tag:theconversation.com,2011:/ca/topics/antibiotic-apocalypse-30922/articlesAntibiotic apocalypse – The Conversation2018-02-07T17:01:54Ztag:theconversation.com,2011:article/914122018-02-07T17:01:54Z2018-02-07T17:01:54ZAntibiotic resistance fight could get a little help from ants<figure><img src="https://images.theconversation.com/files/205318/original/file-20180207-74470-hweqft.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A giant ant carries a dead fellow in the name of cleanliness.</span> <span class="attribution"><a class="source" href="https://en.wikipedia.org/wiki/Social_immunity#/media/File:Giant_Ant_(Camponotus_gigas)_carrying_a_dead_fellow_(15571767495).jpg">Dupont/Wikipedia</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span></figcaption></figure><p>The world is facing an <a href="https://theconversation.com/what-will-happen-when-antibiotics-stop-working-59938">antibiotics crisis</a>. Due to overuse, many once-powerful drugs are <a href="https://theconversation.com/is-the-antibiotic-apocalypse-nigh-51006">now useless</a> against certain strains of serious bacterial infections. So scientists are <a href="https://theconversation.com/new-class-of-antibiotics-discovered-and-why-there-may-be-more-to-come-36085">on the hunt</a> for new ways to attack harmful microbes.</p>
<p>One possibility is to investigate how other species have evolved ways to defend themselves. A <a href="http://rsos.royalsocietypublishing.org/lookup/doi/10.1098/rsos.171332">new study</a> highlights how most ants, even from small colonies, produce antimicrobial chemicals in their bodily secretions. It also suggests those ants that don’t make these substances are likely to have some other method of controlling bacteria that could be investigated. So perhaps the answer to antibiotic resistance is under our feet.</p>
<p>Like humans, the more than <a href="http://journals.plos.org/plosbiology/article?id=10.1371/journal.pbio.1001805">12,000 species</a> of ants are all highly social. This behaviour increases the chance that they come into to contact with germs. Comparable to our towns and cities, ant colonies take communal living to the next level, with up to tens of millions of individuals cohabiting in a single nest.</p>
<p>Colony survival depends on worker ants going out into the environment to collect food. Workers return to their densely inhabited nests loaded with food, but also harmful microbes. Returning workers then share their food and their germs through mouth-to-mouth feeding – essentially vomiting <a href="http://www.wired.co.uk/article/ants-throwing-up-hormones-development">into each other’s mouths</a>.</p>
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<p>If this wasn’t enough, the warm, moist conditions in ants’ nests make them ideal nurseries for disease-causing microbes. Finally, the members of almost all ants in a colony are related, so if one ant is susceptible to a germ, <a href="http://rspb.royalsocietypublishing.org/content/243/1306/55">it is likely that many others will be, too</a>.</p>
<p>Despite this longstanding threat of disease, ants are incredibly successful creatures. They dominate some environments and have diversified into thousands of species over <a href="https://phys.org/news/2006-04-ancient-ants-arose-million.html">150m years of evolution</a>. This suggests ants have found ways to deal with the high threat of disease. So what can we learn from them? </p>
<h2>How ants deal with disease</h2>
<p>Scientists have found that ants use a number of tricks to limit disease. Like humans, ants are exceptional cleaners. Many species have efficient waste-removal systems, ensuring diseased waste (including dead ants) is <a href="http://rspb.royalsocietypublishing.org/content/283/1831/20160625">removed from the nest or contained in special chambers</a>. They also regularly clean themselves and each other, and group together to <a href="http://rstb.royalsocietypublishing.org/content/370/1669/20140108">disinfect contaminated ants</a>.</p>
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<img alt="" src="https://images.theconversation.com/files/205319/original/file-20180207-74479-c26g2o.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/205319/original/file-20180207-74479-c26g2o.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=606&fit=crop&dpr=1 600w, https://images.theconversation.com/files/205319/original/file-20180207-74479-c26g2o.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=606&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/205319/original/file-20180207-74479-c26g2o.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=606&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/205319/original/file-20180207-74479-c26g2o.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=761&fit=crop&dpr=1 754w, https://images.theconversation.com/files/205319/original/file-20180207-74479-c26g2o.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=761&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/205319/original/file-20180207-74479-c26g2o.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=761&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">You scratch my back…</span>
<span class="attribution"><a class="source" href="https://en.wikipedia.org/wiki/Social_Immunity#/media/File:Lasius_neglectus_grooming.jpg">Pull/Wikipedia</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span>
