While the world was watching the Texas water ballet with Melanie Trump on stiletto heels, about 1500 people died in South-East Asia because of floodings. And while the western world is searching for another irrelevant mcr-gene, Patrick Musicha soberly describes the true antibiotic resistance crisis in Malawi, see. It is becoming more and more obvious that antibiotic resistance will be the next plague for the least privileged on earth.

In all its simplicity (a description of the contents of a laboratory database) this paper depicts a gruesome picture. This was the setting: a 1000-bed hospital in Malawi where (between 1998 and 2016) sepsis was treated either with chloramphenicol and benzylpenicillin, or with ceftriaxone (available since 2004). During this period, antiretroviral therapy (ART) programmes, malaria control interventions, and improvements in food security and community management of malnutrition were rolled out. The proportion treated with ART (of those in need) increased from 2·3% in 2004 to 67·0% in 2014. Conjugate vaccines against Haemophilus influenzae type b (in 2002) and pneumococcus (in 2011) were widely implemented and there were considerable reductions in mortality among children younger than 5 years and among HIV-infected adults. So far, all well.

The paper describes the microbiology of blood cultures obtained from patients with fever when admitted to the hospital during the 18 years (1998-2016). Proportions of positive cultures declined, as did incidence rates with Salmonella species, Streptococcus pneumonia, Enterobacteriaceae and Staphyolococcus aureus. Still, all well.

Now for the Enterobacteriaceae: “ESBL production was first detected in E. coli in 2004 and in Klebsiella spp and other Enterobacteriaceae in 2003. Both frequency and incidence of ESBL-producing isolates have since increased markedly in all non-salmonella Enterobacteriaceae.” In 2016 proportions were around 20%, 85% and 80% for E. coli, Klebsiella species and other Enterobacteriaceae, respectively. That’s not good, especially as these are considered community-acquired infections.

Being a descriptive study, explanations are beyond its scope. What now could cause such an increase of resistance in the community in a country that controlled other diseases so effectively? Pneumococci almost disappeared as pathogen. I have never been there, but could it be antibiotic use (in humans or animals or both), or “ESBL-impregnated Dutch retail chicken meat”, or poor sanitation? Obviously, we definitely need studies over there to answer these questions.

The poorest parts of the world will pay the price of antibiotic resistance. Without efficient control measures it will be a matter of years for these ESBL strains produce carbapenamases. The new antibiotics that will (inevitably) come forward from recent and future investments will be expensive and will help us treat the next infectious complication in patients already benefiting from the achievements of modern medicine. Yet, will these antibiotics be available in lower-income countries? That, and XDR-TB, will depict the faces of AMR. Hope Bill Gates stays around for a while. (ego-quote from blog March 27, 2017).