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The spread of SARS-CoV-2, the virus that causes Covid-19, has shown only too well how quickly infectious agents can move around the world. Although increasing antibiotic resistance and Covid-19 are not directly linked, there is a serious consequence for human health, since many of our last-resort antibiotics are critical to saving patients with secondary infections that can cause death.



This may drive the next major pandemic, as it exemplifies the significant chance that our suite of current antibiotics will fail to combat many new biological infections, including ones that might spread globally.



Tackling antibiotic resistance



Newcastle University's Professor David Graham, an environmental engineer who has spent almost 20 years studying the environmental transmission of antibiotic resistance around the world, has contributed to new recommendations for tackling the environmental spread of antibiotic resistance, published jointly in 2020 by the World Health Organisation (WHO), Food and Agriculture Organisation (FAO), and the World Organisation for Animal Health (OIE).



Local "hot-spots" of antibiotic resistance are known to exist around the world, particularly in densely populated regions with inconsistent sanitation and poor water quality. The new guidance, which has since been translated into six languages, provides a framework for countries to create their own locally driven national action plans.



It centres around growing evidence, including research at Newcastle University, which suggests the problem of increasing antibiotic resistance will not be solved by prudent antibiotic use alone and improving environmental quality around the world may be of equal or greater importance.



The research



Commencing with work analysing antibiotic resistance in water samples from the Ganges River near human pilgrimage sites, Professor Graham's team and colleagues at the Indian Institute of Technology, Delhi, extended their research to a range of other locations and environmental contexts, including solid waste landfills in China, aquaculture facilities in Thailand, soils near the North Pole, and wastewater treatment plants and networks in many countries.



This suite of work showed that not only does environmental resistance exist around the world, but that the main driver is local antibiotic resistance evolution and spread differs from place to place. It highlighted that antibiotic-resistant genes can move fast between microbes and through many pathways, even to places where antibiotics functionally are not present, such as in polar regions, considered to be the last 'pristine' places on earth.



Finding a solution



"The only way we are going to win the fight against antibiotic resistance is to understand and block the environmental and other pathways that lead to spread," explains Professor Graham. "Our work has shown that although the types and drivers of resistance are diverse and vary by region and country, there are common roots to its spread such as inappropriate antibiotic use in medicine and agriculture, industrial pollution, and inadequate sanitation, resulting in poor water quality.



"There is no such thing as a cookie-cutter solution – each country needs to have its own plan for preventing and addressing the spread of antibiotic resistance that considers that country's particular situation.



"This means rapidly improving waste management, sanitation, and water quality on local and global scales – especially in emerging and developing countries where the social impacts of resistance are often the greatest – otherwise antibiotic resistance will continue to increase, making the next pandemic even worse."



Professor Graham's recent work with the UN Environment Programme, which led to the seminal 2023 report "Bracing for Superbugs: Strengthening environmental action in the One Health response to antimicrobial resistance", shows the scale of the global problem. This report, which Graham was a co-lead author, recommends prevention of antibiotic resistance at its root and increased integrated surveillance across sectors (a One Health approach) as the two critical actions needed to start winning the fight against antibiotic resistance.



This includes using antibiotics more prudently in every context, but also encouraging governments and public health and other authorities to move towards more locally suitable actions, such as towards local, low cost, easily deployed, yet high impact solutions for human waste management.



Central to this is the importance of greater international co-operation to bring about improved water, sanitation and health (WASH) provision as a way to prevent the next global pandemic.



"Once improved sanitation and hygiene exist at global scales, as well as fairer access to clean water, our reliance on antibiotics will decline," says Professor Graham.