Antimicrobial resistance (AMR) is widely recognised as one of the major threats to modern medicine and global health. However, AMR should not be understood solely as a problem of resistant microorganisms or inappropriate antibiotic prescribing. It is also a profound challenge to sustainability, health equity, healthcare systems, and global development. Antimicrobial medicines are essential for treating bacterial and other infections and for making many modern medical interventions possible. Surgery, cancer treatment, transplantation, intensive care, and the management of serious injuries all depend on the ability to prevent and treat infections effectively. The effectiveness of antimicrobial medicines can therefore be viewed as a shared and finite therapeutic resource that must be protected for both present and future generations.
Sustainability requires meeting the needs of the present without compromising the ability of future generations to meet their own needs. This principle applies directly to antimicrobial effectiveness. If antimicrobials are used inappropriately or excessively, resistant microorganisms can emerge and spread, reducing the effectiveness of medicines over time. However, sustainability should not be interpreted simply as reducing antimicrobial consumption. Antibiotics remain essential medicines, and restricting access without addressing underlying health needs could disproportionately harm vulnerable populations. The goal of antimicrobial stewardship should therefore be to ensure that antimicrobials are used appropriately, responsibly, and equitably: the right medicine, for the right patient, at the right dose, for the appropriate duration, and only when clinically indicated.
This balance between access and stewardship is central to the relationship between AMR and health equity. Some populations face excessive or inappropriate antimicrobial use, while others experience inadequate access to effective treatment. In low-resource settings, patients may lack access to reliable diagnostics, quality-assured medicines, vaccination, infection prevention, and timely healthcare. As a result, infections that could be prevented or treated effectively may become severe before appropriate care is available. At the same time, limited diagnostic capacity can lead to empirical prescribing, in which antibiotics are given because the cause of an infection cannot be confirmed. Addressing AMR must therefore involve both reducing unnecessary antimicrobial use and ensuring that people have access to the essential healthcare interventions needed to prevent and appropriately treat infections.
AMR is fundamentally a global health challenge because microorganisms and resistance mechanisms do not respect national borders. Resistant organisms can spread through international travel, migration, healthcare systems, food production, animals, water, wastewater, and the wider environment. Human mobility and global trade mean that resistance emerging in one region can have consequences elsewhere. This interconnectedness demonstrates why isolated national responses are insufficient. Effective AMR control requires international surveillance, information sharing, coordinated policies, research collaboration, and equitable access to effective interventions. Countries with greater financial and technical capacity have an important role in supporting global efforts while recognising that sustainable solutions must also be locally led and adapted to specific contexts.
AMR also illustrates the close relationship between human, animal, and environmental health, making it a clear example of the need for a One Health approach. Antimicrobial medicines are used not only in human healthcare but also in veterinary medicine and agriculture. Their use in animals can contribute to the development and selection of resistant microorganisms, while resistant organisms can subsequently spread between animals, humans, food systems, and the environment. Antimicrobial residues and resistant organisms may also enter wastewater, soil, rivers, and other ecosystems. Addressing AMR therefore requires collaboration between physicians, pharmacists, veterinarians, agricultural professionals, environmental scientists, microbiologists, policymakers, and communities.
Water, sanitation and hygiene (WASH) are central to this One Health response. Many infections can be prevented through access to safe drinking water, adequate sanitation, effective waste management, and good hygiene practices. Preventing infections reduces the need for antimicrobial treatment and therefore decreases opportunities for resistance to develop. Effective wastewater treatment is also important because healthcare facilities, pharmaceutical production, households, agriculture, and other sources can release antimicrobial residues and resistant microorganisms into the environment. Strengthening WASH infrastructure, particularly in underserved and low-resource communities, can therefore provide multiple benefits: reducing infectious diseases, lowering antimicrobial use, limiting environmental contamination, and improving overall health and dignity.
Prevention should consequently be at the centre of sustainable AMR strategies. Vaccination can reduce the incidence of infectious diseases and, in some circumstances, reduce the need for antibiotics. Strong infection prevention and control programmes in hospitals and communities can prevent transmission and protect both patients and healthcare workers. Hand hygiene, appropriate sterilisation, environmental cleaning, safe injection practices, adequate isolation facilities, and effective surveillance all contribute to reducing infections. These measures are particularly important in healthcare environments, where vulnerable patients may be exposed to resistant organisms.
