Skip to 0 minutes and 13 secondsBut what we do with antibiotics, because we give the wrong doses of antibiotics to people or we give the right doses but people end up dosing themselves incorrectly because they don't take a full prescription or because we give antibiotics to healthy farm animals, what we do in all those situations is we set up a sort of Darwinian battleground within the body of the human or the animal who's getting the antibiotics in which the weak, susceptible bacteria are knocked out by the drug, but the strong survive. And it unfortunately occurs more rapidly than you might think. Because they go so quickly as a community of organisms, if there's a way to become resistant, they can find it.
Skip to 1 minute and 4 secondsAbout 3/4 of the way through my fellowship, we began to see just an explosion of highly resistant infections. And that was can concordant with it happening all over the country and the world. There's nothing unique about our setting. And I remember the first patient that I took care of who had an untreatable infection. It could not be treated. And it was a woman in her 20s who had two small kids who had leukaemia.
Skip to 1 minute and 55 secondsAnd she developed an infection in her blood by acinetobacter.
Skip to 2 minutes and 1 secondSo we started treating it with the drug that we had left at the time, which was a drug called Imipenem. That was the big gun. That was the last ditch. And she looked like she was getting better at first, but then the infection came back. And it was resistant to the Imipenem. It develop resistance in the middle of a course of therapy. And when it came back, I have this just vivid recollection of looking at the computer screen. And you see a printout on the computer screen of all the antibiotics that the bacteria is resistant to. Resistant, resistant, resistant, resistant. There was nothing. It was resistant to everything.
Skip to 2 minutes and 47 secondsAnd I couldn't fathom how in the 21st century an infectious disease specialist would run out of stuff. I mean, since penicillin, we've expected that we're going to have relatively, inexpensive, safe, tremendously effective drugs to treat infections. And this woman had returned to 1935. She had returned to the pre-antibiotic era. And she died. And there was nothing to do.
The personal impact of resistance
Watch this clip from the “Resistance” video produced by ‘small-r’ in which a doctor explains the impact resistance has on his ability to treat his patient. Once you have watched the clip read the article below by Dr David Jenkins, consultant medical microbiologist and infection prevention and control (IPC) doctor at University Hospitals of Leicester (UHL) NHS Trust.
In 2014 WHO published a report looking at resistance around the world. This survey highlighted major gaps in data on the extent of antibacterial resistance and types and number of infections caused by bacteria that had become resistant to antibacterial drugs.
Issues of concern included the lack of microbiology laboratories in some areas of the world and differences in laboratory susceptibility testing methods. Bacteria that are described as sensitive in some laboratories may be classed as resistant in labs using different testing protocols. There may also be variation in the types of clinical specimens studied, the number of bacterial isolates tested and the range of anti-bacterials investigated. In countries with few laboratories the susceptibility reports may only reflect the situation in limited parts of the country.
In order to compile the report, the WHO looked to ministries of health, national reference laboratories and public health institutes for surveillance information. When these were unable to provide data, surveillance results from unofficial networks and published articles were sought.
The basis of the WHO document was the availability of data on resistance for selected bacteria-antibacterial drug combinations. The largest gaps in data were in Africa, the Middle East and European countries outside the European Union.
The report focused on 7 different bacterial species: Escherichia coli, Klebsiella pneumoniae, Staphylococcus aureus, Streptococcus pneumoniae, non-Typhoidal Salmonella species, Shigella species and Neisseria gonorrhoea together with their susceptibility to clinically important antibacterial classes. The take home message was that antibacterial resistance is indeed a global problem. All of the WHO regions have problems with resistance, however information about susceptibility came from only a few countries, therefore we have no idea of the extent of antibacterial resistance.
However, it is worth pointing out that in some regions of the world there are active and organised steps to carry out surveillance. Two good examples are ReLAVRA (Latin American antimicrobial resistance surveillance network) and EARS-Net (European Antimicrobial Resistance Surveillance Network) which is hosted by the European Centre for Disease Prevention and Control (ECDC).
An example of antimicrobial resistance surveillance by ECDC reported on the prevalence of selected bacteria causing infections acquired in intensive care units across Europe. The overall picture is one of increasing resistance: within one year the proportion of S. aureus infections caused by MRSA increased from 36% to 46%. Between 2009/10 the proportion of infections by E. coli resistant to 3rd generation Cephalosporins increased from 16%-23%. While the proportion of infections caused by Klebsiella species resistant to these antibiotics increased from 28%-38%. Nearly 90% of Acinetobacter species infections were resistant to Carbapenems, antibiotics often considered to be the last hope for treating infections caused by this organism. The evidence for a global resistance crisis is overwhelming:
In the USA the large majority of 99,000 deaths each year caused by hospital acquired infections are caused by resistant bacteria and the annual cost of managing these infections may be as much as $34 billion per year.
In Europe antibacterial resistant organisms account for 25,000 deaths per year at a cost of 2.5 million extra hospital days. The cost is approximately 1.5 billion euros per year due in part to 600 million days of lost productivity.
Developing countries are also hit hard by resistance: Thailand has more than 140,000 antibiotic resistant infections each year causing 30,000 deaths; in Pakistan 71% of infections in neonates are caused by resistant infections, and in Peru and Bolivia the majority of hospital infections are caused by antibiotic resistant bacteria.
The World Economic Forum in its 2013 Global Risks Report put antimicrobial resistance on a par with the unrestricted proliferation of weapons of mass destruction and global economic meltdown.
The report points out that many people take for granted that antibiotics will always be available when we need them and that even in the highest income countries few people go through out life without needing antibiotics.
Consequently, the emergence and spread of resistance is something that should cause fear in all of us.
How familiar are you with the situation in your country, location or organisation? Are others in your country, location or organisation aware of this situation?
See more about the Resistance film here.
Please note that this text and video are used by kind permission of the University of Dundee and are taken from the FutureLearn course Antimicrobial Stewardship: Managing Antibiotic Resistance.
© Edel Malone/ FilmBuff & Michael Graziano/ small-r