Addressing Antimicrobial Resistance for Better Cancer Care Outcomes

Antimicrobial Resistance

Addressing Antimicrobial Resistance for Better Cancer Care Outcomes

Antimicrobial Resistance Fighter Coalition

2/1/2023

The emergence of antimicrobial resistance (AMR) poses a serious and growing threat to global health. According to the World Health Organization, if not addressed, AMR could cause 10 million deaths and up to $100 trillion in economic damage by 2050.

This is especially concerning for cancer patients, who are particularly vulnerable due to their weakened immune systems, increased risk of infection from medical devices, and reliance on antimicrobials for treatment. The misuse and overuse of antimicrobials have been identified as key factors contributing to the increase in drug-resistant pathogens, making it critical that we take steps towards better cancer care outcomes by addressing AMR.

There is no single solution to the AMR crisis, and it needs to be addressed at every level of healthcare delivery — from policymakers working on national strategies and regulations to medical professionals prescribing antibiotics, to individual patients understanding when it is appropriate to take them.

A multi-layered approach that focuses on preventive measures such as:

improved hygiene practices

responsible stewardship of antimicrobial medicines by healthcare providers

increased research into new treatments, and

better management of cancer patients’ overall health will all play a role in reducing AMR.

In 2019, the Union for International Cancer Control (UICC) assembled a task force composed of experts from both infectious disease and cancer communities to design solutions for AMR’s impact on cancer care outcomes. This included a special supplement created by UICC in collaboration with Global Health Dynamics, which serves as an important reference resource for policymakers concerning antimicrobial resistance and cancer care outcomes.

Furthermore, in September 2016, the High-Level Meeting (HLM) at UN General Assembly pledged to collaborate on strategies to combat AMR. This is incredibly encouraging news for advocates aiming to make strides toward understanding this global crisis, as another HLM will take place in 2024. Now more than ever, it’s imperative we join forces and bring attention to this important cause.

Five barriers to addressing antimicrobial resistance

To guarantee safe cancer care outcomes, it is essential that we confront the five major roadblocks of antimicrobial resistance.

Firstly, enhancing public awareness about AMR and its potential consequences is critical for meaningful progress. This includes educating individuals about effective hygiene practices, responsible use of antibiotics, and making the general public more aware of the dangers posed by AMR — particularly to cancer patients.

Secondly, understanding that there is difficulty in defining clear solutions due to the complexity of healthcare systems and the numerous factors contributing to drug resistance. Not only is it complex to accurately pinpoint the source of AMR, it is also difficult to design a specific policy solution for how best to combat it. Without a thorough understanding of how these factors interact, it can be challenging for policymakers and healthcare providers to create effective plans that address AMR from all angles.

Thirdly, there is an absence of visual indication when addressing AMR. This makes it hard for policymakers and stakeholders at all levels to respect the seriousness of the situation concerning its impact on global health. Compared to other pandemics and fatal illnesses, such as HIV/AIDS, antimicrobial resistance is largely an invisible crisis.

Fourthly, emerging economies lack proper access to antimicrobials, and even worse, there is a severe deficiency in monitoring the success of AMR policy implementations. According to the AMR Control Supplement, millions of dollars have been allocated to raise awareness about the antimicrobial crisis and develop new financial incentives for research. Yet it is difficult to determine how successful those investments are in improving the proper use of antibiotics, causing an ongoing debate concerning the links between health programs and effective antibiotic usage.

Lastly, a lack of economic incentives exists for pharmaceutical companies to develop new antibiotics. The World Health Organization (WHO) recently reported that the pipeline for novel antimicrobials is in a drought-like state.

“The clinical pipeline of new antimicrobials is dry.” (Source: WHO)

In 2019, the WHO revealed that of the 32 antibiotics they have identified in clinical development since 2019, only a meager six were categorized as “innovative.” In addition, access to quality antimicrobials is still a huge problem. The scarcity of antibiotics has impacted nations in every stage of development, particularly in healthcare systems.

Ultimately, all five of these barriers must be addressed if we are going to make tangible progress in tackling antimicrobial resistance and reducing its effects on cancer care outcomes.

The impact of AMR on cancer care

Antibiotic resistance is developing and spreading at an alarming rate – partly due to overuse and misuse across all One Health sectors (human, animal, and environment) – threatening to decline the health and economic benefits of antibiotics.

Resistance to antibiotics endangers the efficacy of modern health care, with fatal outcomes for cancer patient populations, such as the close to 10 million people each year (and rising!) who receive chemotherapy for cancer as a first-line treatment.