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<p>But even with good hygiene habits, disease can still be an issue. Ants have evolved ways around this by using their own form of medicine. For example, some ants, when infected, eat toxins such as hydrogen peroxide <a href="http://onlinelibrary.wiley.com/doi/10.1111/evo.12752/abstract">to fight disease</a>. Others collect conifer resin, which they incorporate into their nests <a href="https://www.sciencedirect.com/science/article/pii/S0003347207005660">as a preventative measure</a>. Some species of ant are able to produce formic acid, which combines with the resin to form a <a href="http://onlinelibrary.wiley.com/doi/10.1002/ece3.2834/pdf">potent antimicrobial</a> agent.</p>
<p>We also know that ants also produce their own antimicrobials <a href="http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2672.1992.tb01822.x/abstract;jsessionid=937BED2D39EA0DCAA544A751A052043C.f04t03">in bodily secretions</a>. Now researchers have tried to work out what affects how these chemicals are made. In a new study published in the journal <a href="http://rsos.royalsocietypublishing.org/lookup/doi/10.1098/rsos.171332">Royal Society Open Science</a>, researchers from Arizona State University investigated the antimicrobial activity of 20 ant species in the US living in nests with between 80 and 220,000 inhabitants.</p>
<p>The researchers predicted that larger nest species would produce more effective antimicrobials, because of a greater risk of coming into contact with disease. Testing external secretions against <em>Staphylococcus epidermidis</em>, a common bacterium not known to cause disease, showed that 60% of the ant species produced secretions with antimicrobial activity. But, surprisingly, 40% didn’t produce an antimicrobial that could kill the bacterium.</p>
<p>What’s more, species in larger colonies were no more likely to have antimicrobial activity than small colonies. This is surprising as it is generally thought that disease is more likely to be spread in larger colonies. The authors suggest that the 40% of ants without antimicrobial activity have other methods of controlling the spread of bacteria. But we also don’t know if these 40% produce antimicrobial agents that work against other microbes.</p>
<h2>Antibiotics for the future?</h2>
<p>This adds to the idea that ants could well be a good source of new antibiotics. Not only do ants produce their own antimicrobial agents, but they can also encourage other beneficial microbes to grow. For example, researchers recently discovered a bacterium living among one ant species that produces compounds capable of killing harmful bacteria <a href="http://pubs.rsc.org/en/content/articlepdf/2014/SC/C6SC04265A?page=search">resistant to conventional antibiotics</a>, including the common superbug MRSA.</p>
<p>Millions of years of evolution in a high-risk environment have made ants a potential source of vital antimicrobials. These substances still need to be turned into effective drugs and then trialled in humans. But the more we learn about the strategies ants use to fight disease, the more likely we are to uncover new ways to deal with the threat of resistant bacteria and disease.</p><img src="https://counter.theconversation.com/content/91412/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Rob Hammond receives funding from NERC and BBSRC.</span></em></p><p class="fine-print"><em><span>Charlie Durant does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Ants produce their own antimicrobial chemicals to fight bacteria.Charlie Durant, PhD Candidate, Department of Genetics and Genome Biology, University of LeicesterRob Hammond, Lecturer, Department of Genetics and Genome Biology, University of LeicesterLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/892662017-12-18T14:58:14Z2017-12-18T14:58:14ZYes we must prescribe fewer antibiotics, but we’re ignoring the consequences<figure><img src="https://images.theconversation.com/files/199700/original/file-20171218-27538-12t0hgx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Pills and ills. </span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/drug-prescription-treatment-medication-pharmaceutical-medicament-541252936?src=95CVAFs3xpmQn3gb0gGjlg-1-62">Adul10</a></span></figcaption></figure><p>Antibiotic resistance is one of the greatest challenges facing mankind. We <a href="http://www.who.int/antimicrobial-resistance/en/">risk a future</a> of common infections and minor injuries once again proving fatal – plus longer hospital stays and higher medical costs. Some infections are already no longer treatable with current drugs. <a href="https://amr-review.org">Around</a> 700,000 people die each year around the world as a result, and some studies predict 10m by 2050 – more than die from cancer. </p>
<p>To avoid this “<a href="https://www.theguardian.com/society/2017/oct/13/antibiotic-resistance-could-spell-end-of-modern-medicine-says-chief-medic">antibiotic apocalypse</a>”, everyone acknowledges we need to limit the quantities of antibiotics people are taking. One key strategy to achieve this is <a href="https://theconversation.com/we-need-more-than-just-new-antibiotics-to-fight-superbugs-44054">antimicrobial stewardship</a> – putting systems in place in hospitals and doctors’ surgeries that restrict antibiotic prescriptions by paying more attention to the type, timing, dosage and duration of courses of treatment. </p>
