Antibiotic (or antimicrobial) resistance developed with the wide distribution of antibiotic medications in the 20th century. Resistance occurs when the medication is no longer capable of killing or preventing the reproduction of bacteria. A major global health challenge, antibiotic resistance makes treating diseases more difficult and expensive, and it results in fewer antibiotics that are effective in managing infectious diseases. Rates of antibiotic-resistant infections are rising in Canada. In hospital settings, infections that resist multiple drugs are also becoming more common. In 2019, an expert panel of the Council of Canadian Academies estimated that resistant infections contributed to more than 14,000 deaths in Canada the previous year. Canadian health agencies, medical professionals and industries are active in multiple efforts to combat this problem.
The bacteria in the culture on the left are sensitive to the antibiotics contained in the white paper discs. The bacteria on the right are resistant to most of the antibiotics.
Canadian Institutes of Health Research (CIHR): Canada’s major federal funding agency for health research. It is an independent agency, accountable to Parliament.
G7 countries: The seven countries that represent the largest industrialized economies: Canada, France, Germany, Italy, Japan, the United Kingdom and the United States.
Pathogen: A disease-causing agent such as a bacterium or virus.
World Health Organization (WHO): An agency of the United Nations that was established in 1948 to promote health and control communicable diseases. There are 194 member states, countries that are members of the United Nations that have signed the WHO constitution.
How Were Antibiotics Developed?
Medical knowledge of antibiotic medicine was first developed in the 1920s. Although French scientist Paul Vuillemin was the first to use the term antibiotic in 1889, it was Scottish physician Sir Alexander Fleming who discovered the first antibiotic based on the finding that bacteria did not develop when the mold penicillium was present. In 1928, he became the first to isolate and extract the active ingredient from the mold. By the end of the Second World War, the antibiotic medication penicillin was widely available.
After the war, many types of antibiotic medications were developed as pharmaceutical research in the field expanded. These medicines helped treat many diseases that had caused severe sickness or even death (such as tuberculosis) and common illnesses (such as severe ear infections). Antibiotics also made new medical treatments possible. For example, organ transplantation, which reduces the patient’s immune response, requires antibiotics to prevent infection.
By 1959, antibiotic resistance had been scientifically documented.
Rifampicin capsules are used in the treatment of tuberculosis and leprosy.
How Are Antibiotics Used?
Antibiotics treat infections caused by bacteria and other micro-organisms; they are not effective against viruses. People often mistakenly believe that antibiotics will cure viral infections such as the common cold or influenza. This belief leads them to pressure their doctors to prescribe antibiotic medication when it is not recommended.
Patients should take the correct dosage and the entire course of antibiotic medication that their doctor prescribes. This helps prevent the growth of antibiotic resistance and increases the chance that the treatment will be effective.
What Causes Antibiotic Resistance?
Bacterial organisms have a short life cycle and continually adapt to their environment. The inappropriate use of antibiotics causes the weak bacteria to be killed, but the stronger bacteria survive and multiply and may become resistant. Bacteria that develop resistance to one antibiotic may also become resistant to others, which is known as cross-resistance. Cross-resistant bacteria can make it especially difficult to treat some common infectious diseases.
The inappropriate use of antibiotics, including their overuse, has contributed to the development of bacteria that are resistant to many different antibiotic medications. Factors that contribute to resistance include misdiagnosing bacterial infections, prescribing ineffective drugs for pathogens (e.g., prescribing an antibiotic for a virus) and not following the medication instructions or not taking the full prescription. The practice of disposing of antibiotics in toilets can contribute to the spread of resistant bacteria through waste water treatment systems.
In Canada, antibiotic medications are subject to strict regulation and enforcement. In countries that lack such controls, quality antibiotic medications are harder to access. A lower-than-required level of active ingredients in medication contributes to the development of resistance because the bacteria are not killed.
Poor sanitation, hygiene and food preparation standards increase the risk of resistant infections because people are exposed to potentially infectious agents in unclean or raw food. For example, Escherichia coli (E. coli) — extremely common bacteria that live in the gut of humans and animals — can both cause illness and transmit resistant genes to other types of bacteria (see also E. coli Infection in Canada).
What Role Does Agriculture Play in Antibiotic Resistance?
Livestock are an additional factor in antibiotic resistance. Animal feed is often supplemented by vitamins, nutrients and antibiotics. Food crops sprayed with chemicals that include antibiotics can promote resistance. These antibiotics can be transferred to humans through the food chain and can make it more difficult to treat antibiotic-resistant organisms. (See also Agriculture and Food.)
Sustainable animal agriculture plays an important role in reducing resistant infections. The Canadian agriculture sector focuses on the appropriate use of antibiotic medications. Its industries have implemented reforms first introduced in Europe to reduce antibiotic use. For example, in 2014, Canadian poultry producers eliminated the preventative use of one class of antibiotics.
Practices vary in other parts of the world. For example, antibiotics are used as a growth stimulant in healthy animals in some countries, and this increases the development of resistance. The spread of resistant infections in livestock can cause negative economic and health effects. Farmers may not be able to afford the treatment, resulting in poor animal welfare and lower income for farms (see also Animal Issues). Additionally, people who work with animals may be exposed to resistant infections.
What Types of Bacteria Are Resistant to Antibiotics?
People are exposed to resistant bacteria in the same ways they are exposed to non-resistant bacteria: through contact with infected animals or people, contaminated food or water, unsafe sexual practices and hospital or clinical settings.