Strong primary healthcare is another essential component. Accessible primary healthcare can provide early diagnosis, appropriate treatment, vaccination, health education, and preventive services before infections become severe. When primary healthcare systems are weak, patients may delay seeking care or require hospital treatment for conditions that could have been managed earlier. Strengthening primary healthcare can therefore simultaneously improve health equity, reduce unnecessary antimicrobial use, and increase health-system resilience. This is particularly important in low-resource settings, where hospitals may already face significant shortages of staff, medicines, diagnostic equipment, and infrastructure.
Diagnostics and surveillance are equally important. Clinicians cannot consistently prescribe antimicrobials appropriately if they lack access to accurate and timely diagnostic information. Expanding affordable laboratory services and point-of-care diagnostics can help distinguish bacterial infections from conditions that do not require antibiotics and can support the selection of appropriate treatment. At the population level, surveillance systems can identify emerging resistance patterns and enable health authorities to respond before resistant organisms become widespread. Investment in laboratory capacity should therefore be viewed as an essential component of both AMR control and health-system strengthening.
Innovation is also critical to addressing the long-term threat of AMR. Research is needed to develop new antibiotics, vaccines, rapid diagnostics, alternative therapies, and technologies that can reduce dependence on antimicrobial medicines. However, scientific innovation alone will not solve the problem. New treatments must be affordable, accessible, appropriately regulated, and available to populations that need them. The development of new antibiotics must also be accompanied by stewardship to prevent newly effective medicines from becoming ineffective through inappropriate use. Sustainable innovation therefore requires balancing access, affordability, responsible use, and long-term preservation.
The economic and social consequences of AMR further demonstrate why it should be considered a sustainability issue. Resistant infections can lead to longer hospital stays, increased healthcare costs, loss of productivity, disability, and premature death. These effects can place particularly heavy burdens on households and health systems with limited financial resources. When treatment becomes more complicated or expensive, vulnerable populations may face greater difficulties accessing care. AMR can therefore reinforce existing health inequalities, creating a cycle in which poverty and limited healthcare access increase vulnerability to infection and resistance, while resistant infections create further economic hardship.
In conclusion, AMR is not merely a problem of resistant microorganisms or antibiotic consumption. It is a global health, sustainability, and equity challenge that reflects the interconnectedness of people, healthcare systems, animals, food systems, and the environment. A sustainable response must combine responsible antimicrobial use with equitable access to essential medicines and healthcare. Prevention, vaccination, WASH, infection prevention and control, strong primary healthcare, accurate diagnostics, surveillance, research, and innovation must all form part of an integrated strategy.
Protecting antimicrobial effectiveness requires a long-term commitment from governments, healthcare professionals, researchers, pharmaceutical companies, agricultural sectors, environmental organisations, and communities. International cooperation is essential because resistance crosses borders, while local leadership is necessary to ensure that interventions are appropriate and sustainable. The objective should not be simply to use fewer antibiotics, but to preserve their effectiveness while ensuring that everyone who genuinely needs them can access them. By adopting a genuine One Health approach and placing equity at the centre of AMR policy, the global community can help ensure that effective antimicrobial treatment remains available for present and future generations.
References
Sartelli M, Mossialos E, Coccolini F, Jammer I, Labricciosa FM, Barie P, Biffl WL, Memish ZA, Maeurer M, Kobinger GP, Ippolito G, Zumla A, Catena F; Global Consortium for Solidarity to Overcome Challenges, Restore Trust and Advance Science for a Sustainable Future. Global health at crossroads: uniting together to overcome challenges, restore trust and advance priorities for a sustainable future. World J Emerg Surg. 2025 Nov 10;20(1):84.
Worldwide Antimicrobial Resistance National/International Network Group (WARNING) Collaborators. Ten golden rules for optimal antibiotic use in hospital settings: the WARNING call to action. World J Emerg Surg. 2023 Oct 16;18(1):50.
Author
Massimo Sartelli
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