Department of Microbiology, City Hospital NHS Trust, Birmingham B18 7QH, UK
Yet another siren sounds a warning on the likely effects on public health unless governments implement controls on the use of antimicrobials (be they antibiotics, or antiviral or antiparasitic agents). The WHO Report on Infectious Diseases1 is timely and follows many others who exhort all to be prudent with these agents. In the UK, the House of Lords Select Committee Report exhaustively described the problem and suggested the way forward; the EU report did likewise and emphasized the possible contribution of agricultural overuse of antimicrobials.2,3 In the US there is currently a bi-partisan senate initiative, with Senators Kennedy and Frist pushing forward the agenda. Recently, the WHO anounced its strategy for controlling resistance.4 A lot of sound, but how much action?
It could be argued that antimicrobials have done more to improve public health in the last 50 years than any other measure. In this very success lies the major problem, overuse. By my calculation the antibiotic market worldwide consumes between 100 and 200 x 106 kg: a formidable selection pressure. Combine this with the global number of bacteria associated with man and animals, possibly in the region of 1028, and the facility with which bacteria and viruses can become resistant, and it is not surprising that to some the problems look relentless and inevitable. In his recent book updating The Origin of Species, Stephen Jones5 states that bacteria are bound to win their war against medicine. Nowhere else does the evolutionary battle take place in an arena where, in effect, one of the players (the bacteria) holds all the cards. He draws the pessimistic view that medicine's finest days may soon be over, but antibiotics, in their brief flowering, have revealed evolution's finest work'. It is therefore clear to me that if such a bleak forecast is to be averted then governments, the medical profession and their patients will need to make some major decisions.
Both the US (www.cdc.gov/drugresistance/actionplans) and UK6 governments have published action plans. They quite correctly suggest that the battle must be on a broad front encompassing a need for more meaningful surveillance, the need for both the medical and agricultural profession and patients to be more judicious in their use of the agents, a greater awareness of infection control, greater research not only into new therapeutic agents and improved diagnostics, but also a better understanding of how bacterial genes spread. The US document is highly detailed and that of the UK paints with a broader brush. More recent developments have been a meeting in Visby under the Swedish Presidency of the EU to discuss the progress on antimicrobial resistance, and in the UK the House of Lords have revisited the problem and highlighted areas of concern.7,8 We now have the formation of the Specialist Committee on Antimicrobial Resistance (SACAR) some 32 years after the Swann Committee first recommended such a group.9 Where, though, should resources be used to obtain the maximal effect?
At its most straightforward, bacteria respond to the selecting pressure: antibiotic use. The House of Lords report2 suggests that in the UK, up to 95% of antimicrobial use is within the community (as against hospitals), although the US National Academy suggests it is closer to 75% (www.cdc.gov/drugresistance/actionplans). In these countries, up to three-quarters of antimicrobials are used to treat respiratory tract infections,10 and 7080% of such prescriptions are for bronchitis, tonsillitis, laryngitis, pharyngitis, tracheitis and other unspecified respiratory tract infections, the vast majority of which will arguably not benefit from antibiotics. Any action plan must have this particular problem firmly in its sights.
There is the theoretical possibility of reducing antibiotic prescribing by 6070%. A major component of these prescriptions would be in the treatment of minor infections of children. Society would need to be reassured on at least two points. First, that no harm would come to these patients and secondly that the nature of bacterial resistance would decline or at least its relentless rise be halted. On the former, I commend the Centres for Disease Control collecting information for the medical profession and their patients on these diseases (www.cdc.gov/ncidod/dbmd/antibioticresistance), and both the US and the UK have developed prescription pads for the trivial viral diseases. A long-term relationship with the lay media will have to be developed as there is, most probably, no more potent influence on prescribing practice than through changing public opinion. Here lies another problem, how to sustain the media's interest for what will undoubtedly be the long haul?
How likely is it that these actions will reduce resistance? It has to be admitted that information on antibiotic resistance and use in the community, as against hospitals, is modest but offers some encouragement.11,12 Inactivity is not an option, unless we wish to have a world without antibiotics as so graphically illustrated in the WHO report.
Notes
* Tel: +44-121-507-4255; Fax: +44-121-551-7763; E-mail: r.wise{at}bham.ac.uk
References
1 . World Health Organisation. (2000). Report on Infectious Diseases. WHO, Geneva, Switzerland.
2 . House of Lords Select Committee on Science and Technology. (1998). Resistance to Antibiotics. The Stationery Office, London.
3 . The Copenhagen Recommendations Report on the EU Conference on the Microbial Threat. (1999). Ministries of Health, Food, Agriculture and Fisheries. Denmark.
4 . World Health Organisation. (2001). WHO Global Strategy for Containment of Antimicrobial Resistance. WHO, Geneva, Switzerland.
5 . Jones, S. (1999). Almost Like a WhaleThe Origin of Species Updated. Doubleday, London.
6 . Department of Health. (2000). UK Antimicrobial Resistance. The Stationery Office, London.
7 . House of Lords Select Committee in Science and Technology. (2001). Resistance to AntibioticsThird Report. The Stationery Office, London.
8 . Department of Health. (2001). Government Response. The Stationery Office, London.
9 . Joint Committee on the Use of Antibiotics in Animal Husbandry and Veterinary Medicine. (1969). The Stationery Office, London.
10 . Source: IM Health, MIDAS copyright © 1999. IMS AG, printed with permission from IMS Health and subject to copyright protection.
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Austin, D. J., Kristinsson, K. G. & Anderson, R. M. (1999). The relationship between the volume of antimicrobial consumption in human communities and the frequency of resistance. Proceedings of the National Academy of Sciences, USA 96, 11526.
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Seppala, H., Klaukka, T. & Vuopio-Varkila, J. (1997). The effect of changes in consumption of macrolide antibiotics on erythromycin resistance in Group A streptococci in Finland. New England Journal of Medicine 337, 4416.