Antibiotic resistance: why we need to care

During the twentieth century, improvements in hygienic conditions, the creation of vaccines and widespread vaccination programs and the development of antibiotics have had a huge impact on life expectancy and quality of life worldwide. Antibiotics are one of the major breakthroughs of modern medicine. The existence of antibiotics has made many of our current “medical miracles” possible: organ transplants, cancer treatments, therapies which beneficially modify our immune system (for diseases such as rheumatoid arthritis, psoriasis or Crohn’s disease, for instance) and complicated surgical procedures. Without antibiotics, the infection complications of these medical interventions would be too frequent, harmful and possibly lethal.

 

Dr. Andrew Gibbons is an Oral and Maxillofacial Surgeon working in NHS England. He gives his point of view on the risk antibiotic resistance poses to his practice.

 

 

Andrew Gibbons MA (Cantab), FDS RCS, FRCS, FRCS (OMFS)


I’ve had patients who’ve responded badly to antibiotics, but so far there’s always been a stronger antibiotic available, although with stronger side-effects as well. Currently, with facial trauma, we can close wounds quickly without a great risk of infection, often helped by antibiotics.

However, without effective antibiotics, this would be too dangerous in dirty wounds. We’d have to leave these wounds open for longer for new healthy tissue to form, and this would have a great impact on the aesthetic result. Implants are often used in reconstructive surgery. Without antibiotics, there is an additional risk of implant-associated infections.

Unfortunately, this frequent use of antibiotics is not the best way to control antibiotic resistance, and despite the high standard of infection control measures, even more preventive actions are necessary. A major shift in thinking is needed, a change in surgical attitude.

 

 

Our over-use and misuse of antibiotics in humans, animals and agriculture, has led to the widespread rise of antibiotic resistance: in livestock, food, hospitals, and the community at large. Growing human and animal populations — along with increasing international trade and travel — have accelerated the transfer and spread of resistant strains of bacteria, turning them into a global concern. When these resistant strains cause an infection, it is no longer a simple matter of prescribing the “usual” antibiotics. Common infections (such as pneumonia, as well as skin and urine infections), when caused by antibiotic-resistant bacteria, are increasingly difficult to treat and threaten rising numbers of people across the world.

 

Every time we take antibiotics or use them in animals, we create a selection pressure on bacteria to mutate or take on new genes in order to survive the antibiotic effect.

 

  • Lack of awareness about the issue, among the general public, prescribers, politicians, and the media.
  • Inadequate waste management and poor water sanitation.
  • Poor infection prevention and control practices (such as lack of hand-washing and hand hygiene to avoid the spread of infections in healthcare settings).
  • Insufficient diagnostic tools for the rapid and reliable detection of resistance.
  • Lack of vaccines for some important infections.
  • Lack of antibiotics to treat infections caused by multi-drug resistant bacteria.
  • Weak or absent antibiotic resistance surveillance programs to track the number and type of antibiotic-resistant infections in a given area, city, country or global region.
  • Lack of a comprehensive, uniform and coordinated response among all countries

 

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Increased mortality

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In India, a child dies every nine minutes from an infection caused by antibiotic resistant bacteria.(3) In the European Union and the USA, some 48,000 people die every year because of antibiotic resistance.(4),(5) In all probability, these are underestimates of the numbers of deaths because of the lack of consistent universal surveillance.

 

The global burden of disease related to antibiotic resistance has likely been underreported. Firstly, because there are no clear and accepted definitions for categorizing bacteria into “resistant” or “susceptible” strains. Secondly, there are no comprehensive global data covering all types of infections and bacteria. In fact, the mortality rate may be 2 to 6 times greater (depending on the bacterial species) when the infection is caused by an antibiotic-resistant when compared to an antibiotic-susceptible bacteria.(6)

Reporting “antibiotic resistance” as a category in death registers might eventually lead to a better estimate, and to raising awareness about the problem.

Increased morbidity

As well as causing increased mortality, infections by resistant bacteria are more difficult to treat and are more likely to complicate many aspects of a hospitalization.

 

The detection of antibiotic-resistant bacteria in the hospital environment or in a particular patient can lead to the increased need for isolation wards, cancellation or delay of treatments and surgery, as well as other costly and impactful consequences to the healthcare system. In fact, doctors increasingly worry that antibiotics, when used prior to a risky medical procedure to prevent infectious complications, may no longer function to prevent these infections. Under these circumstances, and faced with the current dearth of new antibiotics, we may have to avoid or reduce high-risk but life-saving medical procedures. When treating such antibiotic-resistant infections, clinicians may have limited therapy options - the use of more toxic options or combining multiple antibiotics which can cause increased side effects.

  • Treatment failure leading to chronic problems
  • Increased morbidity (disability, poor outcomes) and mortality
  • Adverse effects of alternative treatments (potentially less effective, possibly more toxic)
  • Relapse of the infection after treatment
  • Increased spread of antibiotic-resistant bacteria and their associated community- and healthcare-acquired infections
  • Increased use of antibiotics
  • Lack of availability of clinically effective antibiotics
  • Longer and more complicated stays in hospital
  • Excess healthcare costs
  • Decreased societal productivity

Economic Impact

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The impact of antibiotic resistance on lives, health systems and economies is considerable and will continue to grow. Some estimates of the economic effects have been published, and the findings are disturbing. For example, the yearly cost to the US health system alone has been estimated at 21 to 34 billion dollars, as well as more than 8 million extra days in the hospital.(7) In the EU, resistance to antibiotics costs an estimated €1.5 billion per year.(8) Medical costs are only part of the economic equation: reduced employment and income, and increased national healthcare spending also have to be taken into account in assessing the financial impact. The EU estimates that resistance to antibiotics causes 600 million days of lost productivity each year, whereas in Thailand some researchers estimate that it leads to US$2 billion of productivity losses per year.(9) The first O’Neill report estimates that by 2050, antibiotic resistance may lead to US$100 trillion in induced world GDP loss.(10)

 

In September 2016, the World Bank also stated that, without antibiotic resistance containment, the annual costs could become as massive as those of the global financial crisis that started in 2008. Moreover, the Sustainable Development Goals for 2030 – such as ending poverty, ending hunger, ensuring healthy lives, reducing inequality, and revitalizing global partnerships – are likely to remain unachieved.(72)