<p>With the UK currently close to completing a <a href="https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/244058/20130902_UK_5_year_AMR_strategy.pdf">five-year implementation plan</a> across the health service, and various <a href="http://www.who.int/hrh/news/2017/AMR2017-2.pdf">other countries also</a> at different stages of development, stewardship is undoubtedly proving <a href="http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD003543.pub4/epdf">effective</a>. There is growing evidence that interventions by managers improve best practice and reduce the length of time that patients spend on antibiotics, <a href="http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD003543.pub4/abstract">without increasing</a> mortality rates. </p>
<p>When <a href="https://academic.oup.com/jac/article-abstract/72/12/3223/4100561?redirectedFrom=fulltext">we analysed</a> the data, however, it became clear that there are also important lessons that need to be learned. The wider effects of stewardship are not well enough understood. The majority of studies into the effectiveness of tighter antibiotic restrictions have only focused on their intended outcome – cutting the quantities of drugs being prescribed. </p>
<p>Few studies have looked at other consequences, and sometimes these are not easy to predict. Even interventions that reduce the use of antibiotics can lead to unwelcome effects elsewhere in the system. </p>
<h2>Knowns and unknowns</h2>
<p>Since many consequences from tighter antibiotic restrictions are predictable, it’s important we start monitoring them from the outset. Measures commonly involve, for example, requiring frontline medics to get prior permission from a more senior colleague to make sure they’re prescribing the right antibiotic. </p>
<p>Another example is introducing stop orders, which end a course of treatment on a particular date if the clinician hasn’t specified one from the outset. Steps like these can interrupt or delay treatments, but we know little about to what extent. </p>
<p>Some restrictions will inevitably be too unwise to justify. When patients are showing symptoms of infectious pneumonia, for instance, it is common practice to start them on antibiotics before the diagnosis has been confirmed. People who turn out not to be infected will sometimes end up taking unnecessary antibiotics. But since the risks outweigh the benefits with this kind of potentially life-threatening condition, this is difficult to avoid. </p>
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<span class="caption">Here’s the plan …</span>
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<p>But if this kind of problem is foreseeable and needs to be exempted from any stewardship system, <a href="https://academic.oup.com/jac/article-abstract/72/12/3223/4100561?redirectedFrom=fulltext">our research</a> has also thrown up consequences that couldn’t have been anticipated. In 2009, for example, the Scottish government aimed to reduce by 30% over two years rates of the <em>Clostridium difficile</em> bug, which causes stomach pains, sickness and diarrhoea. This effort involved changing the type of antibiotic normally given to patients prior to various types of surgery to protect them from post-surgical infections. </p>
<p>One result was that more orthopaedic patients <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4214537/">ended up</a> developing acute kidney infections – ten more cases per month in one hospital. The managers setting up the stewardship system did not realise that stopping the antibiotic could lead to kidney infections in these patients. They ended up having to stay longer in hospital and needing more clinical interventions as a result. </p>
<p>Unexpected consequences can also be positive sometimes. One example is <a href="https://smw.ch/article/doi/smw.2014.13981">a study</a> of over 10,000 babies thought to be at risk of sepsis, a potentially deadly infection in the blood. The study looked at whether dispensing with the routine diagnostic blood test on these babies and relying only on other clinical examinations delayed the point at which you could start those testing positive for sepsis on a course of antibiotics. </p>
<p>If so, it would mean they would need more antibiotics for a longer duration and that the blood test was therefore a necessary means of controlling levels of prescriptions. Instead, however, the study confirmed that it made no difference, and in fact meant the infants could be given antibiotics earlier – so reducing the need for prescriptions. </p>
<h2>Pause for reflection</h2>
<p>This hopefully gives a glimpse into the complexity in this area, and the limitations in simply looking at cause and effect. <a href="https://siscc.dundee.ac.uk/work/improvement-science-methods/">As part</a> of our research, we have worked with practitioners around Scotland to understand how to monitor and predict consequences more effectively. </p>
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<span class="caption">Until next time.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/patient-meeting-doctor-735167506?src=o5PGEE9iW88_z_4OqIXZXA-1-4">Rawpixel.com</a></span>
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<p>We’ve now produced a <a href="https://siscc.dundee.ac.uk/work/improvement-science-methods/">framework</a> to help managers to identify risks from the outset. It promotes the idea of an “improvement pause” to review the new system after a few months and make any necessary adjustments – hopefully making all the professionals involved more confident that the changes are benefiting patients and families. Unpleasant surprises in particular need to be carefully evaluated to see if any harm being caused is enough to stop or adapt the intervention.</p>
