What next against the microbes?

Anti-microbial resistance is a rapidly growing problem and one that is going to hit future generations hard. Back in march this year, Margret Chan, director of the World Health Organization, highlighted in a speech to ECCMID (European Congress of Clinical Microbiology and. Infectious Diseases) the risk of the last 80 years of medical advances being wiped out in one stroke as bacterial diseases such as TB and even E. coli infections become once again fatal. Maternal death rates will rise and even a grazed knee could put a toddler at risk of serious illness. Procedures such as hip replacements and organ transplants could not go ahead. Even something as common place as an appendectomy would become a high risk procedure.

So how do we slow this advance? What other options do we have? There are three main directions of approach that are being taken.

Firstly, the antibiotics that we currently have must be used correctly. This means using them in the right combinations and in the right situations. Antibiotic resistance was first noted in the late 1950s when the drugs were used in vast quantities to promote livestock growth. The Swann report banned such use of drugs then involved in human medicine in 1969 however, a decade is more than enough time for plasmids coding for enzymes conferring resistance to enter the gene pool and these developments were more seen as "voluntary reforms" rather than an out-right ban. Ways around the ban were quickly found as more antibiotics were discovered.



In recent months however, the FDA has been accused of withdrawing proposals for back in 1977 (that ban the use of penicillin and tetracycline antibiotics in farm animals) in the USA. To respond to this accusation, a new ban on cephalosporin antibiotics was announced in January if this year. This ban only has an effect on around 0.2% of antibiotics currently used on American farms. In Europe, all-encompassing bans have stood for well over a decade.

In more recent years, GPs have reported patients demanding antibiotics for colds (which are caused by viruses, thus antibiotics will, at best, have a placebo effect) and, more frequently, failing to finish a course of antibiotics as they felt better after only a few days. These situations both lead to increased levels of resistance in populations of bacteria. Here it lies in the individuals’ responsibility to use their common sense and simply read a set of instructions on a packet. However it is surprising how frequently people fail to do so.

An important focus in the correct use of antibiotics is in using the right drug for the infection presenting; this means a vast improvement in many current diagnostic techniques. This is crucial in the tackling of super-bugs. The drugs used to treat such illnesses tend to have many toxic side effects, and you risk increasing antibiotic resistance in the bacterial strain if it is overly exposed to less than fully effective antibiotic. 

Currently, the average, well-supplied hospital in the developed world takes around 48 hours to fully identify a bacterial strain (samples must be taken, sent to a lab, grown up and then returned with information about the strain and appropriate drugs). A new approach, discussed at the ECCMID, was the promotion of “labs on a chip” technology (such as those already in use for AIDs or liver disease diagnosis) which would allow treatment to be tailored to the infection much more efficiently.

The second area is the development of new antibiotic drugs. In the four years between 2008 and 2012 only two new antibiotic drugs were improved for human consumption but back between 1983 and 1987 the FAD (Federal Drug Administration in the USA) approved the use of 16 new antibiotics. The problem really lies (as it often does) in the money.  A course of antibiotics is usually taken for a few weeks whilst a drug to lower cholesterol or to increase longevity will be taken for life. The comparative profit in antibiotics is small.

A complete overhaul of the drugs industry would be ideal, whereby the financial rewards are based around in usefulness of the drugs rather than the quantity sold. This is unlikely. However the pharmaceutical company GlaxoSmithKline announced last year that is involved in a $40million contact with the Biomedical Advanced Research and Development Authority and the Defence Threat Reduction Agency (two USA government agencies). It seems that the potential threat of bioterrorism is enough to get people putting up the cash.

Finally, as always it is the simple things that make the difference. Proper hand washing in hospitals, going back to the basics of regulated sterilizing techniques, has seen a fall of 80% in cases of MRSA infections in NHS hospitals since the peak in 2003. Infection control had become lax due to over reliance on the power of antimicrobial drugs.

Multi-drug resistance is not a problem that will go away; it will become a greater and greater issue to future generations. But many agencies and organisations are now working on solutions and new approaches to give us more time for the next Fleming to revolutionise medicine again.

Published in The Yorker October 19th, 2012