Antibiotic resistant infection (AMR)

According to the National Risk Register of Civil Emergencies, a government document published by the Cabinet Office last month, if there was a widespread outbreak of a bacterial infection that antibiotics were unable to tackle, approximately 200,000 people could suffer an antibiotic-resistant blood borne infection, of which it could be expected that 80,000 of them might die.  It is not clear what the chances of this occurring actually are, but the document goes on to state that the number of infections complicated by resistance by bacteria is expected to increase markedly over the next 20 years and that high numbers of deaths could be expected to occur from other forms of antimicrobial resistant infection (AMR).  It has previously been estimated that AMR accounts for 50,000 deaths each year in Europe and the US alone and that by 2050 it could account for as many as 10 million deaths a year globally.  It has also been estimated that, at present, only 1% of bacterial infections are truly multi-resistant in the UK, compared to about 10-20% in India, but it will not take long at the present rate for this country to reach equivalent levels.

Antibiotics have become a mainstay of the success of modern medicine in the last 60 or so years, since Alexander Fleming famously, and somewhat fortuitously, first discovered penicillin in 1928, and turned it into a highly effective antibiotic. Further antibiotics were subsequently discovered.  However, with increasing resistance by bacteria and with consequently less effective antibiotics, minor surgery and routine operations can become high-risk, with eventual significantly increased morbidity and mortality.  Particular bacteria that are displaying resistance are Staphylococcus aureus (MRSA), E. coli and Klebsiella species.

There are many factors that are likely to be responsible for this problem, including amongst others increasing antibiotic use, with, for example, family doctors (especially out of hours GPs) prescribing unnecessarily for viral infections such as the common cold; a greater expectation amongst the public that antibiotics are required for all and any infection; and doctors not reviewing the period for which patients are taking antibiotics in hospital.  It is also a global problem, though, with antibiotics being used liberally in a multitude of countries across the world not just to treat humans but also livestock.  These problems are enhanced by the lack of new antibiotics being discovered and made available.

Ultimately, this is an extremely serious issue, with both the Chief Medical Officer, Dame Sally Davies, and the Prime Minster recently warning that there is a very significant risk that modern medicine will be cast back into a pre-antibiotic era akin to the dark ages.  There could be an almost unimaginable impact: for example, the danger that maternal and child mortality during childbirth, which fell 50 fold in the 20th century, could return to previous levels.

Yet, despite the apocalyptic warnings, it is apparent that doctors are not really heeding them: between 2010 and 2013 prescriptions increased by 6% from 25.9 to 27.4 doses per 1,000 people per day, and it is perhaps notable that there was also a 12% increase in E. coli infections in the blood over the same period.  There is no doubt that antibiotics have been, and still are, critical to the success of modern medicine.  However, at least from the perspective of prescribing, it is necessary both for patients to appreciate the problem and not put undue pressure on doctors to treat them with antibiotics and for doctors to strike the right balance between treating patients appropriately for bacterial infections and over-prescribing antibiotics.  It is, however, a fine line: under-treatment could result in a patient suffering avoidable harm; over-treatment could be contributing to the problem of AMR.  Only time will tell what the ultimate outcome of AMR will be.

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