A threat without a starting gun
Antibiotic resistance does not need a dramatic arrival to become a security problem. It can appear as an infection a clinician recognises but cannot treat as reliably as before, or as a hospital struggling to protect patients already made vulnerable by illness. The damage accumulates through ordinary care. Preparedness has to operate at that same level.
WHO's 2025 surveillance findings estimated that one in six laboratory-confirmed bacterial infections covered by its analysis in 2023 were resistant to antibiotic treatment. The report examined eight common bacterial pathogens and resistance to 22 antibiotics across selected infection types. The estimate concerns those infections and the evidence used to assess them. It is not a statement that one in six people, or one in six infections of every kind, face an identical risk.
Our argument is that resistance belongs inside biological-security planning because it erodes the reliability of the response itself. A health system needs treatments that work when patients become ill. Preserving that ability requires sustained attention to everyday clinical infrastructure, including the parts that rarely attract the language of national preparedness.
The burden is large; the definitions still matter
A 2024 analysis in The Lancet estimated that bacterial antimicrobial resistance was associated with 4.71 million deaths in 2021, including 1.14 million attributable to resistance. The two measures ask different questions. Associated deaths compare resistant infection with no infection; attributable deaths compare it with an equivalent drug-susceptible infection. Substituting one figure for the other changes the claim.
The study also found sharply different age trends: estimated deaths attributable to resistance fell by more than half among children under five between 1990 and 2021, while increasing by more than 80% among adults aged 70 and over. Its reference forecast projected 1.91 million attributable deaths annually in 2050. That is a modelled future under stated assumptions, not an observed outcome or an inevitability.
These distinctions matter for planning. A prevention programme, a treatment-access programme, and a new drug address different parts of the burden. A serious investment case should state which outcome it expects to change. Large aggregate numbers establish urgency; they do not determine the best intervention for a particular hospital or population.
The map is only as good as the reporting behind it
WHO reported that 48% of countries did not submit resistance data to GLASS for 2023, and that about half of reporting countries lacked systems capable of generating reliable data. Its surveillance announcement identifies limited laboratory and reporting capacity as a central obstacle. A country with less information should never be casually described as having less resistance.
The practical issue extends below national boundaries. Before comparing two facilities, researchers should establish who gets tested, what information is retained, how results are reported, and whether the records represent comparable patients. Those questions are the groundwork for interpretation. A larger database can amplify a hidden difference as easily as it can clarify a genuine trend.
Our view is that research funding should reward improvements in the evidence available to underserved settings. A useful project might help a hospital produce a consistent account of its own problem and connect that account to decisions about care. The value lies in the decisions made possible. An international dashboard is a means of sharing evidence; it should not become the endpoint that defines whether local work succeeded.
Access and stewardship have to advance together
Resistance is not a reason to make necessary treatment harder to obtain. WHO's AMR fact sheet identifies inappropriate use as a driver of resistance while also recognising inadequate access to medicines, diagnostics, and vaccines. It reports that Access-group antibiotics accounted for 53% of global human antibiotic use in 2022. These are medicines recommended as first choices for many common infections; the global 2030 target is at least 70%. That population-level target does not replace clinical judgement about an individual patient.
CDC's stewardship framework centres on measuring and improving prescribing and use. It explicitly recognises that programmes must fit different care settings. The objective is dependable treatment with fewer avoidable harms.
That requires attention to the conditions surrounding a prescription. Does the clinician have relevant information? Is appropriate expertise available? Can the patient obtain the medicine? Does feedback arrive soon enough to help? A research programme that measures only a reduction in consumption risks missing whether care improved. The stronger question is whether necessary treatment became more accurate, accessible, and accountable.
Prevention changes the amount of treatment required
WHO's 2024 infection-prevention report describes healthcare-associated infections as a persistent burden and a contributor to antimicrobial resistance. It identifies substantial preventable harm and links effective infection control to basic water, sanitation, and hygiene services. These are foundations of safe care, with consequences for patients and staff every day.
Vaccines provide another route to reducing treatment demand. A WHO modelling assessment released in October 2024 estimated that vaccines against 23 pathogens could reduce antibiotic use by 22%, or 2.5 billion defined daily doses annually. The scenario included better use of existing vaccines and development of vaccines not yet available. It was a potential impact estimate, not a reduction already achieved. A defined daily dose is a standard consumption measure, rather than a count of patients treated.
The research implication is that discovery and prevention should compete for funding on evidence of benefit, with implementation costs included. A promising intervention has to survive contact with staffing, supply, maintenance, and access constraints. Preventing an infection has value that never appears in a count of new therapeutics.
A candidate pipeline is not a treatment supply
In its June 2024 pipeline assessment, WHO reported 97 antibacterial agents in clinical development in 2023, up from 80 in 2021. Yet among 32 antibiotics targeting infections on its bacterial priority list, only 12 met its innovation criteria, and only four of those had activity against at least one critical-priority pathogen. The assessment also identified gaps affecting children, convenient oral formulations, and access to authorised products.
These findings show why a simple count of projects is an incomplete measure of progress. Candidates occupy different development stages, address different needs, and face different probabilities of reaching patients. The relevant question is whether the eventual portfolio can fill an important treatment gap under realistic delivery conditions.
Our position is that development plans should consider evaluation and access early. What evidence will establish the proposed benefit? Can the product be used in the settings carrying the burden? What diagnostic support would its use require? Who will sustain availability? These questions do not diminish scientific ambition. They specify what the science must ultimately accomplish and make the remaining uncertainties visible.
Make preparedness accountable to routine care
Resistance demands continuity across surveillance, prevention, diagnosis, treatment, and discovery. Each can produce a plausible success story in isolation while the patient remains poorly served. A new test that cannot inform a timely decision, an effective medicine that cannot be obtained, or a surveillance report that never reaches clinical teams leaves part of the problem unresolved.
We propose evaluating a biological-security research programme through the changes it enables in a defined setting. Establish the starting conditions. Identify the decision or service expected to improve. Measure the effect, including burdens transferred to staff or patients. Publish what did not work. These are practical standards for learning, and they leave room for ambitious discovery alongside improvements to existing systems.
Antibiotic resistance forces a precise definition of preparedness. The system has to function on an ordinary day, for a patient whose infection is already familiar, with the people and resources actually available. Building that reliability is a demanding scientific and institutional task. It is also where biological security becomes visible to the person who needs treatment.