“A post-antibiotic era means an end to modern medicine as we know it. Things as common as strep throat or a child’s scratched knee could once again kill.”
(Director-General of the World Health Organization) – 2012
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.
“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.”
Testimonial from a Dental Surgeon
Andrew Gibbons MA (Cantab), FDS RCS, FRCS, FRCS (OMFS)
Dr. Andrew Gibbons is an Oral and Maxillofacial Surgeon working in National Health Service England. He gives his point of view on the risk antibiotic resistance poses to his practice.
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.
Over-use and misuse of antibiotics
Antibiotics save millions of human and animal lives worldwide every year, but in many cases they are misused or unnecessarily consumed. In developed countries, between 10 and 20 courses of antibiotics are prescribed to children before the age of 18 years. Blaser M. Antibiotic overuse: Stop the killing of beneficial bacteria. Nature 2011;476:393-394. DOI:10.1038/476393a Furthermore, it has been demonstrated that up to 50% of all antibiotics prescribed in human medicine are not needed or not prescribed appropriately. CDC website about antimicrobial resistance.
- In Europe, the use of antibiotics as alleged growth promoters for food-producing animals has been banned since 2006. But such a use for antibiotics is still allowed in many other countries.
- Antibiotics are still mistakenly used to treat viral infections, for which they have no effect.
- Antibiotic regimens are too often not followed as prescribed. When people stop taking their pills as symptoms clear up, it potentially allows resistant bacteria to develop.
- In some cases, antibiotics may be taken by patients as self-medication (for instance to treat upper respiratory tract infections, the majority of which are caused by viruses for which antibiotics are ineffective). This can also lead to generation of resistant bacteria.
- Access to antibiotics is too easy in many countries (“over the counter” without a medical prescription).
The increased consumption of antibiotics is also a cause of concern because a proportion of this quantity will eventually appear in the environment. This is because antibiotics are seldom fully metabolised, either by humans or by animals, and can show up in their urine and feces. In the case of livestock, antibiotics are usually administered orally in the feed, then they are only partially digested and appear in the feces which may be used as manure and then spread onto agricultural fields. These drug residues can leach into the soil, contaminating water resources and our food supply. A study has also shown that residues of tetracycline antibiotics have an unexpected effect on the development of many life forms and can potentially reduce the growth of plants. Moullan N et al. Tetracyclines Disturb Mitochondrial Function across Eukaryotic Models: A Call for Caution in Biomedical Research. CellReports 2015;10:1681–1691.
DOI: 10.1016/j.celrep.2015.02.034 Beyond the fact that antibiotic residues can cause allergic reactions, a major concern stems from these residues being present at relatively low concentrations, which facilitates the emergence of antibiotic-resistant bacteria during contact.
Furthermore, the nature and intensity of side effects caused by antibiotics vary considerably from one person to another. They depend on the class of antibiotic used, and on whether other drugs are being taken at the same time. Skin rashes, allergies, diarrhoea or an imbalance of the intestinal flora are among the most common side effects of antibiotics. Granowitz EV et al. Antibiotic Adverse Reactions and Drug Interactions. Crit Care Clin 2008;24:421–442.
(http://clinicalevidence.pbworks.com/w/file/fetch/51306022/REACCIONES ADVERSAS A LOS AB.pdf)
Another advantage of implementing stewardship programs lies in the reduction of the various side effects of antibiotics. One of their most common adverse events is the difficult-to-treat diarrhoea caused by Clostridiodes difficile is the main infectious cause of healthcare-associated diarrhea, and can lead to extremely serious and incapacitating pseudomembranous colitis.
Due to its oral-fecal route of transmission and the persistence of spores on inert surfaces, C. difficile is highly contagious and requires drastic measures involving patient isolation, hygiene and disinfection. infection. Such side effects have also been reported in animals, for example, calves routinely treated with antibiotics are twice as likely to suffer from diarrhoea. (ref.82)
Leading factors facilitating the spread of antibiotic resistance
- 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.
Most efficient ways to prevent the spread of antibiotic resistance
Consequences of antibiotic resistance
- 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