<p>The point is that to protect patients, all outcomes associated with changes to antibiotic prescriptions need to be monitored carefully. We’re not seeing nearly enough of this happening after systems are put in place. While interventions are vital to protect us all from antibiotic apocalypse, they still need to be balanced against the needs of patients today.</p><img src="https://counter.theconversation.com/content/89266/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Madalina Toma has received funding from the Economic and Social Research Council. </span></em></p><p class="fine-print"><em><span>Julie Anderson does not receive relevant direct funding but the SISCC receives funding from Scotland's Chief Scientist Office, Health Foundation, NHS Education for Scotland and Scottish Funding Council.</span></em></p>Antimicrobial stewardship is proving effective, but we’re not fully across what is happening.Madalina Toma, Research fellow, University of DundeeJulie Anderson, Associate Director, Scottish Improvement Science Collaborating Centre, University of DundeeLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/686572016-12-06T20:58:45Z2016-12-06T20:58:45ZFactCheck: Is Australia’s use of antibiotics in general practice 20% above the OECD average?<blockquote>
<p>A particular focus will be Australia’s high use of antibiotics in general practice, which is 20% above the OECD average. <strong>– Minister for Health and Aged Care Sussan Ley, <a href="http://www.health.gov.au/internet/ministers/publishing.nsf/Content/health-mediarel-yr2016-ley089.htm">media release</a> announcing implementation of the <a href="http://www.health.gov.au/internet/main/publishing.nsf/Content/1803C433C71415CACA257C8400121B1F/$File/amr-strategy-2015-2019.pdf">National Antimicrobial Resistance Strategy 2015-2019</a>, November 10, 2016.</strong></p>
</blockquote>
<p>As she launched the implementation plan for Australia’s <a href="http://www.health.gov.au/internet/main/publishing.nsf/Content/ohp-amr.htm">National Antimicrobial Resistance Strategy</a>, Health Minister Sussan Ley said Australia’s use of antibiotics in general practice is 20% above the OECD average. </p>
<p>Is that right?</p>
<h2>Checking the source</h2>
<p>When asked for a source to support her statement, a spokesperson for Sussan Ley said:</p>
<blockquote>
<p>This statement is based on information contained in the <a href="http://www.health.gov.au/internet/main/publishing.nsf/Content/ohp-amr.htm">National Antimicrobial Resistance Strategy, page 11.</a> This data comes from the <a href="http://www.oecd-ilibrary.org/social-issues-migration-health/health-at-a-glance-2013/prescribing-in-primary-care_health_glance-2013-44-en">OECD Health Statistics 2013</a>.</p>
</blockquote>
<h2>Does Australia have ‘high use of antibiotics in general practice’, at 20% above the OECD average?</h2>
<p>Yes, it is high; no, it is not 20% above the OECD average. </p>
<p>The data Ley quoted is out of date, and it includes antibiotic use in all human health sectors – not just general practice (that said, the lion’s share of antibiotic scripts written in Australia are written by GPs). </p>
<p>But her broader message is correct: it is true that Australia’s antibiotic use is high and it is well above the OECD average. This is dangerous because overuse of antibiotics can lead to antimicrobial resistance, which is where antibiotics that once worked effectively no longer do.</p>
<p>The minister sourced the figure of 20% to the <a href="http://www.oecd-ilibrary.org/social-issues-migration-health/health-at-a-glance-2013/prescribing-in-primary-care_health_glance-2013-44-en">2013 OECD Health at a Glance</a> report. Using data from 2010 or the nearest year, that report found Australia’s antibiotic use to be 17.5% above the OECD average. Ley rounded that up to 20%, which is fair enough.</p>
<p>But that figure is out of date. The most recent OECD Health at a Glance report, <a href="http://www.oecd.org/els/health-systems/health-at-a-glance-19991312.htm">published in 2015</a>, shows Australia’s antibiotic use has fallen slightly since 2013. It’s now 10% higher than the OECD average. (An improvement, but still dangerously high.)</p>
<p>And the figures in both the 2013 and 2015 OECD reports include antibiotics prescribed by all health practitioners – including dentists and optometrists, for example – not just GPs. </p>
<h2>‘Defined daily doses’: findings from 2015 vs 2013</h2>
<p>There is an internationally agreed measure for comparing the use of medicines: “defined daily doses per 1,000 people per day”. Defined daily doses are <a href="http://www.whocc.no/">set and published</a> by the World Health Organisation. The OECD used this method in its reports. </p>
<p>The 2015 OECD report found that, using data from 2013 or the nearest year, 22.8 defined daily doses of antibiotics were prescribed per 1,000 people in Australia every day. The OECD average is 20.7 defined daily doses per 1,000 people every day. That makes Australia’s prescription rate 10% higher than the OECD average. (Remember, this includes antibiotics prescribed by all health practitioners, not just GPs.) </p>
