“I’m worried,” announced Dame Sally Davies, the UK chief medical officer and author of The Drugs Don’t Work, in a TEDx presentation in September 2013.
Her concerns for the future are shared by health professionals and policymakers all over the world. The issue of antibiotic resistance has become an increasing, ubiquitous and ever-present threat to health care that could potentially throw modern medicine back to the early 19th century.
The speech echoes her
annual report published in March, in which she stated that antimicrobial resistance (AMR) poses a “catastrophic threat” to world health. In Europe, 25,000 people a year die of sepsis (bacteria entering the bloodstream), largely due to drug-resistant bugs. In the US, the “conservative estimate” is 23,000. And in Southeast Asia, a young child or baby dies every five minutes because of antibiotic resistance.
So-called “Gram negative” bacteria, such as E. coli and Klebsiella pheumoniae, have developed strains that are impervious to antibiotic treatment. Other diseases, such as tuberculosis, have also developed resistance. Even the last-line class of antibiotics, the carbapenems, have become useless in fighting these superbugs.
GETTING CLOSER TO THE CLIFF
A 114-page report, “
,” published by the US Antibiotic Resistance Threats Centers for Disease Control and Prevention in September 2013 stated that at least 2 million US residents succumb to infection from antibiotic-resistant bacteria every year, and more than 23,000 die from those infections. It also lists infections from 17 different drug-resistant bacteria – one of which is resistant to nearly all the antibiotics available and has been discovered in health-care facilities in 44 US states. Dr. Michael Bell, a spokesperson for the CDC, remarked, “We are getting closer and closer to the cliff.”Several factors contribute to this alarming turn of events. Overuse of prescription antibiotic drugs is cited as a main cause of AMR. The CDC holds that about half the antibiotics prescribed for human use is “not needed or not optimally effective.” Its report cites that, for every 1,000 persons of all ages in the US, between 500 and 1200 prescriptions for antibiotics were issued, with great variance from state to state.
Licensed medical practitioners have been too quick to prescribe antibiotics for viral illnesses that don’t respond to them, such as influenza and the common cold. Incorrect use of antibiotics contributes to growing AMR, for example when medication is prescribed to combat a disease such as tuberculosis and the proper antibiotic course is not completed. The remaining, stronger bacteria that weren’t initially killed live on, generate more and stronger bacteria and can pass on their resistance to others.
Bacteria have also developed new resistance mechanisms, such as enzymes, that help them destroy last-line antibiotics. This type of resistance has cropped up even in ordinary human pathogens, such as E. coli, which can cause bowel and urinary tract infection.
Another problem consists in the excessive amount of antibiotics administered to livestock and fish in the food industry. “One-third of countries globally use antibiotics instead of hygiene as a cheap way to fatten meat and fish up,” says Davies. The US government estimates that more than 70% of the antibiotics used in the country are administered to animals to make them grow faster. The CDC condemns this practice as “unnecessary and inappropriate.”
NO NEW ANTIBIOTICS FOR 26 YEARS
Despite the direness of the situation, no new antibiotics have been discovered since 1987. “The cupboard is bare,” says Davies, because pharmaceutical companies have no real incentive to produce new ones. As opposed to an antibiotic, which someone might take for an illness for one week once a year, patients with diabetes, high blood pressure or high cholesterol take a table every day for the rest of their lives. “No prizes for seeing where the money is for the shareholders of pharma companies and why we have an empty pipeline,” she remarks.
The gravity of the situation goes far beyond the prospect of not having an antibiotic to deal with your sore throat when you’re sick. People with weaker or suppressed immune systems, such as diabetics and AIDS patients, will pick up bugs more quickly and easily and will not be able to receive life-saving treatment for them. Without effective antibiotics, “we won’t have good modern cancer treatment,” explains Davies. Transplants will become impossible. Premature babies will get sepsis and die. Routine operations will become far more difficult and dangerous. And the health-care and other associate costs are incalculable. Varying estimates place the amount to the US alone as high as $20 billion in direct health-care costs, with additional costs to society in lost productivity at up to $35 billion a year.
Already diseases such as tuberculosis and gonorrhoea, previously believed to be held in check or on the wane, are making a comeback due to the antibiotic resistance of the pathogens that cause them. Some diseases, such as gonorrhoea, are impossible to treat without antibiotics. In the US, the CDC has identified three strains of bacteria that pose an urgent threat, with another 12 pathogens (including one fungus) classified as “serious” and a further three as “concerning.”
The problem is so severe that the UK
Antimicrobial Resistance Strategy is calling on the government to list it along with climate change, terrorism and a possible flu pandemic on the National Risk Register during the next assessment in 2014. The European Centre for Disease Prevention and Control have been increasingly active in raising political and public awareness of this urgent and calamitous situation with programs such as European Antibiotic Awareness Day, during which they did a live question and answer on Twitter. And the Innovative Medicines Initiative has invested in a program called Combatting Bacterial Resistance in Europe, which seeks to support the discovery of new antibiotics. The CDC holds an annual Get Smart About Antibiotics week from 18 to 24 November.
“This is very serious,” warns Davies. “If we don’t preserve the antibiotics we’ve already got and develop new antibiotics, we’re going to have a problem… and modern medicine as we know it is not going to be there.”