The increasing resistance of microorganisms significantly complicates the treatment of infectious diseases and elevates the risk of complications associated with various medical interventions, such as surgical operations, cesarean sections, chemotherapy, and others. According to the World Health Organization (WHO), the world is facing a critical crisis in the supply and accessibility of antibiotics, necessitating urgent action. The WHO emphasizes the imperative need for the rational use of antibiotics and the strengthening of preventive measures to preserve the effectiveness of antimicrobial agents and to reduce the emergence and spread of antibiotic-resistant bacteria.
According to the World Health Organization’s (WHO) 2025 assessment, antimicrobial resistance (AMR) remains one of the leading causes of mortality worldwide. Mortality rates are particularly high in low-income countries, where, in 2021, bacterial resistance was associated with approximately 1.14 million deaths. The WHO’s latest report indicates that global antibiotic resistance increased by 40% between 2018 and 2023, substantially diminishing the effectiveness of antibiotic therapy and further complicating the treatment of infectious diseases. Recent data are especially alarming regarding the growing resistance of Gram-negative bacteria to antibiotics. Among the most concerning pathogens are Acinetobacter spp., Escherichia coli, Klebsiella pneumoniae, Pseudomonas aeruginosa, and others.
Global trends:
According to the World Health Organization’s (WHO) 2023 report, one in every six laboratory-confirmed bacterial infections was found to be resistant to antibiotics. It has been determined that the annual rate of increase in antimicrobial resistance (AMR) averages between 5% and 15%, posing a serious global public health challenge. The prevalence of resistance is particularly high in the South-East Asia and Eastern Mediterranean regions, where one out of every three infections is caused by a resistant strain. In light of this alarming trend, WHO Director-General Dr. Tedros Adhanom Ghebreyesus stated: “Antimicrobial resistance is outpacing the progress of modern medicine and threatens the health of families across the world.”
The situation is particularly alarming regarding the spread of Gram-negative bacterial pathogens in countries with limited resources to effectively respond to antimicrobial resistance. In developing nations, Acinetobacter spp., Escherichia coli, and Klebsiella pneumoniae play a leading role among resistant pathogens. These bacteria are frequently responsible for bloodstream infections, sepsis, multiple organ failure, and death.
Resistance to fluoroquinolones and third-generation cephalosporins has been detected in 44.8% of Escherichia coli isolates and in 55.2% of Klebsiella pneumoniae cases. The situation is particularly critical in the African region, where the resistance levels of these bacterial species exceed 70%.
To mitigate antimicrobial resistance, the World Health Organization (WHO) has introduced a specialized classification system known as “AWaRe” (Access, Watch, Reserve). The purpose of this system is to promote the rational use of antibiotics and to strengthen global surveillance based on their intended clinical application.
According to the “AWaRe” classification, antibiotics are divided into three main subgroups:
- Access Group – This category includes antibiotics recommended for use as first- or second-line agents in the empirical treatment of common infections. Antibiotics in this group are associated with a relatively low risk of developing antimicrobial resistance. They are generally narrow-spectrum, widely available, and considered safe. Representative examples include amoxicillin, penicillin, co-trimoxazole, first-generation cephalosporins, and most aminoglycosides. Ensuring their broad accessibility and rational use is essential for enhancing therapeutic effectiveness and reducing the emergence of resistance.
- Watch Group – This category comprises broader-spectrum antibiotics that are typically more expensive and carry a higher risk of promoting antimicrobial resistance. Their use is recommended only for specific clinical indications, particularly in severe infections or when the causative pathogen is suspected or confirmed to be resistant to first-line agents. This group includes third- and fourth-generation cephalosporins (e.g., ceftriaxone, cefepime), fluoroquinolones (e.g., ciprofloxacin), carbapenems (e.g., meropenem), and glycopeptides (e.g., vancomycin).
According to WHO recommendations, the use of these agents must be strictly controlled and permitted only when clinically justified, within the framework of antimicrobial stewardship programs, to preserve their efficacy and limit the spread of resistance.
