THE EARLY descriptions of the use of penicillin in the 1940s are dramatic and inspiring. Common life-threatening infection could be treated for the first time and infections, which had been lethal in previous generations, seemed now vanquished.
Antibiotics were quickly recognised as wonder drugs, as “magic bullets”, and the possibilities they offered were infinite. Indeed by 1967, the US Surgeon General in an address to Congress said, “The time has come to close the book on infectious disease.”
Yet 60 years later, that golden era is drawing to a close; mankind has squandered this extraordinary resource. The use and misuse of antibiotics in human and veterinary medicine and their role as growth promoters in intensive farming has resulted in the rapid emergence of resistance. Indeed, in some parts of the world, common infections in hospitalised patients are untreatable and there have been several such cases encountered in this country.
Antibiotics were unquestionably one of the major medical advances of the last century and it is fair to say that much of modern medicine is predicated on their availability. They are crucial in the treatment of infections, which occur following major trauma or in patients in intensive care. They also play an important role in the prevention of infection following surgery or in the treatment of life-threatening infection in patients with cancer or leukaemia.
Antibiotics are a crucial part of modern medicine and it is very clear that our capacity to offer the kind of aggressive treatments available for many diseases today, such as cancer with chemotherapy and organ failure with transplantation, would not be possible without them.
With the advances in medical science which followed the second World War, multiple different groups of antibiotics were rapidly developed. However, because bacterial evolution was little understood and the pipeline of new agents seemed endless, there was no attempt to use these agents judiciously. As soon as resistance to one agent emerged, newer more effective drugs were introduced.
The problem of resistance was overcome by the introduction of the latest wonder drug, often heralded as the antibiotic against which resistance would never arise. The treatment of gonorrhoea is a case in point. Penicillin was given to GIs on leave in southeast Asia during the Korean war to prevent gonorrhoea. All this did was lead to penicillin resistance and this emerging resistance has continued to this day; just recently the bacteria causing gonorrhoea, Neisseria gonorrhoea, has become resistant to the last available oral agent and now the only treatment is a painful intramuscular injection.
It is sobering to consider that over the past 60 years the bacteria which cause infection in man have evolved and mutated more than they did in the billions of years prior to the introduction of antibiotics.
So what can be done? The approach needs to be multi-faceted and international. Bacteria do not respect national boundaries. Indeed, just recently we have seen the consequence of both cosmetic and transplant medical tourism in India, resulting in the importation into the UK of the so called New Delhi strain, which causes serious infection in both hospitalised patients and those in the community. This has now spread across Britain.
The story of its emergence is salutary. High-tech first world medicine is sometimes practised in an environment with limited clean public water supplies, poor sanitation, and potentially contaminated irrigation water and hence food and healthcare workers often live in Third World conditions. This has been a potent and dangerous mix, resulting in the emergence of these highly resistant bacteria.
In addition in India, as in many other countries, antibiotics can be bought over the counter. In some countries, families can purchase expensive intravenous antibiotics for administration to their loved ones in hospital, but they may not have the resources to purchase a full course, leading to worsening resistance.
In the developed world, there is more regulation and better standards but not necessarily better compliance.
Microbiologists ensure the proper diagnosis, treatment and prevention of infection in both hospitals and in the community, and in this country there are insufficient numbers to ensure that the threat posed by antibiotic resistance is kept at bay.
It is essential that hospital doctors and GPs have easy access to microbiology laboratories to help diagnose infection and to identify resistance, so that patients get the best treatment, and infection- control measures can be rapidly deployed to prevent further spread.
It is important to ensure that we are measuring infection rates and intervening quickly when outbreaks are detected or unexpected resistance is encountered.
It is also essential that doctors, nurses and allied health professionals at all times observe good hand-hygiene practice and comply with appropriate infection-control precautions.
Prescribers must use antibiotics carefully. Microbiologists, medical scientists, antimicrobial pharmacists, surveillance scientists and infection-control nurses all play a significant part in reducing the threat of antibiotic resistance.
There are also however, greater regulatory, governmental, industrial and research issues at play here. Every antibiotic introduced into clinical use since the discovery of penicillin by Alexander Fleming, a microbiologist at St Mary’s Hospital in London in the 1930s, has been as a result of the work of the pharmaceutical industry. But now the low-lying fruit has been picked, there are few new drugs in the pipeline and the future looks very bleak indeed.
The cost of research and development (RD) is immense – up to $30 million (€23 million) per drug – and the returns are limited due to inbuilt obsolescence with the almost inevitable emergence of resistance. Industry is now focusing on the treatment of chronic disease, where treatment may be life-long and the profits consequently greater. Short patent life and regulatory difficulties also militate against the development of novel antibiotics.
The World Health Organisation, the EU, the Foods and Drugs Authority in the US and the providers of research funding need to incentivise antibiotic RD and governments internationally need to co-ordinate and strengthen their campaigns against resistance.
Closer to home, the HSE needs to build on the strengths of the current system but, despite our budgetary situation, further investment is essential. Indeed, there is good evidence that such investment will save money in the short to medium term by reducing the incidence of costly healthcare associated infection, resulting in less antibiotic use.
We are at a crossroads in the fight against infection. If we fail to act, there is real risk of a return to the pre-antibiotic era with untreatable life-threatening infection. Common infections in the community will not respond to routine treatments and our sickest and most vulnerable patients in hospitals across this State and in Europe will die of untreatable infection.
Dr Edmond Smyth is a consultant microbiologist, at Beaumont Hospital, Dublin, and president of the Irish Society of Clinical Microbiologists
