Feb 10, 2013

Death by Infection, the End of Modern Medicine

A post-antibiotic era means, in effect, an end to modern medicine as we know it. Things as common as strep throat or a child’s scratched knee could once again kill.
~ Dr Margaret Chan, Director-General of the World Health Organization

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Death by Infection, the End of Modern Medicine
In its recent annual report on global risks, the World Economic Forum (WEF) concluded that “arguably the greatest risk . . . to human health comes in the form of antibiotic-resistant bacteria. We live in a bacterial world where we will never be able to stay ahead of the mutation curve. A test of our resilience is how far behind the curve we allow ourselves to fall.”

As I read those words I shuttered.

For example, operations are dependent on antibiotics. Operations we now take for granted like heart bypass or hip replacements might not be available to us in the not so distant future.

The reason is simple and straightforward - without effective antibiotics to treat potential infections the risk of death will be greater than the potential reward from the operation.

I started talking about this phenomena last year when I first read The Top Ten Facts About Antibiotics and Antibiotic Resistance. The facts were compiled to mark European Antibiotic Awareness Day.

While the facts presented below apply to the UK they can be extrapolated for other industrialized countries.

Not a single person I talked to had any idea what I was talking about.

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Top ten facts about antibiotics and antibiotic resistance

To mark European Antibiotic Awareness Day (EAAD) Professor David Livermore an international expert on antibiotic resistance and the HPA’s lead in this key area has devised his top ten facts about antibiotic resistance and antibiotics.

David’s top ten facts:

Antibiotics revolutionised medicine.
  • They make many different infectious diseases treatable and surgery much safer. Some medical procedures, such as transplants, would have been unthinkable without antibiotics as the risk of infection is too high.
Antibiotics carry the seeds of their own destruction.
  • Antibiotics kill sensitive bacteria whilst resistant ones, which arise naturally, survive to infect further patients. This is a great demonstration of Darwin's theory of natural selection, but one that creates problems for treatment.
Some antibiotics have already been lost to resistance.
  • Penicillin is no longer effective for staphylococcal wound infections, ampicillin (a form of penicillin) is no longer used for infections of the urinary tract and ciprofloxacin (a synthetic antibiotic) is now useless in treating gonorrhoea. Many more are under threat.
New antibiotics are hard to find and to licence.
  • From the 1940s to the 1990s the answer was to develop new antibiotics, but this development has slowed. New antibiotics are less profitable than treatments for chronic diseases, and much of the pharmaceutical industry now concentrates on other areas of medicine.
We need to try to slow the selection and spread of resistance.
  • That means not using antibiotics for common colds, which are viral infections and do not respond to antibiotics. It means using antibiotics better - the 'right drug, right dose, right duration'. It means preventing patients getting infected the first place - which includes everything from doctors washing their hands between patients to using condoms to stop the spread of resistant STIs.
We have had successes.
  • The number of cases of MRSA blood poisoning (bacteraemias) in English hospitals has been reduced by over 80 per cent since its peak early in 2003/4 largely by better infection control. New vaccines have reduced the number of bacteraemias due to Streptococcus pneumoniae, and particularly those due to resistant strains.
The tide of war against resistance runs against us although we win some battles.
  • Resistance is increasing in other pathogens, especially in those referred to as ‘gram-negative’ bacteria, which mostly cause infections in hospitalised patients. In the year 2000 two per cent of E. coli from bloodstream infections were resistant to cephalosporins (a group of antibiotics) and four per cent to ciprofloxacin (another antibiotic). These rates are now 11 per cent and 21 per cent respectively. This matters because infections with E. coli are common – these bacteria causes one third of all bloodstream infections, which number over 30,000 cases per year.
We are now using our ‘reserve’ antibiotics.
  • Rises in resistance like those seen for E. coli force doctors to use carbapenems, which were previously the 'reserve' antibiotics for use when other treatments had failed. But now we using carbapenems much more and are seeing the spread of resistance to them as well. This is due to enzymes that destroy carbapenems, called 'carbapenemases'. Bacteria with these enzymes cause infections that are very hard to treat.
Some of the other reserve antibiotics that doctors are now forced to use are toxic or not very effective.
  • You can still almost always find an antibiotic to treat any bacterial infection. But these are not ideal and cause other serious side effects or just aren’t as good at killing the bacteria. In severe infections, treatment has to start 'blind’ in that doctors don’t know what bacteria it is until they have identified it in the laboratory which can take two days. The more resistant the bacteria, the more likely the blind treatment will not work. Where there is blood poisoning (sepsis) that roughly doubles the risk of death, from 20 per cent to 40 per cent.

We must rise to these new challenges.
  • We can do this partly by 'antibiotic stewardship' which means getting the best out of the antibiotics we do have by choosing those most appropriate for the infection that are known to still be effective. To complement this we need good infection control, and to reduce the number of patients who get antibiotics when they don’t need them. New technological solutions are also needed with reinvigoration of antibiotic development and new diagnostic tests that will enable doctors to quickly identify which patients really need an antibiotic, and which one. This is key to much better-targeted antibiotic use in the future.
David said: “On European Antibiotic Awareness Day it is important for us to think about our attitudes towards antibiotics and how we use them.

“Over the last ten years or so there has been a major rise in the numbers of resistant bacteria and we cannot let this go unchecked. The fact that we are using our reserve antibiotics to treat some infections is of concern, as resistance is now increasing to them too.

“While disaster isn’t imminent just yet we do need to take action now to protect ourselves for the future.”

Source: Health Protection Agency

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