Apocalypse Now? Antimicrobial Resistance

It takes a global team to diffuse a ‘ticking time bomb’!

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Today, we received the news via the WHO and Imperial College London that women in South Korea and other industrialised nations will have an average life expectancy of 90 years by 2030. Progress on longevity would seem to be inexorable. Yet will this really turn out to be the case? A recent news story concerning the death of a 70 year old woman in America seems to throw this positive scenario into doubt…

In January, a BBC News headline ran, ‘Bug resistant to all antibiotics kills woman’. No fewer than 26 different antibiotics had been tried in an attempt to keep the woman in question alive, following an infection she’d picked up after a long stay in India (a nation well known for long-term and widespread misuse of antibiotics.) Of the 26 used, even Colistin, the drug of ‘last resort’ – one that’s kept under lock and key for only the very worst cases – had failed. Samples of the infection taken from her wound were sent to the Centre for Disease Control, which established she was infected with Klebsiella pneumoniae – a species of bacteria that normally lives in the gut without causing disease, but had spread out of control.

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It’s well known that prescribing antibiotics un-necessarily, and their misuse by patients, breeds bacterial resistance, rendering specific antibiotic drugs powerless over time. However, despite being someone who communicates regularly about health and disease, I was genuinely shocked by reading the slim, yet, powerful, Penguin paperback, The Drugs Don’t Work, by Professor Dame Sally Davies. Davies is the first female Chief Medical Officer for England, and an inspiring communicator. For sure, it takes highly effective communicators to get any ‘prevention is better than cure’ message across. As humans we are our own worst enemies, thanks to our ability to mentally discount potential threats…

The Drugs Don't Work book

The book starts with a whistlestop tour of antibiotic history, from the infamous accidental petri-dish discovery by ‘messy’ Alexander Fleming of bacteria-eating mould (penicillin), its timely mass production during WWII, through to development of other classes of antibiotic that have revolutionise not only medicine, but daily life – for the majority of the world.

A surgeon filmed by our team recently stated that without effective antibiotics, there’d be no surgery as we know it. Consider this: women undergoing C-sections (around a quarter of births), those undergoing hip or knee surgery, and many other surgical patients are routinely given these drugs as a preventative measure – as are chemotherapy and radiotherapy patients, whose immune systems are compromised.

Davies’ book serves as a warning in its largest sense: We have been using and abusing these life saving medicines to the extent that they are becoming redundant because, in the true Darwinian sense, survival of the fittest prevails: ‘bugs’ always fight back. Put simply, when antibiotics are abused (courses not completed by the patients, the wrong drugs prescribed, over-use by the veterinary and farming industry) any bacteria that survive the medicine will pass on resistance via their genes to the next generation of resistant bacteria.

A GLOBAL DECLARATION: TO ‘DIAGNOSE FIRST, NOT JUST TREAT’

Such is the seriousness of this ‘ticking time bomb’ that history was made in September 2016 when AMR became the subject of a United Nations High Level Meeting – only the fourth time ever that a health topic has made it onto the agenda.

The result was that 193 countries signed a declaration committing their nation to tacking the crisis, with a specific commitment to focus on innovative ways to improve diagnosis. (Only by diagnosing first, rather than prescribing antibiotics in an ‘un-targeted’ way, will this class of drug continue to be effective.)

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Worrying, the pharmaceutical industry has not kept up with a regular stream of new antibiotics in their drug pipelines because they see little profit in it. Their view is that the cost of development is not matched by the potential return on investment, partly as antibiotics tend only to be used for a matter of days rather than months or years, unlike drugs for diabetes, dementia, cancer and so on. Added to this, antibiotic misuse leads to resistance, shortening the overall saleability of their drug. Interestingly, a potential solution Dame Sally poses is extending the patent period from 20 to 25 years.

SOLUTIONS ARE NEEDED FAST! 

Certainly, solving the problem of antibiotic resistance won’t be easy, but Davies’ book offers several options. One of the most interesting involves the genomic revolution, whereby the ‘troublesome’ bacteria’s genetic code is mapped in order to tailor a precise treatment – rather than using the blunter option of treating it with a broad-spectrum drug (that would also kill off harmless bacteria).

Gene mapping can now be done for as little as £100 and is becoming an ever faster technique, which can make all the difference for the patient (given a population of bacteria can double in number of hours under the right conditions). That said, Davies cites the case of a major pharmaceutical company that spent 7 years testing over 500,000 compounds in 67 screening programmes against potential bacterial targets: In the end, only 5 showed any promise, and not a single compound made it to the clinical trial stage.

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Yet, far from only predicting apocalypse, Davies implores scientists and governments to work together to find solutions to counter the frightening scenario of going to the medicine cabinet, only to find it bare. For sure, incentives must be in place. As long ago as 1795, Napoleon, knowing an army ‘marches on its stomach’, put up a reward of 12,000 francs for whoever discovered a way to preserve food for his troops. Not long after, Nicholas Appert invented the canning process, using heat treatment of food in sealed champagne bottles. (We hope the champagne wasn’t wasted…)

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If Napoleon can do it unilaterally, surely we can club together at a global level to find new antibiotics to replace the ones that aren’t working. In the meantime, we must all preserve antibiotics for their right and proper use, and this requires education: Teaching people from a young age about microbial resistance will help, via projects such as the Europe-wide E-Bug www.e-bug.eu – tailored for various ages using engaging content such as animated characters to explain how resistance occurs. Teaching adults, too, is all-important, and the media have an important role: they recently reported that Klebsiella, which killed the woman above, is becoming resistant to chlorhexidine, an antimicrobial contained in some mouthwashes. Should we as consumers ask if this ingredient is essential to keep teeth and gums healthy, or must be saved for hospital?

EYES ON THE PRIZE

Coincidentally, there’s an C18th spirit surrounding the Longitude Prize which was set up in 2014 by British lottery-funded charity, Nesta. The project will donate £10m to an organisation that finds an easy, cost-effective test for bacterial infections which can be used by medics to determine if, and, when, to give out antibiotics. At this year’s annual meeting of the World Economic Forum at Davos, Switzerland, Dame Sally announced £250,000 in Discovery Award seed funding for tests that could win the main Longitude Prize. Expect to hear more about use of adjuvants – ‘resistance breakers’ and ‘antibiotic potentiators’ in future…

Some key facts:

  • Antibiotics add 20 years to our lives, on average
  • No new class of antibiotics has been discovered since the 1980s
  • Resistant bugs kills 25,000 per year in Europe, the same number dying from road traffic accidents
  • SCRUB UP! Practice regular hand washing for 20 seconds with soap and hot water – especially before eating. A study of 3,700 people at bars in Michigan showed that 1 in 10 people didn’t wash their hands, and a third didn’t use soap after using the lavatory!

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