Resistance is futile: Are antibiotics killing us?
As bacteria gets smarter and with the human race becoming more and more reliant on antibiotics, are we reaching crisis point?Josh Sims March 27, 2017
The end of H.G. Wells’ The War of the Worlds comes not with a bang, but with a whimper, albeit a dramatic twist of a whimper. The Martian invaders of Earth are repelled not by might – they seem all but invincible – but by microscopic bugs. “There are no bacteria on Mars,” the narrator notes, “and directly these invaders arrived, directly they drank and fed, our microscopic allies began their overthrow”.
But now comes a real, less sci-fi horror: those allies turning against us, bringing about our end. All those antibiotic and antimicrobial medicines that have annulled diseases which, less than a century ago, would have been killers to us as well as Martians? Well, the drugs don’t work.
“The situation is really quite alarming, and even more so for the fact that a lot of people just aren’t aware of it,” says Dr Marc Sprenger, director of the antimicrobial resistance department of the World Health Organisation (WHO). “This is not media hype - this problem could potentially be devastating.”
Indeed, deaths attributable to antimicrobial resistance each year – that, in short, is the bugs developing a tolerance of the stuff designed to kill them – are now estimated to dwarf the numbers of people killed by road traffic accidents, diabetes, diarrhoeal disease and even cancer. Some estimates predict 10 million deaths, preventable were it not for antibiotic resistance, globally every year by 2050. And that comes with a $210 trillion cost to the global GDP. No wonder in September 2016, the General Assembly of the United Nations gathered to make a commitment to address the issue, such is its concern.
To put that in some perspective, in the history of the UN the General Assembly has only focused high-level meetings on health issues three times before, and they were for HIV, Ebola and obesity. This time it concluded it was dealing with a “nightmare” and a “catastrophic threat”. And this summer sees the World Congress on Antibiotic Resistance bring together the world’s experts to discuss whether what we’re doing to tackle the problem is too little too late. But as for the people going to their doctors demanding drugs to cure minor ailments, the chances are they don’t even know there is an issue.
March 17 this year marks the 75th anniversary of the first use of penicillin, the wonder drug created by Alexander Fleming. But even then Fleming knew there could be trouble ahead. “He indicated that the development of antibiotic drugs to tackle all kinds of illnesses would be to enter a kind of rat race – that we would always need to discover new classes of antibiotics,” says Sprenger – the first bacterium resistant to penicillin was discovered just four years after the drug was introduced and even today a drug might have, at best, a shelf-life of some 13 to 16 years before some resistance to it develops. “But the fact is that we haven’t discovered a new class of antibiotics in the last 30 years,” he adds.
Consequently diseases that used to kill people in their millions, but which have not done so for decades, are making a return. Tuberculosis, for example, is now multi-drug resistant. Over half of those 480,000 who each year are unlucky enough to contract a resistant form of TB will die from it. Pneumonia is increasingly a killer. And the problem extends to even minor ailments that modern people forget once did away with their ancestors: urinary tract infections, for example. It may not be as spectacular, but it’s a long, painful way to go. And some 30 per cent of those organisms that cause such an infection are now drug-resistant. Without effective antibiotics, the success of major surgery is compromised, as is chemotherapy. As a way of describing illnesses, ‘drug resistant’ is a phrase you’re likely to hear more of.
“If you just stop to think how antibiotics are used in modern medicine and take that away, then the scale of the problem becomes apparent,” says Marc Mendelson, professor of infectious diseases at the University of Cape Town. “Lose antibiotics and it’s a game changer, unless we quickly reverse or at least limit the situation. It’s not just about the likes of TB. Just consider resistance to the treatment of common infections, the ones you get, the ones your family gets. That’s the real concern.”
But then, it seems, we’ve all become drug addicts, with the expectation that when we go to our family doctor with some kind of health problem, we will be given antimicrobial or antibiotic drugs to solve it, regardless of the need for or suitability of those drugs. And it’s widespread usage - and often incorrect usage, with people often giving up taking tablets before the end of the course, when they judge themselves to be better - that is allowing resistance to bacteria, fungi, parasites and viruses to develop.
