{"id":5166,"date":"2020-04-08T10:20:32","date_gmt":"2020-04-08T10:20:32","guid":{"rendered":"https:\/\/randomthoughtsltd.com\/?p=5166"},"modified":"2024-04-06T17:06:23","modified_gmt":"2024-04-06T17:06:23","slug":"antimicrobial-resistance-can-we-outrun-evolution","status":"publish","type":"post","link":"https:\/\/randomthoughtsltd.com\/?p=5166","title":{"rendered":"Antimicrobial Resistance: Can We Outrun Evolution?"},"content":{"rendered":"\n

First published in the NASGP Newsletter in February, 2020<\/em><\/p>\n\n\n\n

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This was written at the end of January 2020. Since then Covid-19 has trumped almost every other medical challenge, but in the future we will need effective antibiotics all the more<\/strong>.<\/p>\n\n\n\n

In his Nobel prize acceptance speech Alexander Fleming sounded a note of warning. He had seen microbes acquiring resistance to penicillin and foresaw that misuse of the drug could undermine its effectiveness.<\/p>\n\n\n\n

Recently,\n at the Frontline Club across the road from Fleming\u2019s old lab, five \npeople whose work as journalists and doctors has helped to bring that \nthreat to public attention reviewed the current crisis. They included \nformer Chief Medical Officer for England Dame Sally Davies and Times \njournalist David Aaronovitch \u2013 whose life was saved by antibiotics when \nhe developed sepsis after a routine operation went wrong. They all \nexpressed the hope that, with a bit more pushing, antimicrobial \nresistance (AMR) will have its David Attenborough moment.<\/p>\n\n\n\n

Not at \nDavos; Health Secretary Matt Hancock\u2019s speech at the meeting of the \nworld\u2019s movers and shakers was anodyne. And coronoavirus has wiped other\n health threats from the headlines.<\/p>\n\n\n\n

In the pre-antibiotic era \u2013 \nonly 75 years ago \u2013 a tiny scratch could lead to sepsis and a 95% chance\n of death. In 2020, most trivial injuries need only simple antibiotics \nor none but, if you are unlucky, a multi-resistant organism can kill \nyou. The economic consequences of AMR are already alarming. It costs the\n NHS around \u00a3100 million each year. The estimates for 2050 are US$100 \ntrillion and 10 million deaths worldwide.<\/p>\n\n\n\n

Unless things change, over the next 30 years modern medicine will be undermined. If there were no antibiotics would you consent to a joint replacement or abdominal surgery? Would you accept chemotherapy? Would you let your kids go on an adventure holiday?<\/p>\n\n\n\n

If no-one is buying their money-spinning cancer treatments, drug companies might risk the investment to develop antimicrobials.<\/p><\/blockquote><\/figure>\n\n\n\n

Those who spoke at the Frontline Club hope it isn\u2019t too late. They hope we can develop new antimicrobials, reduce overuse and misuse to preserve the effectiveness of those we already have, and reduce the need for antimicrobial treatments.<\/p>\n\n\n\n

Because \nBig Pharma puts profits ahead of its social obligations, it\u2019s 30 years \nsince we last saw a new antimicrobial. Yet, if companies discover that \nno-one is buying their money-spinning cancer treatments because \nimmunocompromised patients are dying from resistant infections they \nmight decide to risk the investment to develop antimicrobials. Phages \noffer a new approach. Because that investment is huge, distasteful \nthough it may be to give Big Pharma tax-payers\u2019 money, partnership \nbetween governments, the pharmaceutical industry and charities is \nprobably essential.<\/p>\n\n\n\n

Meanwhile, we have to regard antimicrobials as\n a non-renewable resource and husband those we have. Antimicrobial \nstewardship is a mechanism through which everyone involved with \nantibiotics promotes good prescribing practice and monitors the results.\n It\u2019s worked in hospitals to reduce MRSA and C diff infections. \nHopefully the remit of stewardship includes being honest: not \nsuppressing press releases and not discouraging the acknowledgement of \nAMR on death certificates.<\/p>\n\n\n\n

There\u2019s been some progress. British GPs\n are now writing fewer prescriptions for antimicrobials. There are \nalways some patients whose demands can be hard to manage, but most \npeople don\u2019t expect antibiotics the way they did 20 years ago. And strep\n throats still respond to penicillin.<\/p>\n\n\n\n

