The Economic Burden of Antimicrobial Resistance in the Developing World

  • S. D. Foster


Antimicrobial drugs are a scarce resource whose misuse, in both industrialized and developing countries, has contributed to an increased economic burden on the health systems of developing countries. The price differential between amoxicillin and the combination of amoxicillin and clavulanic acid, for example, is on the order of a factor of 20; the change in standard therapy for malaria from chloroquine (CQ) and sulfadoxine/pyrimethamine (SP) to artemisinin-containing therapy (ACT) has increased the cost of treating a case of malaria by a factor of 10 or more. Looked at another way, the same malaria drugs budget will now treat only one-tenth the number of patients as before. These cost increases are forcing health staff and policy makers to confront terrible choices, between using a drug which they know to be ineffective in many cases and which may lead to increased morbidity or mortality, or spending ever-increasing amounts on higher cost antibiotics and antimicrobials, often at the expense of buying enough to meet their needs. Improving laboratory capacity to detect and monitor antibiotic resistance can be a cost-effective strategy in many cases, especially as resistance forces us to use more expensive and scarce antimicrobials.

The specter of the permanent loss of many classes of antimicrobials due to resistance – and the failure of the pharmaceutical industry to engage enthusiastically in the search for new ones – means that the developing world, which still bears the vast majority of the world’s infectious disease burden, will soon find itself with fewer and fewer options for treatment. “Resistance without borders” will disproportionately affect the developing world. It is in everyone’s interest to use these scarce and dwindling resources as efficiently and as carefully as possible.


Antimicrobial Resistance Informal Sector Clavulanic Acid Public Health Importance Syndromic Management 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


