How health systems are fueling antimicrobial resistance
Controls intended to limit antimicrobial exposure are frequently inconsistent, under-resourced or misaligned with operational realities.
Antimicrobial resistance is often framed as a clinical challenge that requires better prescribing. That framing is accurate, but incomplete.
Antimicrobial resistance (AMR) is better understood as system failure. It is the predictable outcome of how healthcare delivers care, how antibiotics are accessed and governed across regions, and how the broader food and environmental ecosystem contributes to microbial evolution. Even within high-performing institutions, the controls intended to limit unnecessary antimicrobial exposure are frequently inconsistent, under-resourced or misaligned with operational realities.
Part One of this series established AMR as a present crisis. Part Two examines the uncomfortable middle. It focuses on how the healthcare ecosystem continues to accelerate resistance, often through decisions that are operationally rational in the moment but strategically damaging over time.
Overuse and misuse
The most direct driver of AMR remains the volume and pattern of antimicrobial use. In everyday clinical practice, misuse is rarely dramatic.
It appears through antibiotics that are prescribed as a precaution rather than based on a confirmed infection; for antibiotics given for viral illnesses; for treatment initiated without diagnostic confirmation.
These behaviors are reinforced because of time pressure, diagnostic uncertainty, patient expectations and workflow constraints reinforce these behaviors. This is not primarily a clinician's knowledge problem. It is a system design problem.
When rapid diagnostics are unavailable or poorly integrated into clinical workflows, antibiotics become a default risk mitigation strategy. When reimbursement structures reward throughput more than diagnostic precision, "safe enough" prescribing becomes normalized.
Globally, antibiotic consumption has risen substantially. Geographic convergence in antibiotic use between 2000 and 2015 has been documented in the Proceedings of the National Academy of Sciences (PNAS) study on global antibiotic consumption. Increased volume directly increases selective pressure, particularly when prescribing controls and access governance are weak.
In many regions, misuse extends beyond formal clinical settings. Where antibiotics are available without a prescription, inappropriate use scales rapidly. A systematic review published in The Lancet Infectious Diseases documented the widespread issue of non-prescription antimicrobial use worldwide, increasing resistance risk through incomplete treatment courses, inappropriate drug selection and avoidable antimicrobial exposure.
Infection prevention breakdowns
If antimicrobial exposure provides the spark, infection prevention failures supply the oxygen.
Hospitals and clinics can become high-density transmission environments for resistant organisms when core controls break down, including hand hygiene and environmental cleaning; sterilization and reprocessing procedures; and device insertion and maintenance protocols.
Resistant infections prolong hospitalization, increase complications and drive further antimicrobial use. This creates a reinforcing feedback loop in which higher-acuity patients receive more antimicrobials, further increasing selective pressure.
The burden of healthcare-associated infections is particularly severe in resource-constrained settings. A major meta-analysis in The Lancet documented the burden of endemic healthcare-associated infection in developing countries, highlighting how infrastructure limitations and inconsistent infection control practices enable resistant pathogens to spread.
Well-resourced settings are not exempt. Research has demonstrated the negative impact of antibiotic resistance on healthcare delivery, including increased clinical complexity and poorer outcomes. Resistant organisms exploit the very features on which modern care depends, including invasive procedures, immunosuppressive therapies and frequent patient movement across care units.
Regulatory gaps and access without accountability
Where antibiotics are readily available, resistance is more easily generated.
In many countries, regulatory oversight is fragmented or inconsistently enforced. Even where policies exist, enforcement mechanisms may be weak, and economic incentives across distribution channels can promote over-the-counter sales.
Research on global antibiotic consumption demonstrates how policy and market dynamics shape use patterns, reinforcing the need for regulation paired with monitoring rather than guidelines alone, as indicated in this PNAS global consumption study.
AMR has increasingly been framed as a governance challenge that extends beyond the health sector. An analysis published in the Bulletin of the World Health Organization argued for an international legal framework to address AMR, reflecting the limits of voluntary alignment in a globalized market.
Agricultural use and resistance pressure
AMR does not originate solely in hospitals. Antibiotics used in agriculture for growth promotion or routine disease prevention create selective pressure at scale. Resistant organisms can spread through food handling and processing, consumption pathways and environmental contamination.
This shifts part of the downstream burden to clinical medicine.
These linkages have been documented across clinical and environmental literature, including work in Clinical Microbiology Reviews examining antimicrobial use in food animals and the impacts of antimicrobials on human health. Global patterns also matter. Antibiotic use in food animals has grown, with trends documented in PNAS research on global antimicrobial use in food animals.
This reinforces the point that One Health is not a conceptual slogan but an operational necessity. The Transactions of the Royal Society of Tropical Medicine and Hygiene described AMR as the quintessential One Health issue, emphasizing that resistance emerges at the intersection of human health, animal husbandry and environmental management.
Environmental pathways and persistent exposure
Antimicrobials and resistant organisms persist beyond their point of use.
Pharmaceutical manufacturing waste, agricultural runoff and improper disposal introduce antimicrobial compounds into water systems and ecosystems, creating low-level exposure environments that foster the development of resistance.
A review published in Chemosphere examined antibiotics in the aquatic environment and described how environmental contamination can drive the persistence of resistance. And environmental considerations in veterinary medicine have also been addressed in work on veterinary medicines in the environment (Royal Society of Chemistry), reflecting the fact that antimicrobial exposure pathways extend well beyond clinical walls.
Global movement and the limits of local control
Even when health systems perform well internally, resistant organisms do not remain local.
Global travel and trade accelerate the spread of resistant pathogens and resistance genes across borders. In this context, fragmented surveillance and inconsistent antibiotic governance represent structural vulnerabilities rather than isolated policy failures.
This is part of why global coordination has been repeatedly emphasized as essential to AMR containment, including in a recent article in The Lancet Infectious Diseases that called on the need for global solutions.
Culture, expectations and the human dimension
Belief systems also drive AMR. Public misunderstanding of antibiotics fuels demand for unnecessary prescriptions and incomplete adherence.
A systematic review in The Journal of Antimicrobial Chemotherapy found persistent misconceptions in the public's knowledge and beliefs about antibiotic resistance. In clinical practice, expectation pressure is tangible, particularly in settings constrained by limited visit time and competing priorities.
Taken together, these drivers explain why AMR persists. The problem is distributed across sectors, reinforced by everyday operational incentives, and often invisible until clinical failure occurs.
For health data and digital leaders, the implication is clear. AMR cannot be managed without visibility, feedback loops and accountability.
Effective oversight requires the ability to measure prescribing variation at provider and service-line levels; diagnostic confirmation rates relative to antibiotic initiation; resistance trends across patient populations and care settings; infection prevention compliance and early outbreak signals; and exposure patterns tied to devices, workflows, and length of stay.
In Part Three, the focus will shift from how controls break down to what works. This includes modern surveillance models such as genomics, stewardship programs embedded into workflows and EHRs, and the innovation pipeline that must accelerate if health systems are to outpace resistance.
Dr. Julia Rehman FACHE, FACHDM, is vice president – Middle East & North Africa (MENA) at the American College of Healthcare Executives and is the founder and chief operating officer of Kota Kompany.