Strategies to combat antimicrobial resistance (AMR) in low-resource settings

By Serene Inulia Kong Kwai Yan

Antimicrobial resistance (AMR) poses a global health threat. It occurs when microorganisms (bacteria, viruses, fungi or parasites) resist the effects of standard medicines used to treat them, leading to inability to treat the cause of infection. These resistant pathogens can infect both people and animals, to the point that there are no more antibiotics doctors can use to treat infections caused. [1] While AMR is a worldwide issue, it disproportionately impacts low-resource settings, where fragile health systems, limited resources, and inadequate sanitation amplify its effects. Addressing AMR in these regions requires targeted, cost-effective strategies tailored to their unique challenges.

Drivers of AMR in low-resource settings

Firstly, poor infection prevention and control (IPC) can contribute to the spread of healthcare-associated infections (HAIs), often caused by AMR germs. For instance, the lack of access to clean water, sanitation, and hygiene (WASH) within healthcare facilities can incubate deadly pathogens. Moreover, improper disposal of waste from pharmaceutical industries and hospitals can release significant amounts of antibiotics and other drugs into the environment, encouraging the selection of resistant strains in natural microbial communities. [2]

Additionally, overuse and misuse of antibiotics can promote AMR, due to selective pressure, genetic changes and transfer of resistant properties. For example, methods to accelerate growth adopted by agricultural industries, such as using antibiotics and pesticides, to meet high food consumption demands, can create resistant strains of bacteria or pests. [3] According to the Centers for Disease Control and Prevention (CDCD), about one-third of antibiotic use in people is not needed nor appropriate. [4]

Moreover, limited diagnostic capabilities, without systems or molecular methods that can quickly identify pathogens and conduct antibiotic susceptibility testing (AST) in LMICs can lead to inappropriate antibiotic use. Without knowing the specific bacterium that's causing infection, healthcare providers may resort to broad-spectrum antibiotics, further driving resistance. [5]

Finally, spread of resistance through international trade and travel can facilitate the spread of resistant pathogens, such as food products or live animals, may carry resistant microbes, spreading them to new areas. [6]

Key Strategies to Combat AMR in Low-Resource Settings

Firstly, surveillance and research of AMR and antibiotic use is crucial for updating EDLs and formulating infection control policies. In Malaysia, there are policies like the National Surveillance of Antibiotic Resistance (NSAR) program, which aim to establish baseline data, and raise awareness among the public and medical staff. Collaborating with regional networks for data consolidation can also inform policy decisions. [7,8] 

Secondly, enhancing Infection Prevention and Control (IPC), which aims to prevent healthcare-associated infections (HAIs) can reduce the spread of infections caused by

AMRs. Promoting basic hygiene practices, such as handwashing, sterilization, cough etiquette and safe injection principles for all patient care is vital, particularly in healthcare facilities and densely populated communities.

Thirdly, public awareness and education through effective communication, awareness and training. Training programs for healthcare workers can enhance their understanding of AMR and improve their ability to implement prevention and control measures. Community engagement initiatives can empower individuals with knowledge about AMR risks and prevention. [9]

Fourthly, improving access to diagnostic tools, especially Rapid Diagnostic Tools (RDT) are essential for better antimicrobial stewardship. They have been proven to reduce mortality, lessen hospital stays, enable more accurate and timely diagnoses and shrink healthcare costs. [10]

Case Studies

Country	Intervention	Purpose
South Korea	Health Insurance Review and Assessment Service (HIRA)	Monitor and assess the proper selection and administration of prophylactic antibiotics in surgical procedures since 2007 Prevent surgical site infections (SSIs) and minimize antibiotic misuse, through evaluating factors like type of antibiotic, timing of administration, duration of treatment, surgical cleanliness and contamination levels
China	National Action Plan for Combating Antimicrobial Resistance (2022-2025)	Promote responsible antibiotic use Improve surveillance systems Enhance infection prevention Advance research and innovation Follows a “One Health” approach, which integrates efforts across human health, animal health, and the environment, recognizing that they are closely connected
Malaysia	Malaysian Action Plan on Antimicrobial Resistance (MyAP-AMR) (2022-2026)	Implement campaigns to inform healthcare professionals, veterinarians, farmers, and the public about AMS. Strengthen Surveillance and Research Optimize Antimicrobial Use by establishing and enforcing guidelines Enhance IPC in healthcare settings, farms, and communities  Foster Research and Innovation