- Reserve Group – This category comprises last-resort antibiotics, intended for use only in cases where infections are caused by multidrug-resistant microorganisms and no other therapeutic alternatives are available. Drugs in this group include colistin, tigecycline, cefiderocol, as well as novel β-lactam/β-lactamase inhibitor combinations such as meropenem–vaborbactam, ceftazidime–avibactam, and ceftolozane–tazobactam. The administration of these agents is permitted only after thorough clinical evaluation and microbiological confirmation, and must be undertaken under the guidance of an infectious disease specialist or another qualified expert. Such cautious use is essential to preserve the effectiveness of these critical antibiotics and to prevent further development of resistance.
Despite WHO recommendations, as of 2025, many high-risk antibiotics—such as carbapenems (which may cause neurological adverse effects, including seizures) and fluoroquinolones—have lost efficacy against Escherichia coli, Klebsiella pneumoniae, and Acinetobacter strains. The increase in carbapenem resistance is particularly alarming. While such cases were rare in previous years, resistance levels have now risen significantly. This situation creates substantial treatment challenges, as patients increasingly require last-resort antibiotics, which are often expensive and difficult to access in low- and middle-income countries.
In 2015, the World Health Assembly adopted a Global Action Plan aimed at ensuring the effective treatment and prevention of infectious diseases using safe medications. Subsequently, the WHO established GLASS (Global Antimicrobial Resistance and Use Surveillance System), a platform designed to monitor antimicrobial resistance (AMR), collect, validate, and share data to inform future national and global strategies. By 2016, 25 countries were participating in the system, and by 2023, this number had increased to 104 countries. However, the 2025 report reveals that 48% of countries did not submit data. These are primarily countries bearing the highest burden of resistance and lacking the necessary infrastructure or capacity for effective AMR surveillance.
In September 2024, the United Nations General Assembly adopted a declaration outlining three key principles for reducing antimicrobial resistance (AMR):
- All countries must provide GLASS with data on the frequency of antimicrobial use and resistance by 2030.
- It should be possible to test all bacterial and fungal pathogens for resistance within countries.
- Strict control measures should be implemented to achieve a 10% reduction in global AMR-related mortality, based on the 2019 baseline of 4.95 million deaths.
Key elements of antimicrobial stewardship:
Antibiotic Stewardship refers to an organized and systematic effort aimed at evaluating and optimizing the prescribing and use of antibiotics. It’s essential that antibiotic prescriptions are rational, targeted, and grounded in evidence-based medical principles to ensure both effective patient care and the mitigation of antimicrobial resistance.
Below are the core principles of antimicrobial stewardship as outlined by the Centers for Disease Control and Prevention (CDC):
The rise in antibiotic resistance has significantly altered strategies for managing infectious processes. MedScriptum spoke with Professor Tsotne Samadashvili, Head of Anesthesiology and Intensive Care at the Caucasus Medical Center and an active member of the Medical Expert Board in the same specialty. Professor Samadashvili actively conducts training sessions at the Vian Educational Center for medical personnel on the rational use of antibiotics and the principles of antimicrobial therapy. For this reason, the main topics of the interview are the principles of selecting empirical therapy, strategies for the rational use of antibiotics, and ways to improve the management of hospital-acquired infections:
According to WHO data, the incidence of antibiotic-resistant infections has increased by 40%, particularly among Gram-negative pathogens such as Klebsiella pneumoniae and Escherichia coli. What strategic measures should be implemented in the near future to reduce antibiotic resistance and improve patient clinical outcomes?
