Proliferation of antibiotics and other anti-microbials in the ecosphere is resulting in serious negative consequences. First used to treat serious infections in the 1940s, antibiotics have saved millions of lives and transformed modern medicine, but during the last 70 years, bacteria have demonstrated the ability to mutate and become resistant to every antibiotic drug developed. Any instance where antibiotics are used exerts more biological pressure on bacteria, consequently promoting development of resistance. The more antibiotics used — the more quickly bacteria develop resistance.
According to the World Health Organization’s Essential Medicines and Health Products Information Portal, antimicrobial misuse leads not only to poor patient outcomes, unnecessary adverse reactions, higher costs, and wasted resources, but also to emerging resistance of bacteria to antimicrobials.
In a free access article entitled“Antibiotic resistance: global response needed” (The Lancet Infectious Diseases, Volume 13, Issue 12, Pages 1001 – 1003, December 2013 doi:10.1016/S1473-3099(13)70195-6 ) published in the 17 November 2013 online edition of the British medical journal, The Lancet Infectious Diseases, a team of UK public health officers notes that In 1945, Sir Alexander Fleming presciently warned of the danger of over-reliance on antibiotics, and the threat of bacteria developing resistance. They observe that 68 years later, Fleming’s apprehension has become a present reality, noting a warning from The Lancet Infectious Diseases Commission on antibiotic resistance (Laxminarayan, et al.) that “we are at the dawn of a postantibiotic era”, with “almost all disease-causing bacteria resistant to the antibiotics commonly used to treat them.” One needn’t be a medical scientist to deduce that the associated implications of that are dire.
A recent report issued by the Centers for Disease Control and Prevention also says antimicrobial resistance is now one of the most serious public health threats, with more than 2 million people developing infections from antibiotic-resistant bacteria every year in the United States, leading to at least 23,000 deaths. The report notes that some pathogenic organisms have even become resistant to multiple types or classes of antibiotics, and that the loss of effective antibiotics will undermine our ability to fight infectious diseases and manage infectious complications. Such complications are common in vulnerable patients undergoing chemotherapy for cancer, dialysis for renal failure, and surgery — especially organ transplantation, for which the ability to treat secondary infections is crucial. Healthcare providers are consequently forced to use antibiotics that may be more toxic and also frequently more expensive and less effective. Even when alternative treatments exist, research reveals that patients with resistant infections are often much more likely to die, with survivors experiencing longer hospital stays, delayed recuperation, and higher rates of consequential long-term disability. almost 250,000 people each year require hospital care for Clostridium difficile (C. difficile) infections, in most of which use (and/or mis-use) of antibiotics was a major contributing factor leading to the illness. At least 14,000 people die each year in the United States from C. difficile infections , and the CDC
The Lancet article’s co-authors, Simon J. Howard (corresponding author), John Watson, and Sally C. Davies of the Office of the Chief Medical Officer, Department of Health, London, UK; and Mike Catchpole of Public Health England, London, UK; observe that: “Rarely has modern medicine faced such a grave threat. Without antibiotics, treatments from minor surgery to major transplants could become impossible, and health-care costs are likely to spiral as we resort to newer, more expensive antibiotics and sustain longer hospital admissions. Infection-related mortality rates in developed countries might return to those of the early 20th Century.”
Use, over-use, unnecessary use, and abuse of antibiotics is the single most important factor leading to antibiotic resistance around the world, antibiotics being among the most commonly prescribed drugs used in human medicine, to say nothing of their use in agriculture. A detailed analysis of the =development of antibiotic resistance in The Lancet Infectious Diseases (The Lancet Infectious Diseases, Volume 13, Issue 12, Pages 1057 – 1098, December 2013 doi:10.1016/S1473-3099(13)70318-9) can be accessed here.
The Lancet article researchers note that this problem is global in scope, and compounded by a lack of surveillance systems and policy in place to address it, by a paucity of basic information about prescribed antibiotic use, and that antibiotics are used virtually world-wide in animal feed and available on a non-prescription basis in many developing countries. One example they cite is that some Chinese hospitals derive about one-quarter of their revenues from antibiotic sales.
However, over-use of antibiotics is rampant in the developed world as well. Reportedly, in 1954, some 2 million pounds of antibiotics were produced in the United States. By 2000, the annual figure had risen to an estimated 50 million pounds, nearly half of which are fed to livestock. The Lancet Infectious Diseases article’s co-authors observe that antimicrobial resistance extends far beyond human medicine, and that the majority of the 100,000-200,000 tonnes of antibiotics manufactured every year is used in the agricultural, piscicultural, and veterinary sectors. The CDC notes that antibiotics are commonly used in food animals to prevent, control, and treat disease, and to promote the growth of food-producing animals, but contends that use of antibiotics for promoting growth is not necessary, and that the practice should be phased out.
