Antimicrobial resistance and pneumonia

18 Nov Antimicrobial resistance and pneumonia

Pneumonia is the leading infectious cause of death in the world. An estimated 2.5 million people died from pneumonia in 2019 and COVID-19 deaths more than doubled the annual death toll from respiratory infections to 6 million in 2021. While many pneumonia deaths are from bacterial and other causes that can be prevented with greater access to antimicrobials, especially among children, there is a large and growing number of deaths due to antimicrobial resistance.

How many? New Global Burden of Disease (GBD) estimates concluded that there were 1.3 million deaths directly attributable to antimicrobial resistance and 5 million associated deaths. Pneumonia accounted for more than 400,000 attributable deaths and 1·5 million associated deaths, making it the most burdensome infectious syndrome.

The good news is that increasing coverage of the highly effective vaccines that target the leading bacterial causes of pneumonia (e.g., Hib and pneumococcal) are reducing the incidence of bacterial pneumonia and the need for antibiotics, especially among children and adults. Recent studies have revealed that the largest proportion of childhood pneumonia cases and deaths across many low-resource settings are now from viral causes, especially Respiratory Syncytial Virus (RSV). This is also true for adults, especially older adults.

But 40% of the world’s children still don’t get pneumococcal vaccines and are dangerously exposed to pneumonia and dependent on antibiotic treatment – if they can access it. According to the new GBD estimates, most of these children live in the areas where pneumonia deaths from antibiotic resistance are concentrated – Sub-Saharan Africa and Asia. There are 21 countries that don’t yet offer the pneumococcal vaccine for children in these two regions. Pneumococcal vaccine coverage is also extremely low among adults in all settings.

In many of these under-vaccinated populations of children and adults, widespread use of antibiotics is well documented (e.g., Haiti, Kenya, Malawi, Namibia, Nepal, Senegal, Tanzania, Uganda, China, and more). Some experts even argue that current World Health Organization (WHO) pneumonia management guidelines are contributing to over-prescription of antibiotics and resistance.

The challenge is how to reduce inappropriate use of antibiotics for the treatment of pneumonia and close any remaining access gaps for pneumonia patients, especially children and older adults, who are missing out, without triggering further waves of antimicrobial resistance. During World Antimicrobial Awareness Week, the Every Breath Counts Coalition is calling on governments and global health agencies to take seven actions to reduce antibiotic overuse in the treatment of pneumonia especially among children and older adults, by:

1. 1. 1. Accelerating coverage of the vaccines that target the leading bacterial causes of pneumonia among children and older adults (pertussis, measles, Hib, and pneumococcal) to above 90% in every nation (and 80% in every district);
      2. Introducing vaccine schedules that limit transmission of pneumonia among children and older adults for longer periods of time (e.g., boosting older children) as per recent studies from Malawi and Somaliland;
      3. Increasing the proportion of children and older adults with pneumonia symptoms who see a healthcare provider trained in the rational use of antibiotics in the public and private health sectors;
      4. Developing new, affordable diagnostic tools that can differentiate between bacterial and viral causes of pneumonia and facilitate their wide adoption at all levels of health systems (this should include the adoption of pulse oximetry which has been found to curb the distribution of antibiotics in low-resource settings);
      5. Ensuring a steady supply of quality, affordable and WHO-recommended antibiotics for adults and children (e.g., child-friendly amoxicillin in dispersible tablet form) including by co-financing their distribution with international donors and implementing agencies in specific low-resource settings as recommended by Results for Development;
      6. Adopting a robust indicator to measure antibiotic treatment coverage by children with WHO-defined pneumonia (e.g., the % of children with a diagnosis of pneumonia who completed the recommended dose of antibiotics, by type of antibiotic) in Multiple Indicator Cluster Surveys (MICS), Demographic and Health Surveys (DHS), and other information collection tools routinely used by health authorities and introducing indicators that measure access to pneumonia treatment among adults in low-resource settings; and
      7. Supporting a WHO review of the current definition of pneumonia in children to measure its impact on antibiotic overuse and resistance and recommend changes that would reduce the risk of antibiotic overprescription as a result of the WHO guidelines, including by reducing the recommended duration of antibiotics treatment for non-severe pneumonia to three days, as recommended in a number of recent review and other studies, and initiating a WHO review of the current state of antibiotic resistance among older patients with pneumonia in member states.

These key actions should form part of national and international efforts to reduce all-cause pneumonia mortality and antimicrobial resistance, and both communities of practice should work together to measure progress to these seven actions. It is important to remember that we are still losing an estimated 672,000 children to pneumonia each year and the world is not on track to achieve the global target of less than three child pneumonia deaths per 1,000 births by 2025. As a result, 54 countries are at risk of failing to achieve the Sustainable Development Goal (SDG) for child survival by 2030. And the pandemic has dramatically increased the number of adults dying from pneumonia in almost every country.

At the same time the scourge of antimicrobial resistance threatens to derail one of our most powerful public health tools and unleash a massive burden of death. Our collective challenge is to adopt public policies and develop new tools that can reduce antimicrobial resistance and close remaining antibiotic access gaps for the populations most vulnerable to pneumonia at the same time.  

In support of World Antimicrobial Awareness Week (WAAW) 

November 2022