Antibiotic resistance: reducing inappropriate use of antibiotics is key

Antibiotic resistance: reducing inappropriate use of antibiotics is key

Since their discovery almost 100 years ago, antibiotics have become a cornerstone of medicine. They are essential in treating and preventing bacterial infections. Many modern treatments, such as cancer therapy and major surgery would be virtually impossible without their help. However, as antibiotic use has increased, more and more bacteria have become resistant to antibiotics.  This phenomenon, known as antimicrobial resistance (AMR), is a normal process of evolution. However, it means there needs to be a supply line of new antibiotics to deal with resistant infections. Worryingly, there are very few new treatments in the pipeline.

Indeed, the WHO describes antibiotic resistance as "a serious threat [that] is no longer a prediction for the future, it is happening right now in every region of the world and has the potential to affect anyone, of any age, in any country".

One reason the problem has become so acute is that many people are self-medicating with antibiotics, often when it is inappropriate, for example to treat colds or the flu. In many countries, they can be bought in pharmacies without a prescription.

Another contributing factor is patients failing to complete the course of their medication. All of this increases the likelihood of bacteria developing resistance. This is making the available antibiotics increasingly ineffective.

The potential consequences of running out of effective antibiotics are serious. Without them, major surgery such as knee and hip replacement or heart bypass surgery would become very risky. Given that Europe's ageing population increasingly depends on such interventions, this is a major concern.

Reducing inappropriate use and slowing the spread of resistance would mean that existing therapies would remain effective for longer.

To help drive awareness of this, the European centre for disease control (ECDC) launched its annual 'European antibiotic awareness day' (EAAD) in 2008. 

Each 18 November is an opportunity to raise awareness of the threat to public health posed by antibiotic-resistant bacteria and the importance of prudent use of antibiotics. This year will see national events and campaigns on prudent antibiotic use in over 40 countries across Europe.

To coincide with EAAD, the ECDC will be releasing its latest data on antibiotic resistance and usage in Europe. It will also provide details of an expert assessment on the spread of bacteria resistant to carbapenems in Europe, currently one of the last lines of defence available in antibiotics.

The European Parliament holds similar concerns. Earlier this year, Italian EFDD MEP Piernicola Pedicini was the Parliament's rapporteur on an own initiative report entitled "Safer healthcare in Europe: improving patient safety and fighting antimicrobial resistance." 

It concluded that the main causes of antimicrobial resistance were "the misuse of antimicrobials, including antibiotics, and in particular their excessive use, as well as stagnation in drug development in the field of antimicrobial medicines." 

The report made clear proposals for reducing the impact of AMR. These included "the need to regulate the prescription of antibiotics for treatment or prophylaxis. In addition, antibiotics should only be used where correctly indicated, at the correct dose and for the shortest duration possible as recommended by evidence-based guidelines."

The report also recommended that "regulation on the sales of antibiotics so that patients can buy only the specific quantity of antibiotics as prescribed by the doctors" was urgently needed. It also pointed to the role that patients could play. 

"We emphasised the importance of ensuring that patients adhere and comply with their antibiotic treatments as prescribed by medical professionals," said Pedicini. "Campaigns on the rational use of antibiotics can make a useful contribution to this awareness."

Pedicini also emphasised that many healthcare associated infections, particularly those caused by resistant bacteria, can be minimised by good management of healthcare facilities.

"This is why it is important that healthcare managers are appointed on the basis of their professional experience and not on the basis of their political affiliations."

Clearly, however, these measures will only buy breathing space for the current treatment; new antibiotics are urgently required. Fortunately, it appears that there may be light at the end of the tunnel.

A number of leading pharmaceutical companies, including AstraZeneca, GSK and Merck, are currently researching new treatments.

John Rex, Chief Strategy Officer and Chief Medical Officer for AstraZeneca's infection business unit, agreed that antibiotics were vital to modern healthcare. 

"We depend on the ready availability of effective antibiotics. They are fundamental. Without antibiotics, you cannot effectively treat cancer, or take care of premature babies or help prevent postoperative infections."

Unfortunately, he said, a number of factors have combined to cause "a frighteningly thin pipeline of novel agents." "The nature of the research is very difficult, although many of the larger R&D challenges are being addressed through major initiatives in the US and EU."

However, economic challenges remain. Any new antibiotics that are developed will need to be reserved - rightly so - as a last line of defence. This means companies are investing in R&D for products that may never be used. There must be a way for them to recoup their investment.

Rex says the answer is to find an effective way to delink the amount of the products used from the revenue that accrues to the developer. There are already efforts underway to find ways effective ways to do this, with promising results. 

He cited an approach currently being modelled in the UK between the department of health and the association of the British pharmaceutical industry to a fully delink antibiotic purchase. "If put into practice, the model will create a powerful new model for addressing the critical challenge of resistance to antibacterial agents."

Richard Bergstrom, Director General of the pharmaceutical industry trade association EFPIA, says the industry is doing its part. However, the problem of antimicrobial resistance was a global one, and requires a response to match. "If we are to successfully develop - and preserve - new antibiotics, we need a comprehensive plan at a global level."

Any plan, he said, "should include a mechanism that dedicates some of these new antibiotics under development for exclusive use in humans. They should not be used in animals."

Bergstrom's comments provided a useful reminder that the challenges surrounding antibiotics use extend further than human use; antibiotics are an important component in animal welfare. 

Roxane Feller, Secretary General of IFAH-Europe, the International Federation for Animal Health, agrees resistance is a serious concern, both for the public and for animal health. "Managing the issue", she said, "requires collaborative action from policymakers, scientists, industry, veterinarians, farmers, medical professionals and the general public."

She stressed that IFAH-Europe members have had a long-standing commitment to the responsible use of antibiotics, urging that they are used carefully and prudently to maintain their effectiveness and minimise any increase in resistance. 

"We support efforts for monitoring both antibiotic use on farms and the development of resistance. Our industry has always strongly supported target pathogen monitoring by the European Animal Health Study Centre (CEEESA). "

"We have also taken part in the European Surveillance of Veterinary Antimicrobial Consumption, sponsored by the European Medicines Agency, which is aimed at assessing veterinary antibiotic usage at member state level."

The latest report suggests that sales of antibiotics for animal use fell by eight per cent between 2011 and 2013.

The contribution of antibiotic use in animals was also touched on in the Pedicini report. "This aspect needs to be monitored and controlled", he said. "The use of antibiotics in animals affects antibiotic resistance in humans."

This point was echoed by Ilaria Passarani, Head of the Food and Health Department at European consumer champions BEUC. She shares concerns over the impact of antibiotic use in animals. 

"Consumers are often advised to go easy [on antibiotics], but this advice should also extend to farm animals" she said. "Resistant bacteria that develop at the farm travel from livestock to humans via air, water and contact. This means that all consumers are affected, not only meat eaters."

She supports the European Parliament's wishes to 'beef up' the Commission's proposals by banning the administration of antibiotics to healthy animals. "We do not have time to spare," she added, "only strict EU-wide rules will prevent a cut finger from becoming a potentially serious health risk once again."

As research to identify new treatments continues, EU citizens need to make sure that they do what they can to prevent further spread of resistance. The EAAD materials are a good place to start.


Piernicola Pedicini

MEP involved

Piernicola Pedicini