The primary strategic approach to reducing antibiotic resistance is evidence-based antibiotic therapy, namely the effective implementation of antimicrobial stewardship programs. This includes the appropriate planning of preoperative antibiotic prophylaxis, the rationalization of postoperative therapy, and the improvement of hospital infection management, including pneumonia and urinary tract infections. Such an approach is essential to minimize deviations from international guidelines and to uphold the principles of rational antibiotic use. The global stewardship framework is grounded in country-specific epidemiological characteristics and high-quality evidence. Accordingly, it is the professional responsibility of every physician to recognize their role in preventing the spread of resistance and to adhere to international standards. To curb the trend of antibiotic resistance, enhancing the quality of education and information is critical through targeted training and continuous medical education within relevant professional groups.
What measures should be implemented to strengthen the rational prescription and use of antibiotics in Georgia?
It’s essential for every medical institution to have a guide for antibacterial therapy, i.e., a stewardship protocol. Each clinic should have its own strategy that aligns with and does not deviate from international standards. This is necessary to prevent situations in which even an apparently “harmless” antibiotic is used inappropriately or thoughtlessly. Clear antibiotic use policies should also be implemented at the primary care level, as it is often within these settings that inappropriate initiation of antibiotic therapy occurs. The implementation of clear, restrictive mechanisms ensures patient safety and reduces the risk of developing resistant flora. Additionally, when aiming to prevent bacterial resistance, monitoring at the pre-hospital stage is crucial. Supervision at this stage represents one of the most significant challenges in healthcare. In the Georgian context, self-medication is common, which becomes not only an individual but also a systemic problem. Such practices have already led to serious consequences, including an increase in drug-resistant infections, significantly higher treatment costs, and excessive financial burdens on the healthcare system.
Besides the irrational use of antibiotics, are there other significant factors that influence the development of antibiotic resistance (e.g., hygiene standards, infection control)?
The development of antibiotic resistance is a complex and multifactorial process. It is important to note that violations of hygiene standards and inadequate infection control play a significant role in the spread of resistant infections. It is often the case that a patient is admitted to the hospital with an infection caused by non-resistant flora; however, due to the neglect of hygienic practices and the irrational use of antibiotics in the hospital setting, resistant microflora subsequently develop.
The WHO 2025 report notes that resistance is spreading not only to cephalosporins but also to carbapenems, drugs considered last-resort antibiotics due to their potential toxic effects. How should the selection of empirical therapy be carried out under such conditions, when resistance has already extended to highly toxic, reserve antibiotics?
The spread of resistance to last-resort antibiotics, including carbapenems, has become one of the most serious challenges. Under such conditions, the selection of empirical therapy should be based on microbiological data and continuous analysis of resistance profiles. Only in this way is targeted and rational management of therapy possible. The emergence of bacteria resistant to multiple antibiotics is largely a consequence of practices within the medical sector. This was particularly evident during the pandemic, when global regulations on antibiotic use were disrupted, significantly accelerating the spread of such strains. Bacteria are constantly seeking ways to survive—this is their natural instinct. Consequently, when antibiotics are used improperly, we are precisely the ones enhancing their adaptive capacity. While it is true that complete prevention of resistance is impossible, the targeted and controlled use of antibiotics can significantly slow this process and allow us to preserve the effectiveness of therapeutic resources.
GLASS 2025: Global Action Plan and Priorities
The GLASS 2025 report identifies the expansion of national AMR (antimicrobial resistance) monitoring systems and the improvement of data reliability as key future priorities. This is driven by the fact that antimicrobial resistance levels remain high worldwide and are unevenly distributed across regions. Against the backdrop of increasing resistance among Gram-negative pathogens, the organization aims to increase the use of “Access” category antibiotics to 70% while reducing the consumption of “Watch” group antibiotics by 2030. The report also emphasizes the need for new research and investments targeting carbapenem-resistant pathogens. WHO places particular focus on improving monitoring and diagnostics, especially in low-income countries, noting that AMR surveillance should be integrated into routine practice in these settings and access to quality diagnostics must be expanded. In low- and middle-income countries, strengthening healthcare systems, expanding social protection, and reinforcing universal health coverage mechanisms are also essential to reduce the global burden of antimicrobial resistance.
Sources:
Global antibiotic resistance surveillance report 2025