  1. Aswapokee, N., S. Vaithayapichet, et al. (1990). “Pattern of antibiotic use in medical wards of a university hospital, Bangkok, Thailand.” Rev Infect Dis 12(1): 136–41.PubMedGoogle Scholar
  2. Attaran, A. (2004). “Where did it all go wrong?” Nature 430(7002): 932–3.CrossRefPubMedGoogle Scholar
  3. Attaran, A., K. I. Barnes, et al. (2004). “WHO, the Global Fund, and medical malpractice in malaria treatment.” Lancet 363(9404): 237–40.CrossRefPubMedGoogle Scholar
  4. Becker, J., E. Drucker, et al. (2002). “Availability of injectable antibiotics in a town market in southwest Cameroon.” Lancet Infect Dis 2(6): 325–6.CrossRefPubMedGoogle Scholar
  5. Bejon, P., I. Mwangi, et al. (2005). “Invasive Gram-negative bacilli are frequently resistant to standard antibiotics for children admitted to hospital in Kilifi, Kenya.” J Antimicrob Chemother 56(1): 232–5.CrossRefPubMedGoogle Scholar
  6. Bosu, W. K. and D. Mabey (1998). “The availability and cost of antibiotics for treating PID in the Central Region of Ghana and implications for compliance with national treatment guidelines.” Int J STD AIDS 9(9): 551–3.CrossRefPubMedGoogle Scholar
  7. Daneman, N., D. E. Low, et al. (2008). “At the threshold: defining clinically meaningful resistance thresholds for antibiotic choice in community-acquired pneumonia.” Clin Infect Dis 46(8): 1131–8.CrossRefPubMedGoogle Scholar
  8. Duke, T., A. Michael, et al. (2003). “Chloramphenicol or ceftriaxone, or both, as treatment for meningitis in developing countries?” Arch Dis Child 88(6): 536–9.CrossRefPubMedGoogle Scholar
  9. Elliott, A. M. and S. D. Foster (1996). “Thiacetazone: time to call a halt? Considerations on the use of thiacetazone in African populations with a high prevalence of human immunodeficiency virus infection.” Tuber Lung Dis 77(1): 27–9.CrossRefPubMedGoogle Scholar
  10. Foster, S. (1991). “Supply and use of essential drugs in sub-Saharan Africa: some issues and possible solutions.” Soc Sci Med 32(11): 1201–18.CrossRefPubMedGoogle Scholar
  11. Gandhi, N. R., A. Moll, et al. (2006). “Extensively drug-resistant tuberculosis as a cause of death in patients co-infected with tuberculosis and HIV in a rural area of South Africa.” Lancet 368(9547): 1575–80.CrossRefPubMedGoogle Scholar
  12. Gill, C. J., L. L. Sabin, et al. (2004). “Reconsidering empirical cotrimoxazole prophylaxis for infants exposed to HIV infection.” Bull World Health Organ 82(4): 290–7.PubMedGoogle Scholar
  13. Govaerts, P. J., J. Claes, et al. (1990). “Aminoglycoside-induced ototoxicity.” Toxicol Lett 52(3): 227–251.CrossRefPubMedGoogle Scholar
  14. Grosskurth, H., F. Mosha, et al. (1995). “Impact of improved treatment of sexually transmitted diseases on HIV infection in rural Tanzania: randomised controlled trial.” Lancet 346(8974): 530–6.CrossRefPubMedGoogle Scholar
  15. Hastings, I. M., E. L. Korenromp, et al. (2007). “The anatomy of a malaria disaster: drug policy choice and mortality in African children.” Lancet Infect Dis 7(11): 739–48.CrossRefPubMedGoogle Scholar
  16. Hawkes, S., L. Morison, et al. (1999). “Reproductive-tract infections in women in low-income, low-prevalence situations: assessment of syndromic management in Matlab, Bangladesh.” Lancet 354(9192): 1776–81.CrossRefPubMedGoogle Scholar
  17. Howard, D. H. (2004). “Resistance-induced antibiotic substitution.” Health Econ 13(6): 585–95.CrossRefPubMedGoogle Scholar
  18. Kallander, K., J. Nsungwa-Sabiiti, et al. (2004). “Symptom overlap for malaria and pneumonia – policy implications for home management strategies.” Acta Trop 90(2): 211–4.CrossRefPubMedGoogle Scholar
  19. Kelesidis, T., I. Kelesidis, et al. (2007). “Counterfeit or substandard antimicrobial drugs: a review of the scientific evidence.” J Antimicrob Chemother 60(2): 214–36.CrossRefPubMedGoogle Scholar
  20. Kelly, P., A. Buve, et al. (1994). “Cutaneous reactions to thiacetazone in Zambia – implications for tuberculosis treatment strategies.” Trans R Soc Trop Med Hyg 88(1): 113–115.CrossRefPubMedGoogle Scholar
  21. Kouyate, B., A. Sie, et al. (2007). “The great failure of malaria control in Africa: a district perspective from Burkina Faso.” PLoS Med 4(6): e127.CrossRefPubMedGoogle Scholar
  22. Larsson, D. G. J., C. de Pedro, et al. (2007). “Effluent from drug manufactures contains extremely high levels of pharmaceuticals.” J Hazard Mater 148(3): 751–5.CrossRefPubMedGoogle Scholar
  23. Levy, S. B. (2002). The antibiotic paradox : how the misuse of antibiotics destroys their curative power. Cambridge, MA, Perseus Pub.Google Scholar
  24. Lubell, Y., H. Reyburn, et al. (2008). “The impact of response to the results of diagnostic tests for malaria: cost-benefit analysis.” BMJ 336(7637): 202–5.CrossRefPubMedGoogle Scholar
  25. Nathan, C. (2004). “Antibiotics at the crossroads.” Nature 431(7011): 899–902.CrossRefPubMedGoogle Scholar
  26. Phillips, M. and P. A. Phillips-Howard (1996). “Economic implications of resistance to antimalarial drugs.” Pharmacoeconomics 10(3): 225–38.CrossRefPubMedGoogle Scholar
  27. Pillay, M. and A. W. Sturm (2007). “Evolution of the extensively drug-resistant F15/LAM4/KZN strain of Mycobacterium tuberculosis in KwaZulu-Natal, South Africa.” Clin Infect Dis 45(11): 1409–14.CrossRefPubMedGoogle Scholar
  28. Quick, J. D., J. R. Rankin, et al. (1997). “Managing drug supply.” Management Sciences for Health in collaboration with the World Health Organization. West Hartford, CT: Kumarian Press.Google Scholar
  29. Reeler, A. V. (1990). “Injections: a fatal attraction?” Soc Sci Med 31(10): 1119–25.CrossRefPubMedGoogle Scholar
  30. Snow, R. W., E. Eckert, et al. (2003). “Estimating the needs for artesunate-based combination therapy for malaria case-management in Africa.” Trends Parasitol 19(8): 363–9.CrossRefPubMedGoogle Scholar
  31. Teklehaimanot, A. and R. W. Snow (2002). “Will the Global Fund help roll back malaria in Africa?” Lancet 360(9337): 888–9.CrossRefPubMedGoogle Scholar
  32. White, N. J., F. Nosten, et al. (1999). “Averting a malaria disaster.” Lancet 353(9168): 1965–7.CrossRefPubMedGoogle Scholar
  33. WHO (2006). “WHO Expert Consultation on Cotrimoxazole Prophylaxis in HIV Infection.” TRS WHO/HIV/2006.01.Google Scholar

Copyright information

© Springer Science+Business Media, LLC 2010

Authors and Affiliations

  1. 1.Alliance for the Prudent Use of Antibiotics (APUA); Boston University, School of Public HealthBostonUSA

Personalised recommendations