Today, we live in an age where antimicrobials, in particular antibiotics, save lives, on average adding 20 years to life expectancy across the globe. Imagine if we reverted to a world without antibiotics. We would lose modern medicine as we know it.
Each year, around 4,000,000 operations are carried out in England and for most of these, antibiotics are key to preventing infections both pre- and post-operatively. One in four births in England is by caesarean section, where antibiotics are used to protect mother and baby. And half of women in the UK will suffer a urinary tract infection at some point in their lives and most of these will need antibiotics to treat the infection.
Most cancer treatments suppress the body’s ability to respond to infections, so antibiotics, antifungals and antivirals help to keep people alive while they receive routine cancer care. Meanwhile, anyone who has had a transplant knows that their life depends on antibiotics to treat and prevent life-threatening infections.
Without effective antibiotics, would you opt for routine surgery, such as hip replacement, if the risk of dying from infection was unreasonably high or would you soldier on with your dodgy hip? Would you opt for cancer treatment in a world without antibiotics or would you decline treatment and focus instead on ticking some things off your ‘bucket list’? We know which we would pick!
So why is antimicrobial resistance now a problem?
Antimicrobial resistance is a process of natural selection, both expected and not something we can prevent. When, in 1945, Alexander Fleming accepted his Nobel Prize for the discovery of penicillin, he predicted the development of resistance. Laboratory studies had shown how easy it was to make microbes resistant and Fleming reasoned that the same would happen in the body.
Resistance is something that develops in bacteria themselves, through spontaneous genetic mutation. Once it has occurred, resistant bacteria will survive treatment with antibiotics and will go on to reproduce, passing the resistant genes on to their off-spring. Resistance can also be passed side-ways, between bacteria, increasing the rate at which resistance develops. Resistant bacteria are then passed between hosts (human, animals or within the environment) through close contact – a process that is enhanced by poor sanitation and lack of attention to basic hygiene and infection control procedures.
Antimicrobial resistance was not a clinical problem in the 1960s, 70s and 80s. During this time we saw many new types of antimicrobial come to the market, meaning that when an infection became resistant to one drug, there was always another to turn to. However, this rapid drug discovery has stopped, partly because the ‘easy discoveries’ have already been made and partly because the business model for antimicrobials does not incentivise pharma companies to invest in drug discovery in this area. As such, the antibiotics currently on the market are based on chemical structures discovered 30 or more years ago. We are now starting to see cases of multi-drug resistance and in some cases extensive drug resistance – where the bacteria are resistant to some or most effective antibiotics. Extensively drug-resistant tuberculosis (TB) has now been identified in 100 countries.
While resistance is a process of natural selection, and thus something we cannot ultimately avoid, there are many instances where we use antibiotics inappropriately and therefore ‘drive’ the development of resistance. Antibiotics are only effective against bacterial infections, and even then specific antibiotics are only effective against specific bacterial infections. So, we need to make sure we use the right antibiotic, at the right time and at the right dose.
We know that only 10 per cent of sore throats benefit from antibiotic treatment (because most are viral), yet antibiotics are prescribed in as many as 60 per cent of cases, meaning that many of these prescriptions are unnecessary. A recent study found that nearly a third of antibiotics prescribed by doctors in the US were prescribed for conditions that do not respond to antibiotics. This translates to 47 million unnecessary prescriptions each year.
It is not only human health where antibiotics are prescribed inappropriately, it also happens in animal husbandry and fish farming where antibiotics are used widely for both growth promotion – where they are often incorporated into feed – and to prevent possible infection – in many cases this is done to compensate for poor sanitation and hygiene. In some cases, antibiotics are given to the whole herd/flock when one animal develops an infection rather than isolating and treating the sick animal.
The solution to tackling antimicrobial resistance is complex, and needs action by everyone across the globe. Any solution would include:
behavioural change – we need to move to a place where antibiotics are used only when clinically relevant (in human and animal health)
rapid diagnostics – we need to be able to quickly determine whether an infection is bacterial – and thus would respond to antibiotics – or viral – and therefore would not. Such tests need to be quick, cheap and heat stable so that they can be used anywhere in the world. This is why the Longitude Prize – a challenge with a £10 million prize fund to be won by the first team to develop a rapid diagnostic which meets the prize criteria – is so important.
better stewardship – we need international stewardship protocols to conserve and protect our antibiotics, using them only when clinically relevant.
improved surveillance of infections and resistant bacteria. If we do not know what resistance is out there, we cannot change and adapt our use of antibiotics accordingly. In some countries, surveillance systems are non-existent. Developed countries have a responsibility to support health systems in the developing world, which is why the UK government has set up the Fleming Fund – £265 million to support the development of laboratories and surveillance systems in the developing world.
alternatives to antibiotics – we need to find ways to reduce our reliance on antibiotics through greater use of other therapies, such as vaccines.
stimulate new drug discovery – we need to encourage basic research and innovation in academia and small and medium-sized enterprises, and the take up of promising compounds by big pharma. This is going to need a combination of ‘push’ and ‘pull’ mechanisms, and big pharma companies need to recognise their role – without antibiotics they do not have a sustainable business model as many of their other drugs are so reliant on effective antibiotics as part of the treatment regime.
prevent infections – this is perhaps the most important intervention, and one which we can all do. Meticulous hand-washing and basic hygiene prevent infections occurring and reduces the transfer of infections.
All of the above apply to animal health, and the use of antibiotics in farming, just as much as they apply to antibiotic use in human health. We know that resistance to antibiotics can develop in animals and the environment, and that these resistant bacteria can transfer to humans.
If antibiotics fail we could see a time where we all think twice about doing something as simple as gardening or shaving in case we cut ourselves, and the cut gets infected. Modern medicine simply would not be able to continue. We have a responsibility to the developing world, which would be hardest hit by drug-resistant infections including TB and malaria.
Antimicrobial resistance is something that is happening now, and we all have a role in the fight. We need to change our behaviour and recognise that antibiotics are a precious resource that we must look after and only use when there is a clinically justified reason for doing so.
If we do not, it is entirely possible that we could see a return to a situation where 40 per cent of the population die prematurely from infections we cannot treat.
The views expressed in this article are those of the author and are not presented as those of The King’s Fund. We have commissioned external authors to write for ‘The NHS if’ series as a way of presenting different perspectives on the future of health and care. We welcome a diversity of views on this issue and encourage you to leave your comments below.
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