Our lethal love affair with antibiotics

  • Niall Hunter, Editor

It was the 'miracle' medical advance of the 20th century. The discovery and development of effective antibiotics in the 1940s and 1950s has meant that many infections such as pneumonia, meningitis and TB are usually no longer seen as potential killers.

We have become used to antibiotics as an essential part of everyday health treatment. Yet we have also grown too fond of them, and this is a love affair that is turning sour.

Patients now often expect as a matter of course to get an antibiotic from their GP, even if their condition, such as a viral infection, might not require antibiotics. Antibiotics can also be overprescribed in hospitals.

Gross overuse has led to the problem of antibiotic resistance, whereby major infections build up a resistance to drugs that have been used over a long period of time and in great numbers.

Ireland is ranked ninth highest among European countries for the volume of outpatient antibiotics prescribed.

According to a study by the Health Protection Surveillance Centre and the European Surveillance of Antibiotic Consumption, for every 1,000 members of the Irish population there are 22.5 daily defined doses of antibiotics per day in Ireland.

Because antibiotics are being overused and serious bugs are therefore becoming resistant to them, many antibiotics are becoming increasingly less effective in treating infection in Ireland.

This is a major issue in both community and hospital treatment. In hospitals, vulnerable patients who have had operations or procedures, or who are getting major surgery or are in intensive care, are prone to developing 'super bugs' resistant to many antibiotics, which can cause serious illness and can be fatal.

According to Dr Robert Cunney, consultant microbiologist with the Health Protection Surveillance Centre (HPSC), antibiotic resistance has been identified by the World Health Organization as the  biggest global health threat.

He points out that antibiotic resistance is already a huge cost factor in the health service in terms of sickness and death and as regards use of healthcare resources.

Dr Cunney feels that if it is not tackled effectively, the problem of resistance could have grave consquences for our health system - an increase in illness and fatalities from the 'super bugs' and a return to an era where there may be no effective treatments for many potentially serious infections.

Says Dr Cunney: "As antibiotic resistance increases, we are running out of antibiotic options as fewer and fewer newer antibiotics are being developed. Unfortunately there are very few new antibiotics in development to replace those that have become resistant to many infections.

"The rate of development of new drugs in this category has slowed down, because it has become too costly for drug companies to develop them, and because of growing antibiotic resistance the drug might have a limited 'shelf-life' and they might therefore not be able to recoup all the costs of developing the drug."

"Because of antibiotic resistance, we may be in danger of returning to the era that existed up to the 1940s and 1950s when infections are difficult or almost impossible to treat," Dr Cunney warns.

The pre-antibiotic era was a time when people lived in fear of getting many types of infection.

Dr Cunney says an infection such as the skin condition cellulitis is now relatively easy to treat and is very rarely fatal. But before the advent of antibiotics it was a common cause of death.

"In the pre-antibiotic era, infections were the main cause of death, whereas now it is heart disease and cancer. Without antibiotics, our healthcare system would not work. "

In some respects, Robert Cunney says, drug resistance is a natural consequence of using antibiotics.

"This is because bacteria evolve very quickly and are able to rapidly adapt, but the more antibiotics we use and the greater the frequency with which we use them, the more antibiotic resistance you will see.

"It is possible to slow down levels of antibiotic resistance but it takes a huge effort at all levels of the health system, from individual patients, through to the prescriber, all the way up to the very top."

Dr Cunney says data from Europe shows that Mediterranean countries which have high antibiotic use tend to have high level of antibiotic resistance, whereas Scandinavian countries and some countries in Northern Europe have low levels of antibiotic use and low levels of antibiotic resistance.

"In these countries, they use fewer antibiotics and invest a lot in infection control programmes in their hospitals."

What can we do to slow down antibiotic resistance?

"Well, a lot is already happening in terms of trying to promote the more prudent use of antibiotics. On the community side we have had a number of public information campaigns. There is very good data internationally to show it is not enough just to educate prescribers - you have to educate the public as well in terms of prudent antibiotic use outside of hospitals."

"The HSE has had a GP education campaign programme going for some time and new antibiotic prescribing guidelines have been developed for GPs. There is some evidence that this is beginning to impact on prescribing patterns in the community in Ireland, but obviously there is still some way to go on that."

Robert Cunney says antibiotic resistance is both a hospital and community problem.

"On the hospital side, the approach to combating antibiotic resistance is different to that in the community.  There is less of a role for patient education. In hospitals, you need much more direct intervention by infection specialists - microbiologists; infectious disease physicians etc."

A lot of hospitals now have what are known as antibiotic stewardship teams in place and are doing a lot of work on promoting more prudent antibiotic prescribing, but this is something that really needs to be in place right across the country, Dr Cunney says.

However, Dr Cunney admits it is difficult to get the the quality of prescribing message out there when health staff are having to do more and more with fewer resources.

