While antimicrobial resistance is an unavoidable process of natural selection, tackling the issue involves solutions that must be adopted on a global scale, write Dame Sally Davies and Rebecca Sugden
The NHS, like other health systems, is facing huge financial pressure. Bold thinking is needed, and the King’s Fund has commissioned a series of articles asking authors to explore radical questions of “What if …” All of the articles can be accessed at The NHS if – essays on the future of health and care. This is one of them.
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 million 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.
Antimicrobial resistance is a process of natural selection, both expected and not something we can prevent
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.
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? 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.
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.
Antimicrobial resistance is something that is happening now, and we all have a role in the fight
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.
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.
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 have a responsibility to the developing world, which would be hardest hit by drug-resistant infections including tuberculosis and malaria
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.
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.
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.
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.
Alternatives to antibiotics – we need to find ways to reduce our reliance on antibiotics through a 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.
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.
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.
Laboratory studies had shown how easy it was to make microbes resistant and Fleming reasoned that the same would happen in the body
We have a responsibility to the developing world, which would be hardest hit by drug-resistant infections including tuberculosis and malaria.
Antimicrobial resistance is something that is happening now, and we all have a role in the fight.
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.
Professor Dame Sally Davies is the chief medical officer for England. Rebecca Sugden is the chief medical officer’s private secretary with responsibility for leading the CMO’s engagement on antimicrobial resistance and other areas of public health.