10 Chapter 1 Antimicrobial resistance Antimicrobial resistance (AMR) has become a major global health threat over the past few decades, and its prevalence continues to increase worldwide (1). AMR is defined as any adaptation by a pathogen that renders an antimicrobial ineffective. Morbidity, mortality and healthcare costs attributable to AMR are increasing worldwide, as affected patients generally require longer and more frequent hospital admissions and more complex treatment (2). Studies have demonstrated that AMR-related mortality in Europe is higher than mortality due to human immunodeficiency virus, tuberculosis and influenza combined (3, 4). While it is a natural phenomenon for bacteria to become non-susceptible to antimicrobials, the (over)use of antimicrobials has accelerated this process and is now the major driver of AMR (5). Use of antimicrobials worldwide has increased to such an extent that we can now speak in terms of an AMR pandemic or silent or slow pandemic. The AMR pandemic exhibits similarities with the tragedy of the commons concept (6-9), a phenomenon whereby common resources that are unprotected by formal regulation tend to be depleted through unrestricted individual use. If users of such resources act to maximize their self-interest and do not coordinate with others to maximize the overall common good, the result may be exhaustion or even permanent destruction of the resource if the number of and demand from users exceeds availability (10). This concept is to a certain extent applicable to the development of AMR, as antimicrobials are widely available, easily accessible and available in some pharmacies without a physician prescription, factors that together result in often uncontrolled overuse. From a broader perspective, AMR is the basis of a classic example of a conflict between personal versus common interest, and between current versus future generations. For the individual patient, use of antimicrobials can be easy and helpful and is unlikely to cause side effects. However, in the long term other patients will suffer from infections caused by resistant bacteria (11). The high prevalence of AMR has resulted in many antimicrobials becoming less and less effective, which in turn leads to increased prescribing of broad-spectrum antibiotics by physicians. In countries with a high prevalence of AMR, physicians often assume drug-resistant micro organisms are at play when treating bacterial infections. This further encourages the prescribing of broad-spectrum antimicrobials, often supported by guidelines advising this course. This relatively uncontrolled spiral of increasing prescription of more and broader spectrum antimicrobials will eventually reach a tipping point beyond which few antimicrobials remain suitable for empirical use. This
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