The development and use of antimicrobial drugs in the 20th century revolutionised medicine. Previously life-threatening conditions can now be treated effectively and quickly, and surgery that was once high-risk is now safe and routine.
However, these advances are now being threatened by the evolution of micro-organisms (bacteria, viruses, fungi and parasites) that are resistant to the treatments that were once effective.
This natural process has been accelerated by the inappropriate use of antimicrobials (especially antibiotics) fuelled by poor infection control and prescribing practices, and a dearth of new alternative treatment options.
The impact of antimicrobial resistance
The UK Chief Medical Officer, Professor Dame Sally Davies, has described antimicrobial resistance as a “catastrophic threat”. She warned that the lack of effective antibiotic provision could, within 20 years, lead to routine operations such as hip replacements and organ transplants becoming deadly due to infection risk.
Such concerns led to antimicrobial resistance being added to the Cabinet Office’s National Risk Register of Civil Emergencies for the first time in 2015. The register warns that a widespread outbreak of a resistant bacterial blood infection could affect 200,000 people in the UK and lead to 80,000 deaths.
Globally, the ongoing public health effects of antimicrobial resistance are already in evidence and, without action, they are set to worsen: a review launched under the previous Government estimated that, left unchecked, antimicrobial resistance could cause 10 million deaths annually, more than cancer and diabetes combined, and a related 2.0 to 3.5% drop in global economic output by 2050.
Chart: Deaths attributable to selected causes
700,000 deaths per year are currently attributable to antimicrobial resistance; but left unchecked, it is projected to lead to 10 million deaths per year by 2050. Deaths attributable to selected causes, millions
Beyond the human health effects, the loss of effective agents for use in farming has the potential to severely affect the agricultural industry, food security and the wider economy.
Tackling antimicrobial resistance
The previous Government’s Antimicrobial Resistance Strategy 2013-18 focuses on seven key areas and calls for the involvement of those working in both human and animal health. The consensus is that any approach to this threat will require a number of actions, some of which are explored below.
Improved prescribing practices
Antibiotics are ineffective against viruses and other diseases not caused by bacteria. However, despite guidance, an analysis of UK GP prescribing published in 2014 showed that antibiotic prescribing rates for coughs and colds in 2011 had increased since 1997.
The need for improved and consistent education for medical students and ongoing guidance for clinicians has been recognised. Public Health England issued an updated antimicrobial stewardship toolkit, Start Smart-Then Focus, for hospitals in March 2015, which seeks to ensure antimicrobials are used appropriately.
The National Institute for Health and Care Excellence (NICE) has also taken a role: it has included advice on antimicrobial prescribing in its guidance, and it is due to publish new guidelines on antimicrobial stewardship in summer 2015.
Public awareness is crucial and can be improved. Nearly half of Europeans surveyed in 2013 (including 41% of people in the UK) did not know that antibiotics are not effective against viruses.
European Antibiotic Awareness Day has provided a good opportunity for raising awareness but the previous Government acknowledged that more work is needed to change expectations.
New treatment alternatives
Compared with drugs for more chronic conditions, antimicrobial drugs are not seen as an attractive, profitable prospect for development by pharmaceutical companies.
In 2014, the Commons Science and Technology Select Committee highlighted the “failing antibiotic pipeline”: only 22 new antibiotics have launched since 2000, and only four major pharmaceutical companies are still working in this field.
An Independent Review of Antimicrobial Resistance was announced by the Prime Minster in July 2014 to look at ways to encourage and accelerate the development of new drugs.
Preliminary recommendations of the review have included the establishment of a global innovation fund to boost early research ideas for new treatments and diagnostics, and a review of existing treatment options.
The final recommendations are due to be published in 2016.
Rapid diagnosis of bacterial infections would improve healthcare professionals’ ability to make informed choices about the need for antibiotics and the most appropriate type to prescribe.
The need for better diagnosis was recognised when the public chose the issue to be the subject of the Longitude prize: £10 million will be awarded to the winning entry to develop a quick, accurate, cost effective and easy-to-use diagnostic test for bacterial infections.
Micro-organisms do not respect borders, and there is a growing consensus that antimicrobial resistance is a global threat that requires a coordinated response.
The World Health Organisation (WHO) recently published its first report on antimicrobial resistance surveillance, which shows the need for an improved global effort on information collection.
A WHO draft global action plan is due for consideration at the 68th World Health Assembly in May 2015.
The Antimicrobial Resistance Strategy
The previous Government’s Antimicrobial Resistance Strategy 2013-18 was developed jointly by the Department of Health and the Department of Environment, Food and Rural Affairs. It aimed to slow the growth of antimicrobial resistance by focussing on seven key areas:
- Improving infection prevention and control practices (in human and animal health)
- Optimising prescribing practice
- Improving professional education, training and public engagement
- Developing new drugs, treatments and diagnostics
- Better access to and use of surveillance data
- Better identification and prioritisation of antimicrobial resistance research needs
- Strengthened international collaboration