“Someone has a common cold and a GP may be inclined to offer antibiotics, and that someone is inclined to pressure their GP to get them too, even though the antibiotics are totally not necessary,” says Sprenger. “GPs have to be much more reluctant to offer them - to explain that a self-limiting disease, which is what a lot of diseases are, doesn’t need them. But that can require a cultural shift.”
Indeed, a preference for antibiotics does often come down to culture and, perhaps, a sense of community responsibility. As Laura Rogers, managing director of George Washington University’s Antibiotic Resistance Center, puts it, “You can take paracetamol as many times as you like, but every time you use an antibiotic it reduces its effectiveness for someone else.”
Live in Scandinavia, for example, and the chances of being prescribed antibiotics (and the desire to take them) are slim; go to Italy and the chances are high. Yet Scandinavians are not, all other things being equal, in any worse health than Italians. Of course, getting cultures to shift is a long, arduous journey and all the more so given the low level awareness of antimicrobial resistance in the first place: when someone dies of an infection, the cause is rarely mentioned at all; if it is, it’s typically reported as a ‘very serious infection’. There’s no mention at all of the part resistance would have played in the failure to treat it. Better mortality registration might help improve awareness.
That’s not all that’s at play here either. Antibiotics are widely used in agriculture too, less as a treatment for sick animals as to promote growth or compensate for the poor conditions in which they’re kept. “This isn’t half the problem though, it’s more than half,” argues Rogers, which led the team that first uncovered the strain of MSRA to come out of farming. “Globally we use more antibiotics with animals than we do with people, and because they’re given constant low doses, it’s a perfect breeding ground for resistance. Even the medical community doesn’t understand the quantities of antibiotics used in agriculture. If you have a ship with two holes, and only plug one, it sinks anyway – so it’s a side of the problem that has to be addressed.”
That’s happening – slowly. This year McDonald’s in the US made the positive move of switching its chicken supply over to that raised without the use of medically-important antibiotics, but now has the uphill task of rolling that policy out worldwide. “That sort of sweeping, global change is what’s required,” Rogers adds. “The situation isn’t apocalyptic just yet, but that change needs to happen fast.”
Then there are market economics at work, which are at the heart of the last three decades’ lack of response to what could prove catastrophic over the next three. Developing new antibiotics is very expensive and drugs companies want a return on their years of investment, but, of course, too much use of any new antibiotic merely encourages greater resistance. As Sprenger stresses, a new model is required to help companies develop new products and then for their use to be carefully controlled. But then there is the scientific challenge too. “Even with endless money the development of antibiotics is still extremely difficult,” he adds. Fleming discovered penicillin some 14 years before it could actually be used medically.
And then there are further complications. For example, in large parts of the world there is no GP system to speak of and no regulation of the distribution of drugs, meaning antibiotics - or what purport to be them - are sold on street corners in uncontrolled dosages. In more developed parts of the world there is a constant battle against the growing army of ‘super-bugs’ that evolve in the wild and outsized petri dish that is your local hospital. Certainly antimicrobial resistance is very much not just a third world problem: the WHO, which will issue an update on the situation in May, reports that treatment failure to the last resort of medicine for gonorrhoea has now been confirmed in 10 countries: Australia, South Africa, Japan, Canada, and six western European nations.
“Antibiotic resistance is a global threat,” says Mendleson, who is doing all he can not to sound gloomy. “After all, we live in an interconnected world and resistance travels. But this is just natural selection at work. What we should be striving for is ecology. In your gut right now are 2.2 kilos of bacteria and they’re essential to life. We need to live more symbiotically again. To get attention people speak of a ‘war’. But this isn’t a war on antibiotics. It’s a war on the use of antibiotics and how they disrupt that ecological balance. For god’s sake, get your children vaccinated. For god’s sake think about antibiotics responsibly. Or we’re all buggered.”