[11,12,13]

Table 1: Brief overview of policies implemented by South Korea, China and Malaysia to combat AMR

Conclusion

Addressing antimicrobial resistance (AMR) in low-resource settings is vital to safeguarding both human and animal health. Effective strategies include strengthening surveillance systems, promoting responsible antibiotic use, enhancing infection prevention and control (IPC) measures, and investing in education to build local capacity. However, lasting progress requires not only national efforts but also sustained global collaboration and strong political commitment. By prioritizing AMR as a public health and development challenge, we can work toward a future where lifesaving treatments remain effective for generations to come.

Citations

1. What is AMR? (2022, November 9). Australian Government. Retrieved January 29, 2025, from https://www.amr.gov.au/about-amr/what-amr 

2. World Health Organization: WHO. (2017, March 21). Water, Sanitation and Hygiene: An essential ally in a superbug age. https://www.who.int/southeastasia/news/opinion-editorials/detail/water-sanitation-and-hygiene-an-essential-ally-in-a-superbug-age 

3. World Health Organization: WHO. (2023, November 21). Antimicrobial resistance. https://www.who.int/news-room/fact-sheets/detail/antimicrobial-resistance 

4. Antibiotics: Are you misusing them? (n.d.). Mayo Clinic. https://www.mayoclinic.org/healthy-lifestyle/consumer-health/in-depth/antibiotics/art-20045720 

5. In low-resource nations, lack of diagnostics hampers fight against antimicrobial resistance. (2023b, April 19). CIDRAP. https://www.cidrap.umn.edu/antimicrobial-stewardship/low-resource-nations-lack-diagnostics-hampers-fight-against-antimicrobial 

6. Memish, Z. A., Venkatesh, S., & Shibl, A. M. (2003). Impact of travel on international spread of antimicrobial resistance. International Journal of Antimicrobial Agents, 21(2), 135–142. https://doi.org/10.1016/s0924-8579(02)00363-1 

7. Uchil, R. R., Kohli, G. S., Katekhaye, V. M., & Swami, O. C. (2014). Strategies to combat antimicrobial resistance. JOURNAL OF CLINICAL AND DIAGNOSTIC RESEARCH. https://doi.org/10.7860/jcdr/2014/8925.4529 

8. MINISTRY OF HEALTH MALAYSIA. (2017). Malaysian Action Plan on Antimicrobial Resistance (MYAP-AMR) 2017-2021(First).

9. Infection prevention & control. (2025, January 22). https://www.who.int/teams/integrated-health-services/infection-prevention-control 

10. Ministry of Health, Malaysia. (2022). Protocol on Antimicrobial Stewardship (AMS) Programme in Healthcare Facilities (2nd ed.). https://pharmacy.moh.gov.my/sites/default/files/document-upload/protocol-ams-2022.pdf 

11. Kim, S. H., Jang, S., Cha, Y., Kim, B., Lee, H., & Kim, G. (2023). How does medical policy on the use of prophylactic antibiotics affect medical costs, length of hospital stay, and antibiotic use in orthopedics? Yonsei Medical Journal, 64(3), 213. https://doi.org/10.3349/ymj.2022.0546 

12. National Health Commission. (2022). National Action Plan to Contain Antimicrobial Resistance (2022-2025). https://cdn.who.int/media/docs/default-source/antimicrobial-resistance/amr-spc-npm/nap-library/china-national-action-plan-on-amr-(2022-2025)---eng.pdf?sfvrsn=e3bf8980_4 

13. Ministry of Health Malaysia, Ministry of Agriculture and Food Security, Mustafa, Z., Infection Control Unit, Medical Care Quality Section, Medical Development Division, Ministry of Health Malaysia, Abdullah, N. H., Director-General of Veterinary Services Malaysia, Ministry of Agriculture and Food Security, Sabu, M., Ministry of Natural Resources, Environment and Climate Change, Hamid, A. N., Sulaiman, M. S., Jaffar, A. L. W., Ghazali, N. H. M., Khalib, A., & Yacob, M. A. (2022). Malaysian Action Plan on Antimicrobial Resistance (MYAP-AMR) 2022-2026 (By Ministry of Health Malaysia & Ministry of Agriculture and Food Security). ATTIN PRESS SDN BHD.