According to a recent publication in the Proceedings of the National Academy of Science, global antibiotic consumption in humans has increased dramatically from 2000 to 2015. The study rings a bell on the complex challenges posed by underuse, misuse and overuse of antibiotics. While reducing unnecessary and inappropriate use of antibiotics is key, a balanced approach should be struck between increasing access to antibiotics and implementing stewardship programs to ensure equitable and sustainable access in low- and middle-income countries (LMICs). Despite the increase, the average antibiotic consumption rate in LMICs is still far below that of high-income countries (HICs).
A group of international researchers led by the Center for Disease Dynamics, Economics and Policy analyzed pharmaceutical sales data in 76 countries over 16 years to assess the antibiotic consumption trends. The global antibiotic consumption estimates, expressed in defined daily doses (DDD), showed a 65% increase in antibiotic use globally, from 21.1 to 34.8 billion DDDs over the 16-year period assessed. Between 2000 and 2015, the antibiotic consumption rate was shown to have increased from 11.3 to 15.7 DDDs per 1,000 inhabitants per day.
The study findings suggest that the global increase in antibiotic use was primarily driven by rising antibiotic consumption in LMICs and that antibiotic consumption rate in LMICs has been converging towards HIC levels over the study period. Their data showed a 115% increase in total antibiotic use and a 78% increase in consumption rate in LMICs from 2000 to 2015.
Limitations in using sales data
A major caveat in using pharmaceutical sales data is that they may not reliably capture the real situations in LMICs where various routes of antibiotic sales are not well monitored and documented. If many sources of sales are missed in acquisition of the data, they are likely to cause a systematic bias in the database leading to underestimation of the use. The limitations on data were duly noted in the publication, and despite the mentioned shortcomings, sales data are the best data currently available. This may change however, as countries including LMICs are starting to enroll into the Global Antimicrobial Resistance Surveillance System (GLASS), which aims to strengthen data collection, including on use and consumption of antibiotics, in the future.
LMICs represent a larger population that suffer under a higher burden of infectious diseases
The shown increase in antibiotic consumption should also be tempered against the fact that LMICs represent a larger population that suffer under a higher burden of infectious diseases than HICs. The increase in antibiotic use in LMICs from 2000 to 2015 was partly due to a previous lack of affordable access to essential lifesaving antibiotics and as a consequence, significant underuse in these countries. The study recognizes that the average antibiotic consumption rate in LMICs is still far below HICs (see Figure 1 below).
Antibiotic consumption correlates with the growing gross domestic product per capita in LMIC
The researchers found that the rising antibiotic consumption rate was positively correlated with the growing gross domestic product per capita in LMICs. Today, global lack of access to essential antibiotics still causes more deaths than resistance. The findings of the study imply that antibiotics and other essential elements in healthcare continue to be unaffordable for many people in LMICs and illustrate the problem of underuse. The overall antibiotic consumption will – and should – rise when more people are able to afford diagnostics and treatment to compensate for the previous underuse. The challenge is to ensure that sustainable access can happen while at the same time reducing misuse.
Improved antibiotic access in LMIC a necessary step
It is critical to acknowledge that improved antibiotic access in LMICs is a necessary step along the pathway towards the universal healthcare coverage. Investing in improving infection prevention and strengthening health systems in these countries is crucial, and includes improved immunization, clean water, sanitation and hygiene. Improvement in diagnostic capacity and implementation of stewardship programs in healthcare are equally critical to ensure sustainable access to effective antibiotics, in LMICs and HICs, now and in the future.