Last week, LSHTM hosted a lecture on AMR in low and middle income countries (LMICs) from Professor Chris Whitty, Chief Scientific Advisor to the Department of Health and Social Care, and who from October will be the Chief Medical Officer (CMO) for England, and the UK Government’s Chief Medical Adviser.

With all available seats taken, and crowds building at the back of the Mason Lecture Theatre, Professor Whitty set out specific AMR problems that could potentially be controlled with greater cross-learning between the ways different infectious diseases have been addressed in LMICs.

Prof. Whitty started with the group of infections (mainly parasitic), where patients are only given a drug if there is a firm diagnosis (due to toxicity or cost) and resistance testing is lacking. If drug resistance occurs in this situation, then alternative drugs are needed. Thankfully, even though Human African Trypanosomiasis and Leishmaniasis commonly effect poorer populations, there are a number of drugs in the development pipeline. This is not the case with antibiotics. Prof. Whitty asked the question, why have public-private partnerships worked for drug discovery of these diseases (and malaria), but not for diseases caused by bacteria?

Secondly, resistance may be mitigated for some infections via aetiological testing. However, while the scale up of rapid diagnostic tests (RDTs) has improved malaria diagnosis in public sectors, this has come with a number of challenges and consequences that must be considered for diagnostics for bacterial diseases. Furthermore, while malaria RDTs detect a specific pathogen response, tests proposed to distinguish bacterial from other causes of disease that are markers of severity may gain little compared with clinical presentation. Thus, Prof. Whitty suggested that RDTs might not be the panacea that they are hoped to be and should be designed-into systems with care.

The third issue addressed was patients whose management requires a diagnosis together with drug resistance profile of their infections. Using the example of Tuberculosis (TB), Prof. Whitty suggested that we do have the ability to detect resistance early on in order to change how we treat TB, but in most cases, this rarely takes place. This can be seen with low levels of resistance testing for rifampicin, outside of Europe and parts of the Americas. Prof. Whitty suggested that the reason behind this is cost, and the need for advanced microbiology services to be available.

Finally, Prof. Whitty spoke about the largest and potentially most complex issue of outpatient non-malarial febrile illnesses, where there is an important gap in accurate diagnosis and drug resistance testing. By weight, this is the problem in which the greatest number of antimicrobials are given. Prof. Whitty commented that while antibiotic resistance is rising across the world as a proportion of infections, this is coupled with a reduction in the overall incidence of severe infections. He cautioned that the burden of these severe infections where antibiotics are likely to fail falls upon the poorest and most immunocompromised, and therefore that restriction models of prescription-only antibiotics will only further the challenge of treatment for this group. Instead, Prof. Whitty proposed learning from other disease groups in managing antibiotic use at a meta level – such as rotation of antibiotics and combination with other drugs. He highlighted that we need to understand more about the reversal of resistance in different bug-drug relationships, and further restrict access to second line drugs, which could be given under prescription in combination with other drugs.

Prof. Whitty concluded by recommending that first and foremost we need to work on preventive interventions that reduce the incidence of infections, predominantly by increasing levels of sanitation and vaccination. This would be a double-win, as it is likely this would cause reductions in the number of people dying from drug-resistant infections and would help reduce pressure to treat infection with empiric antibiotics. Equally, we need to manage co-factors such malnutrition and HIV, to reduce the burden of infectious disease on those who are immunosuppressed in LMICs and for whom AMR is the greatest burden.

Everyone at Antimicrobial Resistance Centre at LSHTM, would like to thank Professor Whitty for his fascinating lecture, and wish him all the best in his new role