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Challenges of drug resistance in the developing world

BMJ 2012; 344 doi: (Published 03 April 2012) Cite this as: BMJ 2012;344:e1567
  1. Ramanan Laxminarayan, director1,
  2. David L Heymann, professor and chair2
  1. 1Center for Disease Dynamics, Economics & Policy, Washington, DC, USA and New Delhi, India
  2. 2Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
  1. Correspondence to: D L Heymann david.heymann{at}
  • Accepted 8 April 2011

Ramanan Laxminarayan and David Heymann examine the factors that make drug resistance a more difficult problem in poorer countries

Resistance to anti-infective drugs, particularly bacterial resistance to antibiotics, is a global phenomenon. Resistant infections increase morbidity and mortality and prolong the time of infectiousness, putting others at risk. In high income countries, where the burden of infectious diseases is modest, the decreasing effectiveness of first line antibiotics is overcome by more expensive second and third line antibiotics. The challenge is greater in developing countries, where the burden of infectious diseases is high and patients with a resistant infection may be unable to obtain or afford any antibiotic, let alone expensive second line treatments. Poor hygiene, unreliable water supplies, civil conflicts, and increasing numbers of immunocompromised people with HIV infection, facilitate both the evolution of resistant pathogens and their rapid spread.1 2

The most complete data on resistance in developing countries come from tertiary care facilities, typically located in large cities. Very little information exists on resistance in other settings and almost none in rural areas. Recent data from community settings in Indian and South African urban and peri-urban areas indicate that levels of resistance are high. In urine specimens collected from November 2003 to December 2004, more than 70% of Escherichia coli isolated from healthy women were resistant to ampicillin and nalidixic acid, and more than 50% of isolates were resistant to fluoroquinolones (fig 1). 3

Fig 1 Antibiotic resistance in E coli isolated in New Delhi during 2003-4

Causes of resistance

Increasing use of antibiotics

Bacterial selection for antibiotic resistance is a natural phenomenon related to the volume of antibiotics used: the more these drugs are used the quicker resistant strains emerge and spread.4 This is true whether antibiotics are medically indicated or not. Antibiotic use is increasing, particularly in Asian and Latin …

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