Cancer patients are 3x more likely to die of infections than noncancer patients. Over one-third (36%) of cancer patients will require surgery, often multiple times, with approximately 5% of these patients developing drug-resistant infections. Following chemotherapy, it is estimated that over 26.8% of pathogens triggering infections become resistant to the standard antibiotics used for prevention.

By 2030, it is anticipated that three-quarters of cancer deaths will be in low- and middle-income countries (LMICs). LMICs also have the highest burden of drug-resistant infections. These forecasts do not bode well and clearly shows that antibiotics remain an integral part of providing quality care to cancer patients.

There is not a lot of research that looks at how much money AMR costs for cancer care. However, it’s expected that expenses will grow as treatment costs and lengthier hospital stays continue to rise. For example, patients suffering from head and neck cancer typically have hospital stays that are 3x longer when they become infected with methicillin-resistant Staphylococcus aureus (MRSA). Without efficient antibiotics to protect against the threats of dangerous infections, progress in patient care will be severely hindered.

Antimicrobial stewardship and optimizing antimicrobial use in the cancer community

The World Health Organization (WHO) outlines antimicrobial stewardship (AMS) as a set of actions that emphasize the appropriate and responsible use of antimicrobials, with the goal of optimizing patient outcomes across all stages of care.

“The policy promotes an integrated approach to preserve antimicrobials and seeks synergy and efficiency for the implementation of comprehensive interventions across essential areas of the human health sector at all levels.” (Source: WHO policy guidance on integrated antimicrobial stewardship activities)

The antimicrobial stewardship (AMS) strategy is a comprehensive approach to curbing the emergence and transmission of antimicrobial resistance, such as:

better-governing antimicrobials

facilitating and regulating access

raising awareness on addressing AMR responsibly

improving infection prevention protocols; and

surveillance strategies concerning AMR and antimicrobial use.

AMS is a means to preserve the effectiveness of antibiotics by ensuring that they are used appropriately and responsibly. This is especially important in the cancer care setting, where antibiotics are essential to treating infections.

The WHO AWaRe (Access, Watch, Reserve)

In May 2015, the World Health Assembly adopted a global action plan on AMR. All antibiotics on the WHO Model List of Essential Medicines (EML) were reviewed, determining first and second-choice options for 34 infections in primary health care and hospitals.

In the context of the global action plan, the AWaRe (Access, Watch, Reserve) classification of antibiotics was introduced in 2017 as a stewardship tool to classify antibiotics according to their potential for resistance:

Access antibiotics have a limited range of activity, lower cost, a good safety profile and generally low resistance potential. They are recommended as empiric first or second-choice treatment options for common infections. Examples of Access antibiotics include penicillin, amoxicillin and gentamicin.
Watch antibiotics are broader-spectrum antibiotics, generally with higher cost and toxicity, and are recommended only as first-choice options for patients with more severe clinical presentations or for infections where the causative pathogens are more likely to be resistant to Access antibiotics (e.g., upper urinary tract infections). Examples of Watch antibiotics include ciprofloxacin, ceftriaxone and azithromycin.
Reserve antibiotics are last-choice antibiotics used to treat infections caused by multidrug-resistant (MDR) bacteria. Examples of Reserve antibiotics include ceftazidime and avibactam, colistin and linezolid.

WHO’s AWaRe classification tool supports AMS efforts at the healthcare facility level by classifying antibiotics into Access/Watch/Reserve groups based on their impact on resistance and the importance of appropriate use.

Conclusion

AMR is a public health issue that needs urgent attention, especially within the cancer community. The significant and growing threat of AMR is undermining key advances being made in cancer care by adversely affecting cancer treatment outcomes and threatening the survival of people living with cancer.

Infection prevention and antimicrobial stewardship are important in cancer care, as antibiotics are essential to treating infections.

WHO’s AWaRe classification tool can help healthcare facilities classify antibiotics into Access/Watch/Reserve groups based on their impact on resistance and the importance of appropriate use. This classification system helps ensure that antimicrobials are used responsibly and appropriately in cancer care settings, which will help to preserve the effectiveness of antibiotics for future generations. With efficient antibiotic usage, patients will have better outcomes and shorter hospital stays while reducing the risk of emerging drug-resistant infections.

By promoting AMS strategies, cancer care providers can help reduce the risk of antimicrobial resistance in cancer patients and ultimately improve patient outcomes.

To learn more about how antimicrobial resistance affects cancer, listen to the podcast Superbugs and You - Episode 7: Silent superheroes — antibiotics in the fight against cancer. In this episode, you will hear directly from a patient who had a resistant infection while fighting cancer, from front-line clinicians, and from a researcher driving policy at a national level.