The presence of resistant bacterial organisms can make otherwise readily treatable diseases such as strep throat (caused by a Streptococcus bacterium) untreatable. Other resistant organisms that cause infections include Staphylococcus. In Canada, there was an eight-fold increase in methicillin-resistant Staphylococcus aureus, or MRSA, in hospital patients between 1995 and 2012. Certain strains of Staphylococcus have become resistant to all known antibiotic drugs.
In rare cases, species of both these bacteria may lead to skin death (necrotizing fasciitis). A prominent victim of necrotizing fasciitis, commonly known as flesh-eating disease, was former Quebec premier Lucien Bouchard, who developed the infection from Group A Streptococcus. Doctors were forced to amputate a portion of his left leg to prevent the gangrene from spreading further.
Diagram showing the difference between non-resistant bacteria and resistant bacteria.
Global Health Challenge
Antibiotic resistance is a major global health challenge. The risk is greatest for people living in poverty and in unsanitary conditions.
Antibiotic resistance threatens to devastate healthcare systems by making low-cost medications unusable while making more effective antibiotics too expensive. Resistance also impacts national and even global productivity, as illness forces people from the labour force and leaves them with less income to put back into the economy.
In 2015, the Organisation for Economic Co-Operation and Development estimated that about 50,000 people in Europe and North America die each year as a result of antibiotic resistance. The death toll in developing countries is difficult to know, as resources for tracking and reporting on deaths from antibiotic resistance vary greatly. Many countries do not have the resources needed to provide such data.
In 2015, half of the human infections in G7 countries were resistant to routinely used antibiotics. That same year, the World Health Organization (WHO) developed a global action plan on antimicrobial resistance. The WHO takes a “One Health” approach that identifies solutions at the intersection of human, animal and environmental health. Its focus is to prevent the need for antibiotics by encouraging good sanitation and hygiene, as well as safe food preparation. The global action plan defines the best use of antibiotics and provides tools to guide their use in human and animal health. It also recognizes the need for some countries to develop laws, regulations and enforcement regarding prescription medications.
Canada is actively contributing to multiple efforts to reduce the impact of this problem around the world. Canada committed financial and research support to implement the WHO action plan across sectors and developed a domestic plan that addresses uniquely Canadian challenges. (See What Is Canada Doing to Combat Antibiotic Resistance?)
Rates of Antibiotic Resistance in Canada
A 2019 report by an expert panel of the Council of Canadian Academies put the rate of resistance to first-line antimicrobials at 26 per cent in Canada. In other words, one in four infections is resistant to the first drug prescribed to treat it. The panel also found it “highly plausible” that the resistance rate will rise to 40 per cent by 2050.
The rate of antibiotic-resistant infections is higher than in past decades. For example, rates of gonorrhea, a sexually transmitted infection, surged by 43 per cent from 2004 to 2013, and half of gonorrhea cases are resistant to at least one of the two antibiotics commonly used to treat the infection in Canada. Rates of resistance to gonorrhea medications are higher in Canada than in the United States and the United Kingdom.
Did you know?
Surveillance data suggest that the number of prescriptions for antimicrobials in Canada has been relatively stable since 2002. Until recently, however, only prescriptions in hospitals and long-term care facilities have been reliably tracked. Fewer data are available from community and clinic settings, where 80 per cent of antibiotics are prescribed.
Where people live can impact their exposure to antibiotic-resistant organisms. Some northern communities experience higher rates of resistance than are typically found in southern regions. Overcrowded living conditions, inappropriate prescribing practices, exposure to people with infections and exposure to healthcare workers are some contributing factors. Researchers are working with community leaders, health workers and medical professionals in the North to monitor the rates of resistant infections and improve care for affected people.
What Is Canada Doing to Combat Antibiotic Resistance?
Health Canada and the Public Health Agency of Canada support several research initiatives, including the Canadian Integrated Program for Antimicrobial Resistance Surveillance (CIPARS). Through CIPARS, Canada is developing and improving strategies to gather data and monitor infection rates.
Federal funding for research and innovation comes from an independent government agency, the Canadian Institutes of Health Research (CIHR). Between 2011 and 2016, Canada invested more than $96 million in antimicrobial research at CIHR. The agency launched an international program in December 2018 to help identify, diagnose and detect antimicrobial resistance in humans and animals.
Working with international governments, Canada’s federal agencies and medical community are developing consistent policies to help prevent the growth and transmission of resistant bacterial organisms in Canada and around the world. Canada has established international research partnerships with the United Kingdom and the European Union to study multiple ways of combatting resistance.
Provinces and territories have hospital-based programs, immunization programs and campaigns to build community awareness. One example was the Northern Antibiotic Resistance Partnership, sponsored by the federal government and the University of Manitoba, which brought together communities in northern Saskatchewan to address antibiotic resistance. Its tools included a program to teach school-age children how germs are spread and how to prevent them from spreading. The partnership developed radio broadcasts for the general public in English, Cree and Dene about the importance of hand washing, caring for skin and soft tissue infections and taking the entire course of prescribed antibiotics.
Experts point to the need for more comprehensive surveillance data on resistant infections across the country. The lack of such data is a barrier to launching well-targeted responses to resistance.
Development of New Antibiotics
In recent years, pharmaceutical companies have not been researching new medications to fight the organisms that currently resist antibiotics. A new class of antibiotics has not been developed since 1987. This type of investment is not considered profitable enough, because restrictions on antibiotic use limit the amount of medication that drug companies can sell.
The WHO suggests that new incentives are needed to drive necessary research on new classes of antibiotics. Ideas to promote investment in antibiotic research include private-public partnerships, where the cost is shared between industry, governments and governmental organizations.