Antibiotic resistance is a huge economic burden for healthcare and for the society. The overall societal costs of antibiotic-resistant infections are estimated at €1.5 billion per year in the EU and up to $55 billion per year in the US. The Review on Antimicrobial Resistance claims that the cost could rise to $100 trillion by 2050. Antibiotic resistance increases the cost of healthcare with lengthier stays in hospitals and more intensive care required. Roberts and associates found that the economic cost of microbial resistance was considerable. In a sample of nearly 1,400 patients, 188 (13.5 per cent) had antimicrobial-resistant infection. The medical costs attributable to resistance ranged from $18,588 to $29,069 per patient in their sensitivity analysis. Excess duration of hospital stay was 6.4 – 12.7 days and mortality was 6.5 per cent. Centre for Disease Control and Prevention estimates that each year in the US, at least 2 million people become infected with bacteria that are resistant to antibiotics and at least 23,000 people die each year as a direct result of these infections. While so many antibiotics are losing efficacy on account of resistance, the problem is compounded by the fact that pharmaceutical industry is reluctant to produce new antibiotics due to reduced economic incentives and challenging regulatory requirements. Mechanism The crisis of antibiotic resistance has been attributed to over-use and misuse of these valuable medicines. Self-prescription is an example of such misuse. Many antibiotics are frequently prescribed to treat viral diseases such as common cold and flu. Other forms of misuse include failure to take the entire prescribed course of the antibiotic and incorrect dosage. Antibiotics have become less effective over time as a result, simply because we haven’t used them right. Animal health practices contributing to resistance include antibiotic use in livestock feed to promote faster growth. When animals get antibiotics, drug-resistant bacteria can survive and multiply in their guts. Resistant bacteria can remain on meat. When the meat is not properly cooked, the bacteria can spread to humans. Fertilizer and or water containing animal faeces and drug-resistant bacteria can be used on food crops. Resistant bacteria in the animal faeces can remain on crops and be eaten. Then the bacteria can spread to humans. The crisis of antibiotic resistance has been attributed to over-use and misuse of the valuable medicines. Self-prescription is an example of such misuse Antibiotics resistance arises from random mutation in DNA or genes. Non-resistant bacteria receive the new DNA and become resistant to drugs. Bacteria that have drug-resistant DNA or genes may transfer a copy of these genes to other bacteria of their species by cell to cell contact pushing through plasmids (bits of circular DNA that can be exchanged between bacteria) or when a bacterial cell scavenges resistant DNA present in the environment or by bacterial phages. Resistant DNA can also be transferred from one species to another (horizontal gene transfer). For example, resistant genes may be transferred from Escherichia coli to Salmonellae. Pakistan Antibiotic resistance data are lacking in Pakistan, as no national surveillance network exists. Antibiotic consumption remains high in healthcare settings, including in many well-established public hospitals, across Pakistan. Quackery, availability of over-the-counter antimicrobials without prescription, bias towards costly broad-spectrum antibiotics, lack of surveillance systems and experts, and widespread use of antibiotics in poultry, dairy, and agriculture are responsible for the crisis. Guidelines for infection control have not been followed, thereby contributing towards antibiotic resistance. Sanitation, hygiene, immunization and shortage of clean water have not received the attention they deserve. The infection control systems in hospitals and clinics are not up to the mark. Irrational prescriptions by physicians, especially general practitioners, add to the problem. Facilities for culture and sensitivity examinations are very expensive and available only in big cities. Many patients fail to take drugs according to the advice of physicians. There are currently no laws governing the use of antimicrobials in poultry and livestock in Pakistan, resulting in a rapid increase in the emergence of drug-resistant strains of pathogens, common to poultry, cattle and humans. Response of public health departments is lukewarm and there is no sense of urgency to control the menace. The WHO mission report has warned that Pakistan is not completely prepared to detect, prevent, and respond to internal or external health threats that could threaten its population, and have the potential to jeopardize travel and trade. Prevention and control Many international and regional efforts to control antibiotic resistance have been initiated over the last two decades. These include the World Health Organization’s Global Action Plan, in May 2015. Several organizations concerned with antimicrobial resistance are lobbying to eliminate the unnecessary use of antibiotics. Steps may be taken at all levels of society to reduce the impact and limit the spread of resistance. Following guidelines prescribed by WHO may be followed. All governments should prepare, finance and implement a comprehensive national plan to control and prevent antibiotic resistance. They need to regulate antibiotic use and make sure there are awareness programmes for the responsible use of antibiotics, both in humans and animals. Regulations may be enacted to prevent sale of antibiotics without prescription. Development of new technologies to combat antimicrobial resistance is required. Efforts may also be made to establish standard laboratory services to collect data about resistance. Governments should create conditions conducive to production of new antibiotics. Measures to control infections may be enforced. The use of antibiotics to promote growth in livestock must be phased out. People should use antibiotics only when prescribed by a certified health professional. They should complete the course of an antibiotic according to the advice of their physician. They should avoid using leftover drugs. It must be stressed that use of antibiotics is no substitute to controlling or preventing infections. Steps may be taken to prevent infections: regular hand washing, vaccination, safe sex, and selection of foods that have been produced without antibiotics for growth promotion are good practices. Physicians should only prescribe antibiotics when there is a definite indication and avoid their use in viral diseases. They should warn patients about dangers of misuse of antibiotics. They should also collect data regarding antibiotic resistance and prescribe antibiotics in the light of culture and sensitivity reports. Healthcare industry should invest in production of new antibiotics, vaccines and diagnostics. Agriculture sector should avoid antibiotics for growth promotion or to prevent disease in healthy animals. Animals should instead be vaccinated to reduce the need for antibiotics. Antibiotics should be administered to animals under veterinary supervision. The writer is Chest specialist in San Francisco