Antibiotics have been around for nearly 70 years. Many people still alive today may remember them first being used to treat casualties from the Second World War.
Around 1944 a newspaper billboard proclaimed that ‘Penicillin cures gonorrhoea in four hours – see your doctor today’ and yet in 2013 we saw the headline ‘Antibiotic apocalypse warning’. That’s a stark contrast, so what went wrong?
It is an unavoidable fact that any use of antibiotics, not only in people but also in animals feeds into the cycle of resistance. This is evolution at its most basic – if you try and kill bacteria they will change and adapt in order to survive. It is “survival of the fittest”.
It was in 1928 that Alexander Fleming first noted that a particular mould produced a substance that killed staphylococci bacteria. Sixteen years later this substance, named penicillin, was developed into the first antibiotic. Even in the relatively short time penicillin has been in use, there are many strains of bacteria which have evolved to become resistant to it: notably MRSA and gonorrhoea. Gonorrhoea is one of the diseases that we now worry may become untreatable.
Other antibiotic drugs have since been discovered, but resistance has also developed to varying degrees. Although there are still antibiotics available to treat most infections, doctors now may have to use combinations of drugs or turn to older antibiotics which have not been so widely used, as the more ‘modern’ ones are becoming less and less effective.
So what can be done to control resistance? We can slow its progress by reducing unnecessary use of antibiotics. It is uncomfortable, but major reductions are needed in the total amount of antibiotics used to slow the development of resistance. This reduces the pressure on the bacteria to adapt, and can be aided by having better diagnostic tests, reducing antibiotic use during surgery and preventing infection by good hygiene, including washing our hands after using the toilet and after handling raw meat and animals. Most of these are very simple measures.
A particular problem is the expectation that a visit to your GP will result in a prescription for antibiotics for a cough or cold. Of course when we have a bad cold or flu we want something to make us feel better, and research shows that most people want, and expect, antibiotics.
This is problematic in two ways. Firstly, antibiotics do not work on viral illnesses which cause most infections that produce runny noses, headaches and sore muscles. Secondly, this feeds into the cycle of resistance with the potentially disastrous outcome that in the future antibiotics won’t then work when you really need them.
There is no turning back now as we cannot easily ‘undo’ resistance. We are fighting against a natural process of evolution that will inexorably continue.
Here are a couple of ‘real life’ examples of the problem of antibiotic resistance. Resistance to the antibiotic of first choice by doctors in the treatment of tuberculosis is just over seven per cent. This means that of the four choices of antibiotic typically used, one does not work to treat the condition in over 7 in 100 cases. In a further 1-2 in 100 cases, two drugs out of a possible four choices may not work. History tells us that the problem will only get worse with time.
Another example is gonorrhoea. There were 25,525 cases of gonorrhoea in England during 2012. Historically penicillin was used, but the bacteria has long since developed resistance and had to be replaced with ciprofloxacin. However, this too had to be replaced as the gonococcus bacteria became resistant, and the next key drug was cefixime. In 2011 the use of this drug started to be compromised due to the bacteria yet again becoming resistant.
The disease is still treatable, but levels of resistance to antibiotics range from under 1 in 100 cases for azithromycin to 76 in 100 cases for tetracycline. This last drug has been in use since 1948, not specifically just for gonorrhoea but for a range of infections and again this shows that in a relatively short time - 65 years – that drugs can become almost redundant in the treatment of some infections.
The recent emergence of resistance to carbapenem antibiotics is possibly the most dangerous recent development in the story of antibiotic resistance. These are often used as antibiotics of ‘last resort’ for severe infections in hospital, and the genes responsible for this resistance can move from one species of bacteria to another. The result is that several different bacteria have become resistant in a short time. This problem is widespread in parts of Europe, and it is starting to develop as a problem in England.
So, why aren’t there enough new antibiotics? The development of any new antibiotic and getting it into mainstream use takes several years and cost several billion dollars. Added to this, the ideal new antibiotic is one we would rarely use except as a backup when other treatments fail, so the returns on investment for drug companies are less than for other drugs. There are measures being looked at to potentially address this such as partnerships between government, industry and academia, reducing regulatory hurdles and looking at the pricing structure for new antibiotics.
The continued reduction in our ability to treat infections is a very inconvenient truth. England’s Chief Medical Officer, Professor Dame Sally Davies, recently said “If we do not take responsibility now, in a few decades we may start dying from the most commonplace of operations and ailments that can today be treated easily”. The spread of antibiotic resistance is slowly creeping up on us and we all need to wake up to this problem and take action to carefully preserve what we do have.