It isn\u2019t just doctors who \nprescribe antibiotics. So, one must hope that paramedics and others are \nalso stewarding their prescribing. But in much of the poor world people \nstill die for want of an antibiotic. Where there are no proper medical \nservices there is no-one to turn to except quacks. How can the quacks be\n regulated?<\/p>\n\n\n\n

So far, so fairly good, but far more antibiotics are \nprescribed to cows than to humans. Not because animals are sick; it\u2019s to\n fatten them up. So, it\u2019s not surprising that it\u2019s in agriculture that a\n lot of the resistance develops. Use as growth stimulants in UK is \nfalling. Even in Bangladesh, where antimicrobial security has to be \nweighed against food security, educating farmers and vets and \nrestricting sales have dented the use of antibiotics.<\/p>\n\n\n\n

Resistance \nalso breeds in the antimicrobial-laden effluent we pump into our \nenvironment. Regulation and monitoring of discharges from pharmaceutical\n production plants is realistic, but unfortunately there is as yet no \nway of removing most medications from sewage. And we can\u2019t stop AMR \nspreading in the droppings of migrating birds.<\/p>\n\n\n\n

Prevention is \nbetter than cure. We can \u2013 we have to \u2013 reduce the need for \nantimicrobials. Fewer germs equals fewer infections. Epidemics arise in \ncrowded environments, and so does AMR. Provision of decent water \nsupplies and sanitation, better housing and adequate food may be out of a\n GP\u2019s control, and we can do little to bring political stability and \nreduce conflict, but we can all wash our hands properly. Hospital \ncampaigns do work \u2013 for a while, but even those who should know better \nbecome lax. In a toilet at my local hospital were four tatty notices \nabout hand washing. One bold poster, replaced regularly with a new one, \nwould demonstrate that the hospital takes handwashing seriously.<\/p>\n\n\n\n

Public education is the key. Some patients firmly believe that it is they, not the \u2018bugs\u2019, that have developed resistance to antibiotics. But AMR is now on the curriculum, and the young, who have their future to lose, should have a better understanding. I saw a sell-out musical at the Edinburgh Fringe in 2018, The Mould that Changed the World. It has spun off professional and school productions that are bringing the word about bacterial resistance to children and their parents.<\/p>\n\n\n\n

Young adults \ntoo need information in a form they relate to. Media and formats \ndesigned by millennials for millennials may make older people cringe, \nbut they will be more effective for their target audience than tasteful \nleaflets. And we shouldn\u2019t be afraid to shock: HIV ads in the 1980s \nworked. And how about a Love Island contestant with resistant GC?<\/p>\n\n\n\n

Then\n there\u2019s immunisation: modern medicine\u2019s biggest achievement at reducing\n infections. Medics and journalists must refute the misinformation \nspread by antivaxxers while new vaccines are developed.<\/p>\n\n\n\n

Is this \nanother war which we can never win? Can we outrun evolution? It\u2019s a much\n more difficult problem than tobacco control. WHO has been issuing \nregular resolutions on AMR since 1998. In 2011 CMO Dame Sally Davies \ndrew attention to the dangers, and \u2013 eventually, in 2014 \u2013 PM David \nCameron announced a review and called for global action. In 2019 the \nSecretary General of the UN endorsed it. Yes, actions have been taken, \nhere, there and around the world, but despite worthy promises there has \nbeen no One Health approach \u2013 governments, civil societies and \nindustrial organisations co-operating. Can Dame Sally\u2019s current work on \nthe UN Inter-Agency Coordination Group on AMR tip words into actions?<\/p>\n\n\n\n

Having\n no antimicrobials wouldn\u2019t be the end of life on earth \u2013 humans existed\n for thousands of years without them \u2013 but it would be the end of life \nas we have got used to living it. Going back to the fears and tragic \nearly deaths of the pre-antibiotic era is \u2013 let us hope \u2013 an avoidable \ndisaster.<\/p>\n\n\n\n

Postscript: <\/strong>Shortly after this article was written in late January 2020, it was announced that machine learning had generated a totally new antibiotic.<\/p>\n\n\n\n

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First published in the NASGP Newsletter in February, 2020 This was written at the end of January 2020. Since then Covid-19 has trumped almost every other medical challenge, but in the future we will need effective antibiotics all the more. In his Nobel prize acceptance speech Alexander Fleming sounded a note of warning. He had … <\/p>\n

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