Midyear the US Centres for Disease Control and Prevention released a report about gonorrhoea. This common sexually transmitted infection, which more often than not displays no symptoms and is relatively easy to both treat and prevent, was fast becoming a major public health concern. Why? Because the bacteria responsible for the infection, Neisseria gonorrhoeae, was rapidly developing resistance to the last two antibiotics that have been effective in treating it.
The CDC report detailed how, between 2013 and 2014, cases of antibiotic-resistant gonorrhoea had increased more than fourfold for the antibiotic azithromycin and doubled for ceftriaxone. The authors wrote: “… treatment has been compromised by the absence of routine antimicrobial susceptibility testing in clinical care and evolution of antimicrobial resistance to the antibiotics used to treat gonorrhea”.
This is a sign of things to come in arguably one of the greatest global health challenges we have ever faced: antibiotic resistance.
Antibiotic resistance, also known as antimicrobial resistance (AMR), is a phenomenon where bacteria that cause various infections and diseases become unresponsive to treatments that were once highly effective in killing them. Sustained exposure to antibiotics due to globalisation and increased use in humans and agriculture, combined with the ease with which bacteria can readily transfer their genetic information between each other, will mean that AMR will become more common. A British government-commissioned review reported this year that AMR is annually responsible for about 700,000 deaths worldwide and this is expected to rise to a shocking 10 million deaths a year by 2050.
Professor Mary-Louise McLaws, an expert in infectious diseases control from the University of New South Wales, says we must increase our efforts to combat this metastasising health threat to avoid catastrophe.
“Multiple-resistant organisms have a really neat way of transferring, genetically, their resistance not just within the same species, but between them,” she says. “It’s potentially a pandemic of multiple-resistance and that’s why it’s unbelievably important that we try to put a lid on this escaped monster. It will be catastrophic.”
Scientists, governments and health bodies have been warning the international community about the rise of AMR for decades. Finally, the United Nations acknowledged this growing sense of urgency by holding a general meeting on this global health issue last month for only the fourth time in its history. UN Secretary-General Ban Ki-moon said at the time that antibiotic resistance was a “fundamental threat” to global health and safety and that if we failed to effectively address the problem, it would “make providing high-quality universal healthcare coverage more difficult, if not impossible”. All 193 UN member states pledged to combat the rise of antibiotic-resistance infections and superbugs and have committed to developing new regulatory systems to monitor the use and sale of antibiotics, encouraging research into the development of new diagnostic tools and antibiotics, and increasing public awareness of the growing health threat.
In 2013, the Australian Commission on Safety and Quality in Health Care set up a national AMR surveillance system as part of its Antimicrobial Use and Resistance in Australia (AURA) project. In its first report released in June this year, AURA reported that in 2014, 10.7 million Australians (or 46 per cent of the population) had been prescribed antibiotics, and that “on any given day in 2014, around 38 per cent of patients in Australian hospitals were receiving antimicrobial therapy”.
McLaws has estimated that there were nearly 270,000 hospital-acquired infections in 2015 and that about 5 per cent of these resulted in death. “If we want to operate on patients and give them a prophylaxis so they don’t get infected while they’re being operated on, but in fact that prophylaxis may not work or give them a different multiple-resistant bacteria, then what’s the point of operating on them if we’re going to cause more damage?” she says. “We will go into the Dark Ages where women will die of a simple urinary tract infection and they’ll die from an infection after giving birth.”
Professor Liz Harry, infectious diseases expert and director of the ithree Institute at the University of Technology, Sydney, says it is crucial for the public to be engaged and brought along on antibiotic resistance.
“It’s a major issue because we’re running out of antibiotics that work. Infection has always been a part of life and before antibiotics, people died quite readily from an infection,” she says. “We need to help the community to become more aware of what antibiotic resistance is and how it’s come about and what that means for their health and making decisions on whether to take them or not.”
Harry explains that people needed to be educated through public health campaigns to cut down on the use of disinfectants in the home, such as antibacterial soaps and wipes, to ensure the ones used in hospitals remain effective. This would help to eliminate one crucial avenue in which bacteria evolve to become more resilient to a hostile environment.
A change in behaviour and attitude towards the use of antibiotics in both the public – such as demanding a prescription from your GP despite their reservations – and the medical community will also make a marked difference. As McLaws explains, even though therapeutic guidelines for antibiotics in Australia are constantly updated, prescribers can often fall into a habit of using specific drugs instead of consulting the guidelines to prescribe the most appropriate one first.
Scientists have also stressed the urgent need to address the overuse of antibiotics in the agriculture industry. Treating sick animals is of course vital for farmers to maintain their livelihoods, but using the drugs as a means to prevent future infections or fatten up their livestock greatly increases the chances of antibiotic-resistant strains of bacteria mutating and jumping across species to humans. Professor Peter Collignon, a microbiologist from the Australian National University who has sat on a number of World Health Organisation advisory committees on AMR, recently blasted the lack of transparency on antibiotic use in the Australian farming industry, which was “undermining efforts to prevent superbugs developing and spreading through the food supply”.
“There is a lack of appropriate controls in Australia for antibiotic use in food,” he said. “We know the US pork industry uses four or five times the amount of antibiotics as the industry in Denmark. In Australia, we don’t really know – we don’t know which antibiotic is given for which animal and how much.”
McLaws says that an absence of legislation on agricultural use of antibiotics, coupled with a lack of incentive for curbing overuse or changing behaviour, make it extremely difficult for researchers and health bodies to mount an effective attack on AMR.
“We don’t have the luxury of time to wait around and we really need a multipronged approach in Australia and the world,” she says. “We have to really demand bans of certain antibiotics used. We also have to demand that the food-animal farmers show very good evidence of why they should give their animals antibiotics.”
She has also urged the federal government to encourage research and innovation into finding not just new antibiotics but also developing alternative drugs and vaccines through incentives such as tax breaks and research grants.
Dr Ramiz Boulos, chief executive of Boulos and Cooper Pharmaceuticals, has echoed the need for more financial incentives to get the pharmaceuticals industry back into the antibiotics field. “I guess the biggest lack of incentive for pharmaceutical companies has been the fact that you only take an antibiotic when you have an infection, as opposed to other high-profiting drugs that you take on a daily basis, for example high blood pressure medications or antidepressants,” he says.
Boulos said Australia could replicate initiatives such as the Biomedical Advanced Research and Development Authority (BARDA) in the US, which provides financial support to the industry to drive new research. “Such initiatives would provide substantial help.”
Shu Lam, a PhD candidate at the University of Melbourne who recently made a huge breakthrough in the field by developing a synthetic antibacterial protein that was extremely effective in killing Gram-negative bacteria (a class of bacteria highly prone to developing resistance), says that combatting AMR should be made “a national research priority”.
“More co-ordinated and strategic research is needed to address the knowledge gaps in this area,” Lam says, “with emphasis placed on both fundamental and applied research – for example, from understanding the development and spread of antimicrobial resistance to devising strategies that could help in containing and/or preventing it.”
The world may have been slow to act in addressing this threat to global health, but there’s hope the UN General Assembly meeting will spur considerable new efforts to conquer antibiotic resistance.
This article was first published in the print edition of The Saturday Paper on Oct 22, 2016 as "Resistance is fragile". Subscribe here.