing enterobacteriaceae, MRSA, Vancomycin
resistant Enterococci and Staphylococci and
3,4,5,6 multidrug resistant typhoid salmonellae.
Although sufficient numbers of comprehensive
studies covering all aspects of the additional
financial burden faced with infections by multi‐
resistant microbes are not found in medical
literature, yet the longer hospital stay, increased
hospital cost, and higher mortality have been
2,7
reported in various studies. However it is
confirmed that the increasing microbial resistance
has got great economic impact on the patient care
because 2nd and 3rd line regimens have been
reported to be 3 times and 18 times more expensive
8
respectively than the first‐line drugs. More
importantly, we are facing a global scenario where
sporadic antimicrobial resistance has been found
9
even to the last resort antimicrobials.
In 2009 a joint technical report presented a data of
financial impact of infections with multi resistant
bacteria and reported death of 25 thousand patients
who died in a year from infection by multi resistant
bacteria in European Union (EU), Iceland, & Norway.
In addition there were approximately 2.5 million
extra hospital days due to infection by these
organisms. The estimated financial burden both
direct and indirect due to antibiotic resistant
bacteria was found to be €1.5 billion (EURO) each
10
year in EU. Centre for disease control and
prevention (CDC) USA has cited a study of 2009
showing an estimate of as high as $20 billion in
excess as direct healthcare costs, and additional cost
to society for lost productivity as high as $35 billion a
year in USA as a result of infections by multi resistant
Departmetn of Microbiology
Islamic International Medical College
Riphah International University, Islamabad
144
JIIMC 2016 Vol. 11, No.4
11 bacteria. A recent study chaired by an economist
have estimated that if the ever increasing bacterial
resistance is not checked at this stage there would be
300 million deaths prematurely in the next 35 years
leading to economic loss of 60 to 100 trillion USD by
12 the year 2050.
Pakistan is one of the top 10 countries in the world
with high burden of tuberculosis. With an average of
510,000 new cases of tuberculosis including 26,000
cases of MDR TB and about 2,500 estimated cases of
XDR TB puts a huge economic burden for its
management and treatment in view of the estimated
per person treatment cost for TB ranges from 100 to
1,000 US dollars in susceptible infection and 2,000 to
20,000 dollars for MDR TB. Moreover the success
rate of TB treatment is up to 83% in susceptible
13
patients, 52% for MDR TB and 28% for XDR TB. This
shows that a very comprehensive infrastructure and
huge funds other than current international
donations are required to cope with the situation.
Similarly addition of 1.5 million cases of malaria
every year with about 12% of these caused by
Plasmodium falciparum and rest by P. vivax is a big
figure for consideration. The current eruption of
Chloroquin resistance in P. vivax can lead to a huge
6
burden on health care budget of the country.
A research report showing the total costs per malaria
episode (including direct and indirect household
costs and health system costs) based on disease
severity and the presence of complications and co‐
morbidities ranged from US$ 7.99 to $ 229.24 in
Ghana, from US$ 5.2 to $ 137.74 in Tanzania, and
14 from US$ 11.24 to $ 287.81 in Kenya.
Due to non availability of a comprehensive data the
financial burden due to infections by MRSA, ESBL and
carbapenemase producing organisms for our
country is difficult to calculate. We have compared
the cost of the antibiotics only for 10 days treatment
of a patient suffering from some systemic disease
caused by Escherichia coli sensitive to 3rd generation
cephalosporins and resistant to that and treated
with meropenem. The cost of antibiotics comes to Rs
7,500 ‐15,000 and 30,000 ‐60,000 respectively. This
example can show us how multi resistant organisms
can influence the health care budget of a hospital,
15 family and a country.
In view of above, there is an utmost requirement of
having serious considerations is planning and
execution of preventive measures against rapid
development & spread of AMR at individual,
hospital, community, national and international
level.
Abdul Bari Khan, Shahina Yasmin. (2016) Changing Patterns of Anti‐Microbial Resistance and Their Financial Impact on Patient Care, Journal of Islamic International Medical College, Volume-11, Issue-4.
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