In April 2014, the World Health Organization released the most comprehensive report to date on the alarming worldwide growth of antibiotic resistance, warning that we are already entering a world without antibiotics. The World Health Organization has sounded a loud alarm bell that many types of disease-causing bacteria can no longer be treated with the usual antibiotics and the benefits of modern medicine are increasingly being eroded.
The WHO in April released a comprehensive 232-page report on antimicrobial resistance with data from 114 countries showing how this threat is happening now in every region of the world and can affect anyone in any country. Antibiotic resistance — when bacteria evolve so that antibiotics no longer work to treat infections — is described by the WHO report as “a problem so serious that it threatens the achievements of modern medicine.” “A post-antibiotic era, in which common infections and minor injuries can kill, far from being an apocalyptic fantasy, is instead a very real possibility for the 21st century,” said Dr. Keiji Fukuda, WHO assistant director general who coordinates its work on antimicrobial resistance. “Without urgent, coordinated action, the world is headed for a post-antibiotic era, in which common infections and minor injuries which have been treatable for decades can once again kill. “Effective antibiotics have been one of the pillars allowing us to live longer, live healthier, and benefit from modern medicine. Unless we take significant actions to improve efforts to prevent infections and also change how we produce, prescribe and use antibiotics, the world will lose more and more of these global public health goods and the implications will be devastating.”
The report, “Antimicrobial resistance: global report on surveillance”, shows resistance is occurring in many bacteria causing different infections. The report focuses on antibiotic resistance in seven bacteria responsible for common, serious diseases such as bloodstream infections (sepsis), diarrhoea, pneumonia, urinary tract infections and gonorrhoea. What is especially alarming is that the bacteria’s resistance has also breached “last resort” antibiotics, which are the most powerful medicines that doctors resort to when the usual ones do not work. When patients do not respond to the usual medicines (known as first-line or first-generation medicines), doctors prescribe newer (second-line) medicines which also usually cost more. When these also don’t work, newer and often more powerful (but sometimes with also more side effects) antibiotics are used, and they are even more expensive. If these third-line or “last resort” medicines are not available or too costly for the patient, or if they don’t work on a patient because of antibiotic resistance, the patient remains ill or dies if the infection is a serious one.
New antibiotics have been discovered in the past to treat infections when the old ones became useless due to resistance. But these discoveries dried up in the past 25 years. The last completely new classes of antibacterial drugs were discovered in the 1980s. Pathogens that are becoming increasingly resistant including to the more powerful antibiotics include E. coli, K. pneumonia, S. aureus, S. pneumonia, salmonella, shigella and n. gonorrhoeae.
Key findings from the report include: Resistance to the treatment of last resort for life-threatening infections caused by a common intestinal bacteria, K. pneumoniae — carbapenem antibiotics — has spread worldwide. K. pneumoniae is a major cause of hospital-acquired infections such as pneumonia, bloodstream infections, infections in newborns and intensive-care unit patients. In some countries, because of resistance, carbapenem antibiotics would not work in more than half of people treated for K. pneumoniae infections. Resistance to one of the most widely used antibacterial medicines for the treatment of urinary tract infections caused by E. coli — fluoroquinolones — is very widespread. In the 1980s, when these drugs were first introduced, resistance was virtually zero. In many countries today, this treatment is ineffective in more than half of patients. The sexually transmitted disease, gonorrhoea, may soon be untreatable unless there are new drugs. Treatment failure to the last resort of treatment for gonorrhoea — third generation cephalosporins — has been confirmed in several countries. In 2008, there were 106 million new cases of gonorrhoea.
Antibiotic resistance causes people to be sick for longer and increases the risk of death. For example, people with MRSA (methicillin-resistant Staphylococcus aureus) are estimated to be 64% more likely to die than people with a non-resistant form of the infection. There are many cases of patients being infected by MRSA in hospitals. The report also gives useful information on the worrisome building up of resistance in four serious diseases — tuberculosis, malaria, HIV and influenza. The re-emergence of TB is especially of great concern. Increasing cases of TB cannot be treated by most known antibiotics. In 2012, 8.7 million people developed TB and 1.3 million died; 3.6% of new cases and 20% of previously treated cases had multidrug-resistant TB. The malaria-causing bacteria have become increasingly resistant firstly to chloroquine and pyrimethamine and now resistance to artemisinin has been identified in some cases in Cambodia, Myanmar, Thailand and Vietnam.
In 2010, 219 million cases of malaria occurred worldwide and 660,000 died from the disease. A major factor accelerating resistance is in the animal husbandry sector, where there is a liberal use of antibiotics mainly to promote the growth of the animals used for food, for commercial purposes. This builds up resistance in the bacteria present in the animals. These resistant germs are passed on to humans who consume the meat. The WHO report has a small section on the animal-food chain, which has been identified as a major problem. The European Union has banned the use of antibiotics as growth promoters in animals, but it is still allowed in other countries. The WHO report mainly provides information on the prevalence and problems of microbial resistance, rather than what to do about the emerging crisis. However, a WHO press release on the report calls for some actions. These include: Setting up basic systems in countries to track and monitor the problem. Preventing infections from happening in the first place to reduce the need for antibiotics.
Only prescribing and dispensing antibiotics when they are truly needed; and prescribing and dispensing the right antibiotic(s) to treat the illness. Regulating and promoting appropriate use of medicines. Patients using antibiotics only when prescribed by a doctor and completing the full prescription, even if they feel better, and never using leftover prescriptions. Developing new diagnostics, antibiotics and other tools to stay ahead of emerging resistance.
By Martin Khor