"There are still hospitals that do not have these stewardship teams in place. Unfortunately, in some places because of the recruitment ban you have situations where pharmacists are being pulled back from their specialist antibiotic resistance prevention work because there are no pharmacists to fill the general pharmacy posts in hospitals."

"Ultimately, the key thing we need to get across is the concept that this is everyone's responsibility - patients, prescribers, everyone."

"There is obviously the challenge that some patients expect an antibiotic whether it is necessary or not, but we need to educate patients that we must preserve the antibiotics we have got so that they will work when they are really needed."

There can be a terrible price to pay for our over-reliance on antibiotics.

"We know that in the hospital setting, even for non-fatal infections, antibiotic resistant infections will frequently double the length of hospital admission. Even for relatively trivial infections, for example, middle ear infections in children, with antibiotic resistance, it becomes very difficult to treat these infections which can therefore become more chronic, so there is a big impact in terms of burden of illness."

"Also, with serious infection caused by antibiotic resistant bacterias, depending on the type of bacteria, the risk of death at least doubles or trebles than with an infection caused by an antibiotic-sensitive bacteria. Antibiotic treatment can also have a deleterious effect on intensive care and post-operative care patients."

"It's a very big threat to healthcare. We have seen in some countries where there are very high levels of antibiotic use. In Greece, we have seen the emergence of CRE (Carbapenem-resistant Enterobacteriaceae) infection, and this has become a massive problem in intensive care units in that country. In patients who get bloodstream CRE infections in ICUs caused by these antibiotic resistant bacteria, the mortality level is something of the order of 70% to 80%."

That, says Robert Cunney, is the sort of mortality from infection you would have seen in the pre-antibiotic era.

"We are seeing the same patterns of antibiotic use in Ireland that led to the emergence of Carbapenem-resistant Enterobacteriaceae infection (CRE) in Greece. In Europe the risk of death from this antibiotic resistant infection is two-and-a-half to three times higher than to antibiotic sensitive infection. Bacteria like like E Coli, Pneumococcal infection, VRE, Klebsiella etc, tend to be resistant to a wider range of antibiotics."

With the exception of MRSA, which has seen a downward trend in recent years, in general in Ireland, resistance rates for all the other major antibiotic resistant bacteria are going up.

"With the exception of MRSA, in general our resistance rates for all the other most important antibiotic resistant bacteria are increasing. These bacteria can be life-threatening." Dr Cunney says.

Latest figures from the HPSC show that the number of multi-drug resistant E.coli bugs has increased in Ireland from around 1,200 in 2005 to nearly 2,500 last year."

"We are seeing, thanks to overuse of antibiotics in the community, patients coming in to hospitals who already have infections caused by relatively resistant bacteria that in turn leads to the use of broader spectrum antibiotics (antibiotics that act against a wide range of bacteria) in hospitals. That in turn can lead to patients getting multi-resistant or completely resistant bacteria. So patients can come into hospital carrying the bug and then become more seriously ill because antibiotics cannot effectively treat their condition"

Dr Cunney says we are also are seeing more and more resistant bacteria in the community, particularly in nursing homes. "There really is a pressing need to improve the level of prudent antibiotic use both in the hospital and community sectors."

There is another important side to all of this - infection control.

Says Dr Cunney: This goes hand in hand with rational antibiotic use. If you can prevent patients from getting the infection in the first place they are not going to need antibiotics and there is less antibiotic resistance."

"And if you do get an antibiotic resistant bug you want to prevent that from spreading from person to person. Infection control would include preventing infections from happening in the first place so, eg proper insertion and care of IV lines, surveillance of surgical site infection, hand hygiene etc."

In Europe, the risk of death from antibiotic resistant infection is two-and-a-half to three times higher than to antibiotic sensitive bugs.

Dr Cunney says in an era of healthcare savings and cuts in Ireland, implementing effective infection control procedures can be a source of concern.

"While there are obviously efficiencies to be gained in the healthcare system, there is a danger that if the prevention of antibiotic resistance and the prevention of infection in healthcare settings is not prioritised then there is a real risk that you are going to see a huge rise in antibiotic resistance and you are going to see the spread of these almost untreatable infections, as happened in Greece and elsewhere."

Is there evidence on the ground of cutbacks affecting infection control?

There is evidence in some hospitals that the staffing for infection control or for antibiotic stewardship have been diverted to compensate for staffing shortageselsewhere, according to Dr Cunney.

"It is difficult to know how much of the increasing levels of resistance that we see is related to increased pressures on the healthcare system, as it is a very multifactorial thing involving antibiotic use, hand hygiene, staffing levels, bed occupancy, surveillance and prevention programmes etc."

"However, international experience should suggest that if you don't factor in maintaining your infection control resources, maintaining safe levels of bed occupancy, maintaining staffing levels etc, that does result in an increase in infections, so that is something that our health authorities need to keep an eye on."







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