Unless we solve the problem of antimicrobial resistance to drugs, we will be facing a post-antibiotic era where things as common as strep throat infection or a child’s scratched knee could once again kill, said Dr Margaret Chan, Director-General of the World Health Organization (WHO), in a speech she gave at an EU conference last week in Copenhagen, Denmark.
Such a prospect would bring a halt to modern medicine as we know it, said Chan:
“Some sophisticated interventions, like hip replacements, organ transplants, cancer chemotherapy, and care of preterm infants, would become far more difficult or even too dangerous to undertake,” she warned.
Chan was addressing a European Union conference on combating antimicrobial resistance (AMR) that was attended by experts and civil servants from EU countries, plus representatives from candidate nations and organizations such as the European Centre for Disease Prevention and Control (ECDC) and the European Food Safety Authority (EFSA).
The purpose of the conference was to highlight the action that is needed now, to prevent further spread of antimicrobial resistance or AMR, calling for an integrated approach in both human and animal populations, as there is a clear link between consumption of antibiotics in animals and resistance development in people.
Chan took the opportunity to congratulate the EU on its approach, and to remind delegates that AMR is a global problem, and there are parts of the world that are in desperate need of help if the whole world is to win the fight.
Just sorting the problem out in our our own back yard will not be enough:
“Drug-resistant pathogens are notorious globe-trotters. They travel well in infected air passengers and through global trade in food. In addition, the growth of medical tourism has accelerated the international spread of hospital-acquired infections that are frequently resistant to multiple drugs,” said Chan.
AMR is a natural process: sooner or later, germs evolve resistance to an antibiotic. Before widespread use of antibiotics, there were already low levels of resistant bacteria, but because use has become more widespread, and there has been an increase in unnecessary and inappropriate use of antibiotics, the resistant bacteria have multiplied and spread, to the point where some strains are now resistant to several drugs (multidrug-resistant, MDR).
Under these conditions, the lifespan of antibiotics becomes shorter and shorter, to the point where pharmaceutical companies can’t see any value in developing new drugs, because they aren’t going to recoup the huge investments in research and development.
So three conditions come together the create the AMR crisis: increasing and inappropriate use of antibiotics in humans and animals accelerates the emergence of resistant strains of germs, increasing world travel of humans and foods spreads resistant strains more widely and more rapidly, and a “dry pharmaceutical pipeline” means no new drugs to fight with in the future.
We are now beginning to see common and life-threatening infections becoming very difficult and even impossible to treat. WHO and other global organizations are arguing that it is time for nations to take much stronger action.
WHO recently published a book, “The evolving threat of antimicrobial resistance – Options for action” that describes examples of policy activities that have addressed AMR in different parts of the world. It aims to raise awareness and to stimulate further coordinated efforts.
In her speech, Chan outlined the progress that has been made in Europe, and in Denmark in particular, drawing attention to some countries that have successfully followed the Danish model, and then turned to the huge problems in developing nations, who are struggling with lack of infrastructure and threats from things like counterfeit drugs.
The threat of AMR has an “irrefutable logic”, said Chan. It is on the rise in Europe and the rest of the world. We are losing our first-line antibiotics, and replacement treatments are more expensive, more toxic, with longer times to treat, and may mean patients spending time in intensive care.
In the meantime, rates of death for patients infected with drug-resistant germs are rising. She gave the example of what is happening with TB.
In 2010 there were 12 million cases of TB, of which the WHO estimates some 650,000 involved multidrug-resistant TB (MDR- TB) strains that do not respond to first-line drugs.
“Treatment of MDR-TB is extremely complicated, typically requiring two years of medication with toxic and expensive medicines, some of which are in constant short supply. Even with the best of care, only slightly more than 50% of these patients will be cured,” said Chan.
But TB is only one of the many pathogens that are developing resistance to multiple drugs. And some pathogens are now resistant to all available drugs.
“Hospitals have become hotbeds for highly-resistant pathogens, like MRSA, ESBL, and CPE, increasing the risk that hospitalization kills instead of cures. These are end-of-the-road pathogens that are resistant to last-line antimicrobials,” said Chan.
Chan praised the work of the ECDC, in so quickly conducting risk assessments of the spread of NDM-1-producing bacteria within Europe. And she also praised Denmark’s pioneering approach to tackling the problem of antibiotic use in food-producing animals:
“Recognizing the potential for a health crisis, this country progressively ended the administration of antibiotics as growth-promoters in the late 1990s, well before the EU-wide ban,” she said.
A WHO international review panel concluded the Danish ban reduced human health risks without significantly harming animal health or farmers’ incomes.
Since then, industry and government data suggest that Denmark’s livestock and poultry production increased following the ban, while antibiotic resistance on farms and in meat declined.
Chan said there is much that we can do to limit “selective pressure” on bacteria to develop resistance. With a concerted effort, we can slow the process right down, to the point where antibiotics have a long lifetime again, and bringing out new drugs becomes a worthwhile thing to invest in.
In the new book, WHO recommend a number of ways to combat AMR:
- Prescribe antibiotics appropriately and only when needed.
- Follow treatment correctly (treatments that are interrupted, terminated early, or adminstered incorrectly can increase the speed of AMR).
- Use antibiotics in livestock production only to treat illness: not as growth promoters.
- Tackle the problem of substandard and counterfeit medicines.
Chan praised the EU’s actions in many of these areas. She mentioned the EU’s “unprecedented collaborative R&D effort” to bring new antibiotics to market. And, in the area of both human and animal health, she praised the EU’s emphasis on prevention of infections in the first place, such as through vaccines and better hygiene.
But there are many areas where this is not happening, and she called for “political will at the highest level” to address the problem. Attention is still “sporadic”, and actions are much too “inadequate”.
“In my personal view, one problem is that the threat of antimicrobial resistance is competing for attention in a world beset by one global crisis after another. These days, doomsday scenarios are a dime a dozen,” said Chan.
But, the problem is a global threat, most starkingly illustrated by examining how developing nations are struggling to deal with it, as Chan explained:
“Many countries are crippled by lack of capacity, including laboratory, diagnostic, quality assurance, regulatory, and surveillance capacity, and control over how antimicrobials are obtained and used.”
“For example, anti-malaria pills are sold individually at the local marketplace. Counterfeit and substandard antibiotics abound. In many countries, the pharmaceutical industry is the principal source of prescribing information for doctors,” said Chan.
“Good public health practices are undermined by utter poverty. When resources are extremely limited, will a doctor use precious money to treat as many patients as possible, or invest in diagnostic tests? When people travel very great distances to reach a health post, they want something in return. They demand something: an injection or some pills. They do not take “no” for an answer,” she added.
Chan said the new WHO book outlines these challenges, and also the many strategies and initiatives that are addressing them successfully.
“We have many challenges ahead, and a long way to go. But we have solid success to build on. And we are steadily on our way,” said Chan.
Written by Catharine Paddock PhD