Often misuse of antimicrobial drugs is due to uncertainty about the diagnosis or the identity and drug susceptibility of the pathogenic organisms causing a disease condition. Common areas of misuse particularly associated with antibiotics include:
• Treatment of minor respiratory and gastrointestinal infections, viral infections and self-limiting bacterial diseases that do not benefit from use of antimicrobials. For example, a study in the March, 2007 issue of the Archives of Otolaryngology found that even though there are no approved drugs to treat sinus infections, more than 90 percent of which are caused by fungi and not bacteria according to the Mayo Clinic, in cases of acute infection cited in the study, roughly 83 percent were treated with antibiotics, as were 70 percent of chronic cases
• Incorrect choice of antimicrobial for common problems, for example the use of a broad-spectrum antimicrobial when a narrow-spectrum agent would be sufficient
• Insufficient dose and duration dispensed or purchased because patients can’t afford the cost of the antimicrobial
• Inappropriate choice of antimicrobial for surgical prophylaxis
• Wrong dose and duration of appropriate antimicrobial prophylaxis and treatment
• The tendency to use newly introduced and expensive antimicrobials, when there is no evidence supporting better drug susceptibility of the newer drug over an older one.
Unnecessarily prescribing antibiotics or prescribing an inappropriate antibiotic is common, the CDC report observes, noting that antibiotics are among the most commonly prescribed drugs, but as many as half of those prescriptions are either not needed or not the best course of treatment for the patient, and that healthcare providers can too willingly relent to pressure to satisfy a patient’s expectation for an antibiotic prescription as an imagined quick fix for routine viral infections. The Canadian Medical Association Journal reported a study by McGill University’s department of epidemiology and biostatistics finding the longer doctors are in practise the more they tend to “soften” to patients’ demands for antibiotics, growing weary of trying to educate patients about appropriate antibiotic use, choosing instead to write a prescription rather than spend time arguing. One MD commenting on an online forum admitted: “I regularly prescribe antibiotics inappropriately — especially towards the end of the day when I no longer have the energy to argue with incredulous patients (especially mothers).” Thus antibiotic abuse is partly a cultural phenomenon, exacerbated by factors like working parents for whom it is inconvenient or difficult to stay home with sick kids, and demand that the doctor “give them something” — usually an antibiotic.
The Lancet Infectious Diseases article’s co-authors also observe that antibiotic prescribing behaviour by health-care practitioners is affected by many factors, “including demands from patients, the threat of competition from alternative systems of health care, and financial incentives to prescribe,” and contend that “because the effect of antibiotic use extends beyond individual patients, there is a public health imperative for use to be closely monitored and regulated,” with a balance needing to be struck “between limiting the availability of antibiotics and ensuring timely treatment for severe infections.”
They suggest that speeding up microbiological diagnostic tests that could help to prevent unnecessary antibiotic use and narrow the spectrum of coverage needed to treat an infection, and that development of more rapid diagnostics could enable targeted antibiotic or non-antibiotic treatment from the outset, along with educating prescribers about the importance of timely application of the results of such tests, which could reduce the overuse of broad-spectrum antibiotics and thereby help slow development of antibiotic-resistant strains. Also that more research is needed on the correlation between use of antibiotics in animals and development of antimicrobial resistance in human beings with the objective of reducing the use of antibiotics in agriculture while maintaining security of food supply even if it results in higher food prices.
Dr. Steve Solomon, director of the the U.S. Centers for Disease Control and Prevention’s Office of Antimicrobial Resistance cited in a U.S. Department of Health and Human Services hearthfinder.gov article says: “This is scary stuff, and we want people to know about it… Patients need to understand that antibiotics are not the solution for every illness. “It’s important that people not take antibiotics when they aren’t necessary. It contributes to resistance, and it also has consequences to the patient in the form of side effects.”
Practical avenues of address suggested by Simon J. Howard and his colleagues include rediscovery of assiduous hygiene practices such as reimplementation of regular and effective hand-washing in health-care settings, improved sanitation and hygiene practices in the community, educating the public about antibiotic resistance, improvement of infection prevention and control practices in human and animal health. optimization of prescribing practice concurrent with improvement of professional education, training, and public engagement, better access to and use of surveillance data, better identification and prioritization of research into antimicrobial resistance, and development of new drugs, treatments, and diagnostics.
Unhappily, Only two new classes of antibiotic have reached the market since the 1970s the Lancet article’s co-authors report, noting that metrics from the U.K. Office of Health Economics indicate that the value of a new musculoskeletal drug to a pharmaceutical company is likely to be 20 times higher than the value of a new antibiotic. They advocate that new models of collaboration, among academia, research funders, and not-for-profit organizations will be necessary to restart the stalled engine of antibiotic discovery.
The U.S. Centers for Disease Control and Prevention
The Lancet Infectious Diseases
U.S. Department of Health and Human Services