Superbug threat is 'ticking time bomb'

There are claims across the media that antibiotic resistance is a ‘ticking time bomb’, with the Daily Express claiming “Superbug threat 'ranks alongside terrorism'”.

These headlines reflect the views of England’s Chief Medical Officer, and arguably could be viewed as understated.

The Chief Medical Officer, Professor Dame Sally Davies, warned of the growing threat from antibiotic resistance ahead of the publication of an in-depth report on the issue (PDF, 3.5MB). In her report, Professor Davies says antimicrobial resistance represents a threat that may be ‘as important as climate change for the world’.

Antimicrobials (drugs used to treat infections from bacteria, viruses and fungi) include antibiotics, which are an essential component of modern medicine and used to treat bacterial infections.

Increasingly widespread use of antimicrobials, and antibiotics in particular, is leading to the organisms causing these infections adapting and surviving. As this resistance develops, it can render treatment of infections less effective and eventually the infections may become untreatable.

Antibiotic-resistant infections, such as MRSA and multi-drug resistant tuberculosis have been increasing over the last two decades; yet few new antibiotics have been developed. While the spread of antimicrobial resistance can be slowed (for example, by good hygiene), new antibiotics are needed to more fully address the problem.

Antibiotic resistance – new threats

The main causes of resistant bacterial infections such as MRSA and Clostridium difficile have fallen sharply in the UK due to simple but effective hospital hygiene measures.

Yet the Chief Medical Officer’s report highlights other causes for concern, such as:

multi-drug resistant tuberculosis – estimated to kill 150,000 each year globally

E. coli – which now accounts for one in three cases of bacterial infections in the blood in the UK

NDM-1 – a bacteria detected in India, of which some strains are resistant to all types of antibiotics

What is antibiotic resistance and how does it develop?

Antibiotics are often used to treat bacterial infections, and are a cornerstone of infectious disease care. They have transformed medical care since they became widely available after World War Two – resulting in a sharp drop in deaths from infectious disease.

However, bacteria evolve in response to their environment. Over time, they can develop mechanisms to survive a course of antibiotic treatment.

This ‘resistance’ to treatment starts as a random mutation in the bacteria’s genetic code, or the transfer of small pieces of DNA between bacteria. If the mutations are favourable to them, they are more likely to survive treatment, more likely to be able to replicate and therefore more likely pass on their resistant nature to future generations of bacteria. When taken correctly, antibiotics will kill most non-resistant bacteria, so these resistant strains can become the dominant strain of a bacteria. This means when people become infected, existing treatments may be unable to stop the infections.

We cannot stop the random DNA mutations that are one way antibiotic resistant strains of bacteria emerge. However, we can exert some control over the speed and spread of antibiotic resistance by several methods, such as:

Breadth of use: the more antibiotics are used, the more quickly resistance generally develops, this makes reducing unnecessary use important (both in healthcare and other fields such as veterinary medicine).

Incorrect use: resistance is more likely to spread if you do not finish a course of antibiotic treatment (as the drugs won’t have a chance to kill off all the bacteria), or if broad-spectrum antibiotics, which often serve as ‘last-line’ treatments, are used where a more narrow and targeted option is available and appropriate.

Infection control: containing and preventing infectious diseases – such as through diligent cleaning and hand washing – can reduce the need for antibiotic use.

How much of a danger is antibiotic resistance?

Antibiotic resistance can render previously treatable infections untreatable. For instance, tuberculosis (TB) cases have been increasing steadily in the UK for the past 20 years, with an increasing number of cases being resistant to the first-choice antibiotics traditionally used to treat the infection.

Widespread antibiotic resistance could have a far reaching healthcare impact. For example, emerging antibiotic resistance increases the chance that surgical sites could be infected by bacteria resistant to antibiotics and cause infection in people who may already be vulnerable as a result of their underlying illness or from having major surgery.

The Chief Medical Officer says that other treatments which lower our immune response – including immunosuppressants (for example, to prevent the body rejecting transplanted organs) or chemotherapy for cancer – would also not be viable in the face of widespread antibiotic resistance. 

Professor Davies, has said that “antimicrobial resistance poses a catastrophic threat. If we don’t act now, any one of us could go into hospital in 20 years for minor surgery and die because of an ordinary infection that can’t be treated by antibiotics. And routine operations like hip replacements or organ transplants could be deadly because of the risk of infection”.

Why have no new antibiotics been developed?

Critics of the pharmaceutical industry would argue that the reason is simple – there is no profit in it.

This has been disputed by the pharmaceutical industry. An industry spokesperson quoted in The Guardian pointed out that there are ‘pharmaceutical companies actively involved in

researching and developing new antimicrobial medicines’.

The Chief Medical Officer argues that the best way forward would be a public-private partnership, where governments help support and fund the work of drug companies in order to create new antibiotics.

What has the Chief Medical Officer called for?

The Chief Medical Officer wants action to tackle antibiotic/antimicrobial resistance in several areas. She wants to change the medical practices that increase the risk of developing or exacerbating resistance, to improve government monitoring of (and response to) emerging resistance, and to create incentives for new antibiotics to be developed.

In healthcare in particular, the Chief Medical Officer recommends:

antimicrobial resistance to be added to the national risk register (a series of contingency plans designed to co-ordinate government response to civil emergencies), and to be taken seriously by politicians worldwide

improving the monitoring and surveillance of resistance, both within the NHS and worldwide

co-ordination of efforts between the healthcare and pharmaceutical industries to prevent resistance to current antibiotics from developing and spreading, and to encourage the discovery and development of new antibiotics

improving hygiene measures to prevent the spread of healthcare-associated infections

The Chief Medical Officer also wants action on antimicrobial resistance beyond hospitals and other areas of healthcare, including:

better home and community based infection control measures

a focus on antibiotic resistance in animals, managed by the Department for Food, Environmental and Rural Affairs

co-operation between Public Health England and the NHS to improve the detection and treatment of infections acquired abroad

better promotion of vaccination programmes, reducing the need for some antibiotic treatments

What is likely to happen next?

The Department of Health is due to publish a UK Antimicrobial Resistance Strategy, outlining how it will take steps to address this issue. This will include plans to:

support responsible antibiotic use

improve surveillance mechanisms

encourage the development of new diagnostic tests, therapies and antibiotics

What can we do to prevent antibiotic resistance?

We can all take steps to help slow the spread of resistant microbes.

Understanding when antibiotics are appropriate can be complicated. We often think of antibiotics being used to treat “a chest infection”, yet most common respiratory infections will go away on their own without any treatment. In addition; most coughs, colds and sore throats are caused by viruses, rather than bacteria, so an antibiotic would be not be an effective treatment for them. If we use antibiotics to treat these relatively minor viral complaints, not only is the treatment ineffective, it increases the chances of antibiotic resistance developing, making other more serious conditions such as TB more difficult to treat.

If your doctor does prescribe antibiotics for you, make sure that you’ve discussed and understood how to take them correctly, and that you take all the prescribed pills, regardless of whether you still have symptoms. This is because if you do not take the full prescribed dose, the chances are that some of the bacteria will not be killed, and that these are more likely to be resistant strains. This could be bad for you, and it could be bad for lots of other people too.

Read more about what you can do to tackle the problem of antibiotic resistance. /NHS