In 2012, a hospital in Kathmandu, Nepal, saw a deadly outbreak of multidrug-resistant Klebsiella pneumoniae, a bacterium that can cause pneumonia and infections of the urinary tract, bile duct, and surgical wounds. K. pneumoniae is one of the most common infections acquired in hospital, and certain strains are resistant to even the most powerful “last resort” antibiotics. Most disconcertingly of all, it also is a major source of drug-resistant genes that have spread to other pathogens.

The Kathmandu outbreak occurred in a high-dependency pediatric ward. These are hospital units one step down from intensive care, for patients needing a higher level of attention than those in an ordinary ward. Of 48 children who were infected, 36 died—a fatality rate of 75 percent. The outbreak was a case study in antimicrobial resistance and virulence of “an increasingly important global pathogen in a typical limited resource hospital,” write the authors of a study analyzing the outbreak.

As the growing threat of antimicrobial resistance (AMR) looms, it’s lower-income countries that will feel the impact most acutely, writes molecular microbiologist Stephen Baker in a recent paper in Science. “The political will and momentum to tackle AMR lies in higher-income countries,” he writes, “but the medical, social, and economic effects of AMR are likely to be felt more in lower-income countries.”

Part of the reason for this is that AMR strains of bacteria arise more often in lower-income countries. To begin with, these areas tend to have more severe infection-causing pathogens, like tuberculosis and typhoid fever. There are also typically fewer restrictions on the use of antimicrobial drugs, which are often widely available for purchase in the wider population, leading to unfinished drug courses and overuse. The same drugs used for humans are also often used for livestock, speeding along the emergence of multidrug-resistant strains.

But even in high-income countries, the situation leaves a lot to be desired, writes infectious disease researcher Manos Perros in a second Science paper. “Innovation in antimicrobial research lags behind other disease areas such as oncology,” he writes. Few new antibiotics are being researched and approved. Relative to other diseases, research into drug-resistant pathogens is chronically underfunded, he argues.

A lack of new drugs isn’t the only shortfall in our failure to address AMR, though. Baker identifies the use of antibiotics without proper diagnostic testing as an essential part of the problem in lower-income countries: antibiotics are often prescribed without doctors first testing to find out what pathogen is causing the infection.

But this is far from being only a third-world problem. Perros explains that the bacterium that caused the outbreak in Nepal, K. pneumoniae, is sometimes resistant to a class of antibiotics called cephalosporins. In these cases, it needs to be treated with a “last-resort” antibiotic, carbapenem. In the United States and northern Europe, only five to ten percent of cases of K. pneumoniae are resistant to cephalosporins, but U.S. and European doctors routinely prescribe the last-resort carbapenem anyway, which will the emergence of deadly carbapenem-resistant strains.

This isn’t because doctors are being irresponsible with their prescriptions. Rather, it’s because prescribing a drug that might be ineffective could put the patient’s life at risk, so it’s safer to move straight to the big guns.

The real problem is the lack of fast diagnostic tests, says Perros. Diagnosing a bacterial infection means testing for different kinds of drug resistance, which can take two to three days—too long to wait when treating a patient with a severe infection. While faster tests are being developed, they need further improvements before they can be widely adopted, especially in low- and middle-income countries.

As poor as the situation in high-income countries is, the rest of the world has a lot of catching up to do, Baker writes. “The impact of AMR in low-income countries is severe and likely to worsen,” he writes, and just developing new drugs won’t solve the problem in the long term. If new drugs enter a system where antibiotics are already misused, the impact would be short-term and might ultimately contribute to the emergence of more life-threatening pathogens.

The most vital steps to be taken are restricting antibiotic use in livestock, he writes, while agreeing with Perros that diagnostic testing is essential. If infections could be diagnosed quickly, most patients could be treated with older, still effective antibiotics. The few patients infected with AMR strains of pathogens could be treated with new, more highly targeted drugs, slowing the development of pathogens that are resistant to the most powerful weapons in our antimicrobial arsenal.

This wouldn’t completely end the problem of antimicrobial resistance, but it would be “a more sustainable practice,” argues Perros, “both in terms of clinical care and antibiotic stewardship.”

Science, 2015. DOI: 10.1126/science.aaa2868, 10.1126/science.aaa3048 (About DOIs).