Not a day goes by where there isn’t a report somewhere about the threat of antimicrobial resistance. Our media is awash with grim stories about ‘superbugs’ emerging in patients and hospitals, with dire predictions about the future of healthcare and even humanity and the planet as we know it. There is much that we know about antimicrobial resistance. We know that antimicrobial resistance is a significant global health and security threat. We know that it is something that is increasingly the focus of the work of busy infection control professionals, ID physicians and pharmacists. We know that governments, non-government organisations and all manner of other organisations and groups around the world are marshalling resources, and launching campaigns and strategies to slow the pace and spread of antimicrobial resistance. We know that use of antimicrobials is the primary driver of resistance, and we know that this is accelerated by what is commonly described as overuse, misuse or inappropriate use. We also know that there is considerable international evidence demonstrating the relationship between antibiotic overuse, misuse or inappropriate use of antibiotics and resistance, and we know the kinds of very many problems that arise from this. Recently here in Australia the First Australian Report on Antimicrobial Use and Resistance in Human Health by the Australian Commission on Safety and Quality in Health Care documented the extent to which Australia has contributed to the rise of global problem. The news this report brought was mixed: in some areas it was cause for celebration; in others our worst fears were realised. We know there is much, much more work to be done.
There are other aspects to this, however, that are not well known to all. There are aspects of this that ‘we’ don’t know well or appreciate. We tend of overlook, forget, and even not appreciate that for millions of people around the world the concepts of antibiotic overuse, misuse or inappropriate use are completely alien. For millions and millions of people around there world there is no access, or very limited access, to antibiotics. Antibiotics are precious commodities that many only dream of having. In their recent commentary in The Lancet Pamela Das and Richard Horton argued that focusing on resistance in terms of misuse or overuse fails to take a global perspective on the needs of the many for whom antibiotics are a precious resource. As they rightly point out, we tend to overlook, or lack an appreciation for, the fact that many more people die from the lack of access, or delayed access,to antimicrobials than from resistant organisms. While this stark reminder should of course in no way serve to discourage efforts to more prudent use of antibiotics in settings where overuse, misuse or inappropriate use occurs, we must also turn our minds to how we can bring about both sustainable access and sustainable effectiveness for all. We must enhance non antimicrobial-based initiatives to reduce the burden of disease, such as immunisation to improve health outcomes with a system of Universal Health Coverage. We know that this is but one critical intervention to realising the efforts for our wider goal to conserve antibiotics and reduce selection pressure that drives resistance. Moreover, we must all think long and hard about who we actually are when it comes to antimicrobial resistance. In doing so we must all work just as hard to ensure fair access to antibiotics as we do to tackling excess.
 Declaration of Interest: Professor Shaban was the project leader of a research consortium at Griffith University contracted by Australian Commission on Safety and Quality in Health Care to contribute to this report. No other interests to declare.
 Das P & Horton R. (2015) Antibiotics: achieving the balance between access and excess. The Lancet, Vol 387, Issue 10014, p102-104.