Microbial resistance

Since the 1940s antibiotics have been used for a range of purposes, not only to treat patients for infectious disease but also for prophylactic use in livestock to maximise yields. Due to antibiotics, many bacterial diseases once incurable have become controllable and the use of antibiotics in surgical wards has drastically reduced post-operative mortality rates. However, the effectiveness of antibiotics has been undermined largely due to their overuse and inappropriate use—ncluding as a treatment for viral infections, such as the ‘common cold’ and in their overuse in animal husbandry. 

There is an increasing threat of antimicrobial resistant ’superbugs’ that do not respond to multiple antibiotics. To date, most of resultant deaths worldwide are attributable to infections acquired in hospitals or other clinical settings, but community-acquired infections have also become a public health concern. There have been a number of reported cases that are related to multi-drug resistant bacterial infection, including one in the US where a 55-year-old male engineer died 13 hours after hospital admission due to MRSA (Methicillin-resistant Staphylococcus aureus) sepsis. In Germany, an allegation of overuse of antibiotics in farm animals led to chicken meat contaminated by antibiotics resistant bacteria in supermarkets. This finding resulted in the introduction of restriction on the use of antibiotics in the animals.

Antibiotic resistant is particularly a problem in low income and in conflict-affected settings, where resources are limited and the health system is weakened. For instance, tuberculosis (TB) is a largely preventable and curable airborne disease, which requires high adherence to the regimen for a relatively long period of time. However, high adherence to the treatment and a good management of TB programme can be difficult in conflict areas and there are on-going fears over the development of drug resistance. Multidrug resistant TB (MDR-TB), which needs a 20-month treatment course including 8-month intensive care, is caused by inappropriate use of the drugs or poor support for adherence. Drug resistance to anti-TB drugs can be promoted by disrupted health system, where suffering from lack of good supervision, instability of staff and supply line, and possibilities of sudden closure of the programme and displacement of people. According to a review published in The Lancet, displaced populations did not necessarily show higher prevalence of MDR than host population, although there were a few exceptions with higher drug resistance such as Somali and Sudanese refugees in Kenya and Laotian Hmong refugees in Thailand. Overcrowding and malnutrition, two risk factors for TB, in refugee populations could also exacerbate this problem.

What is more threatening is that while bacteria are evolving at fast rate to evade antibiotics, antibiotic development in the drug industry is currently not keeping up with it. As of January 2012, there were 109 candidates in development pipeline, but only 9 of them were in phase 3 (final testing) of a clinical trial. There are several challenges to the discovery of new antibiotics. Antibiotics give low profit margin to pharmaceutical companies, for instance compared to drugs for chronic diseases, making them hesitant to risk great amount of investment costs for developing new antibiotics, which can become ineffective quickly.

As concerns around antibiotic resistant bacteria are growing, there are international calls for more concerted actions to address antibiotics resistance. The rate of spread of antibiotics resistance needs to be slowed down to preserve currently effective antibiotics, and the discovery of new antibiotics should be encouraged. To tackle rapid spread of antibiotics resistance, concerted efforts of different actors including government, healthcare providers, pharmaceutical companies and patients are needed. Academia, governments and different sectors have long recognized the issue. Specifically, during their presidency of the Council of the European Union in 2009, the Swedish government commissioned a report to highlight the need for collaborative action of member states on the problem.  Policy recommendations included promoting better access to research, retaining scientific personnel with appropriate knowledge and experience, direct funding and tax incentives for the pharmaceutical sector.

We are now observing what was warned by Alexander Fleming in his Nobel Lecture in 1945—nearly 70 years ago—about misuse of antibiotics, particularly underdosage, that could make microbes resistant to the drug: “There is the danger that the ignorant man may easily underdose himself and by exposing his microbes to non-lethal quantities of the drug make them resistant.” ‘The ignorant man’ can become more aware through effective education and communication not only in terms of prescribing or use of the drug but also in terms of preventing infection.