Antimicrobial resistance, the greatest challenge of modern medicine
Antimicrobial Resistance (AMR) has been addressed multiple times as the greatest threat to modern medicine. Even though experts say that we are running out of time to solve this rising problem, the most important health organizations and political leaders are working to fight this mutual enemy. With national and global action plans being implemented and by slowly changing attitudes there is a chance that we might win this war against multiresistant microbes. Dr Marc Sprenger, the Director of the World Health Organization (WHO) Antimicrobial Resistance Secretariat told us at the 2017 Autumn Assembly in Budapest that we, future doctors could make a difference. We had the chance to discuss with him the present and future of the AMR battle.
Current AMR situation
Antimicrobial resistance is a natural phenomenon, Sir Alexander Flemming warned us about it a long time ago when receiving the Noble Prize for discovering the first antibiotic, penicillin in 1945. His prediction has become a real threat in recent years. Before his discovery, people died from diphtheria, pneumonia, syphilis and other infectious diseases. In a post-antibiotic era, with the rise of AMR, life would be just as dangerous as it was 70 years ago when simple infections would lead to death.
As Dr. Sprenger mentioned in his presentation, the total global antibiotic consumption increased 30% between 2000-2010 from 50 to 70 billion standard units1. In 2010, 63,200 tons of antibiotics were consumed by livestock1 only. “The most important thing is to look at the use of antibiotics both in humans and animals. The more antibiotics you use, the higher rates of resistance you will see,” said Dr. Sprenger. Moreover, it is possible to reduce the use of antibiotics for example in livestock. “One recent example is the United Kingdom: antibiotic consumption was reduced within the British poultry industry by 70% and this change has increased the productivity! All it took was paying more attention to reducing and replacing the use of antibiotics. The industry has realized that it is not about the costs but the attitude. Denmark, for example has a huge pork industry and they do not use any antibiotics,” said Dr. Sprenger.
There are significant differences in AMR levels among European countries. “The amount of antibiotics in the countries with the least use is about 25% of the countries using the most antibiotics. Doctors need to explain to patients that antibiotics are not needed for a sore throat or several other banal illnesses, instead, they just need to wait and explain to patients that this is self-limiting. If necessary use a painkiller,” said Dr. Sprenger. Another good option would be reducing the duration of the treatment. “I know for example that the treatment for urinary tract infections is sometimes two weeks while it could be much shorter. You can administer the same medication for one week and have a similar effect. All these measures reduce the unnecessary use of antibiotics,” Dr. Sprenger explained.
Fight against AMR
If the rise of AMR continues, in the absence of effective antibiotics we would not be able to treat immunosuppressed cancer patients anymore. We could not treat urinary tract infections either, which are very common and involve many resistant microbes. “Nowadays some people are dying from a multidrug resistant Klebsiella pneumonia because there is no regular antibiotic to treat it. The last antibiotic we have is carbapenem and once it proves to be ineffective we use the toxic colistin, a very old-fashioned antibiotic and in parts of Europe we have already seen resistance against it,” explained Dr. Sprenger.
The development of new drugs is often driven by pharmaceutical companies, although sometimes it is financially supported by governments as well. The development of antibiotics is important where the need is the highest. From this perspective, we need to develop antibiotics against Gram-negative bacteria. That is why WHO has created a list for priority pathogens. “We hope that tax money will be available to support the research and development of antibiotics against these most important pathogens,” said Dr. Sprenger.
“On the one hand we have the scientific point of view for developing new drugs which is very important. The other side is being much more reluctant with antibiotics. In more than 50% of cases antibiotics are prescribed for wrong indication,” explained Dr. Sprenger. “We should pay much more attention to stewardship and guidance. Hospitals need strict procedures not only on handwashing but also guidelines about treatment, first and second line therapies,” he explained.
The training of doctors to follow procedures has a high importance. “We can only get a hold of this situation if we are willing to follow the guidelines. The European Commission for example is very active; they have just released a very important document, the guidelines for the prudent use of antibiotics,” said Dr. Sprenger.
Besides educating healthcare professionals about AMR, it is important to spread knowledge to the public as well. “WHO has established a group of world leaders on behavioural change to ask their advice about how we can change the behaviour of doctors, vets and the general public. I am not sure whether an awareness campaign is the only solution because this issue is much more complicated than that and that is why we need the advice of the world’s experts on this issue,” said Dr. Sprenger.
The target groups of AMR education are mostly outside the hospital; family doctors and pediatricians, for example, are very important. Educating parents could also help, since young children are administered a lot of antibiotics and parents often place pressure on doctors to prescribe antibiotics.
The future for doctors fighting against AMR
There are several countries, which present examples of proper use of antibiotics. It has to do with good education, and changing attitudes of doctors and of the public. “The countries with a very low resistance, like Scandinavian countries and the Netherlands, do a lot to improve IPC (infection prevention and control),” said Dr. Sprenger.
The greatest achievements on antimicrobial resistance have so far happened on a political level, ministers and even heads of states are aware that AMR needs attention. A lot of governments have developed action plans and have started to work on implementing them. “China, for example, has taken important measures that will really change the situation. Also India and all the European countries are taking steps to fight against AMR. Political attention is always important and needed in addressing global health issues,” said Dr. Marc Sprenger.
Besides the attention of policy makers, the new generation of healthcare professionals also have a significant role in raising awareness and spreading knowledge about AMR. “My hope is very high because you, young doctors, can change the world. If you do your internships, please pay attention to infection prevention like hand washing procedures. Have open discussion with your colleagues and your supervisor in case they don’t follow these protocols. Explain how important this is in order to stop the spread of resistant bacteria in health care settings. My advice for young doctors is to look at modern literature and WHO guidelines for IPC and follow that,” said Dr. Sprenger.
The interview was made by Lili Diana Szabo, Medical Science Director at the Autumn Assembly’17 Budapest.
1 Van Boeckel et al. The Lancet Infectious Diseases 2014 14, 742-750DOI: (10.1016/S1473-3099(14)70780-7