The burden of antimicrobial resistance

Antimicrobial resistance (AMR) remains one of the most critical global health threats, which could result in 169 million people dying of AMR-related causes between 2025 and 2050. Despite the magnitude, it is a “silent pandemic” because it receives far less attention than traditional pandemics. However, if we examine the problem closely with the appropriate surveillance tools, we will see clearly that it is a raging pandemic, rather than a silent one.

AMR refers to the microorganisms (i.e., bacteria, viruses, fungi, and parasites) that survive exposure to antimicrobial agents. Antimicrobials include antibacterial, antifungal, antiviral, and antiparasitic agents with usage overarching multiple sectors, including in the human and veterinary clinical spheres for patient therapy/prophylaxis and in the agricultural sphere for animal growth promotion and crop protection.

These resistant organisms spread across humans and animals and through the environment. This is therefore, not just a human problem, but a multi-sectoral One Health problem. One Health is an integrative approach to health that recognises the connection between humans, animals, and the environment and emphasises the need for a comprehensive strategy that involves all sectors to effectively tackle the global threat of AMR.

The state of antimicrobial resistance in South Africa

South Africa faces a complex mix of infectious and non-communicable diseases, driving high antimicrobial use across the health system and fuelling rising antimicrobial resistance (AMR). Over the past decade, the national AMR action plan and the Ministerial Advisory Committee on AMR advanced a strong One Health response, strengthening surveillance, improving stewardship in health facilities, and raising awareness among healthcare workers.

Yet AMR pressures extend beyond hospitals. Intensive food-animal farming relies on antibacterial agents similar to those used in humans, while widespread antifungal use in crop production contributes to environmental resistance. Regulatory and surveillance systems are improving, but significant gaps remain.

To address this, South Africa’s two-tier AMR surveillance system, anchored by the National Institute for Communicable Diseases’ national AMR dashboard, integrates data from public and private laboratories. This platform tracks priority bacterial and fungal pathogens, guides treatment decisions, supports national reporting, and highlights growing threats such as multidrug-resistant Candidozyma auris, now endemic in more than 100 hospitals in the country.

Drivers of AMR and public health impact 

The drivers of AMR are multifaceted and interconnected, encompassing biological, behavioural, social, and systemic factors. In Africa and other ow- and middle-income countries (LMICs), where the burden of infectious diseases remains high, these drivers are further amplified by weak health systems and limited resources.

A major contributor to AMR is the overuse and misuse of antibiotics and antifungals in humans and animals. In healthcare facilities, antibiotics are frequently prescribed empirically, in the absence of laboratory confirmation. Recent Global Point Prevalence Survey (GLOBAL-PPS) data recorded that almost 90% of patients were prescribed antibiotics empirically.

Similarly, the unregulated use of antifungals in agriculture and human medicine has accelerated the emergence of resistant fungal species such as C. auris and azole-resistant Aspergillus fumigatus.

Recommendations for best practice to address AMR in South Africa

For government

At the governmental level in South Africa, the first and most critical need is a dedicated, formal, funded multisectoral AMR programme with sustainable resources (such as human resources, consumables, systems support, etc.), clear governance, and measurable targets. The WHO’s Global Action Plan on AMR, initially published in 2016, is being updated, with a strong focus on One Health responses as a result of gaps identified through review of the National Action Plans on AMR globally.

For healthcare workers in human health

Healthcare workers are encouraged to focus on appropriate antimicrobial use and effective use of surveillance data. Following the five “rights” of prescribing is the first step to take, i.e., ensuring the right drug is prescribed to the right patient, for the right diagnosis, at the right dose, and for the right duration, according to the AWaRe classification.

For civil society and the public

The involvement of civil society has been pivotal in policy change related to many diseases, including HIV/AIDS and COVID-19 vaccines and medication. Civil society has many roles to play in mitigating AMR locally and globally by raising awareness and promoting responsible antimicrobial use across human, animal, and environmental health. This includes advocating for One Health reporting of surveillance data, supporting public education on appropriate antibiotic use, and participating in awareness initiatives such as World AMR Awareness Week.

Conclusion

Although AMR data underscore an escalating global health threat over the next 25 years, it is not a problem of the future. It is very much a problem of the here-and-now, and it is accelerating year by year. There are a number of potential solutions that need to synchronise with each other and require input from various sectors. One cannot overstate the role of civil society in advocating for policy change to address AMR and to advocate for the responsible use of antimicrobials, responsible sharing of data, and changing behaviours around antimicrobial use.

South Africa stands at a crossroads. We can stand back and watch AMR overwhelm our hospitals, farms, and communities – or we can invest now in the systems that prevent it. Responsible antimicrobial use is essential not only in human health but also in agriculture, where producers must balance animal welfare and food security with the need to preserve antimicrobial effectiveness. Strengthening surveillance from a One Health perspective, transparent data sharing, and cross-sector co-ordination will allow us to act early and act together. 

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