<p>The chart below is from the 2015 OECD report.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/146886/original/image-20161122-24547-ul8heu.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/146886/original/image-20161122-24547-ul8heu.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/146886/original/image-20161122-24547-ul8heu.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=265&fit=crop&dpr=1 600w, https://images.theconversation.com/files/146886/original/image-20161122-24547-ul8heu.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=265&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/146886/original/image-20161122-24547-ul8heu.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=265&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/146886/original/image-20161122-24547-ul8heu.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=334&fit=crop&dpr=1 754w, https://images.theconversation.com/files/146886/original/image-20161122-24547-ul8heu.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=334&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/146886/original/image-20161122-24547-ul8heu.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=334&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Overall volume of antibiotics prescribed, 2013 (or nearest year). Data refer to all sectors (not only primary care).</span>
<span class="attribution"><a class="source" href="http://www.oecd-ilibrary.org/docserver/download/8115071e.pdf?expires=1479769805&id=id&accname=guest&checksum=19FF31289B832A45D0299E175CF0C652">OECD 2015 Health at a Glance report.</a></span>
</figcaption>
</figure>
<p>In the OECD chart above you will see the term “2nd line” in fine print (at the top). This refers to classes of antibiotics that medical experts say should be used conservatively to reduce the chance of germs developing resistance to them. These classes of antibiotics are called “quinolones” and “cephalosporins”. But Australia did not report the data for first and second line antibiotics separately, which is why Australia’s column in the first chart is all one colour.</p>
<p>The chart below shows Australia vs other OECD countries from the 2013 OECD report.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/146884/original/image-20161122-24533-1iuxpot.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/146884/original/image-20161122-24533-1iuxpot.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/146884/original/image-20161122-24533-1iuxpot.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=329&fit=crop&dpr=1 600w, https://images.theconversation.com/files/146884/original/image-20161122-24533-1iuxpot.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=329&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/146884/original/image-20161122-24533-1iuxpot.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=329&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/146884/original/image-20161122-24533-1iuxpot.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=413&fit=crop&dpr=1 754w, https://images.theconversation.com/files/146884/original/image-20161122-24533-1iuxpot.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=413&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/146884/original/image-20161122-24533-1iuxpot.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=413&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Overall volume of antibiotics prescribed, 2010 (or nearest year). Data refer to all sectors (not only primary care).</span>
<span class="attribution"><a class="source" href="http://www.oecd-ilibrary.org/docserver/download/8113161ec044.pdf?expires=1479775366&id=id&accname=guest&checksum=69C541FABEE7C649DEE1EFB2C7CE6570">OECD, Health at a Glance report 2013.</a></span>
</figcaption>
</figure>
<p>Experts often consider the <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3900872/">benchmark</a> <a href="https://www.ncbi.nlm.nih.gov/pubmed/18545950">countries</a> to be those in <a href="https://www.wired.com/2010/09/antibiotic-resistance-scandinavia-gets-it/">Scandinavia</a> and the Netherlands. Australian health practitioners prescribe antibiotics at a rate 25% higher than those in <a href="http://www.oecd.org/els/health-systems/health-at-a-glance-19991312.htm">Finland</a>, and 111% higher than the <a href="http://www.oecd.org/els/health-systems/health-at-a-glance-19991312.htm">Netherlands</a>.</p>
<h2>Limitations of the OECD data</h2>
<p>There are a number of drawbacks to using the “defined daily doses” measure for comparing antibiotic use.</p>
<p>The defined daily dose applies only to adults, yet there are quite high rates of antibiotics scripts written for children.</p>
<p>The measure also fails to account for variation in standard doses in different countries. This can result in a different value for the statistic, even when the same proportion of the population took the same number of courses of antibiotics in a year.</p>
<p>Australia now has a national surveillance system for <a href="https://en.wikipedia.org/wiki/Antimicrobial">antimicrobial</a> use and resistance, and its <a href="https://www.safetyandquality.gov.au/publications/aura-2016-first-australian-report-on-antimicroibal-use-and-resistance-in-human-health/">first report</a> was released in June. The report contains a more detailed look at antibiotic use in the Australian community, using 2014 data from the Pharmaceutical Benefits Scheme. </p>
<p>Apart from counting the “defined daily doses” there’s another way to assess antibiotic use: by counting prescription numbers per head of population. </p>
<p>In 2014, there were more than 30 million scripts dispensed for systemic and topical antibiotics in Australia. It was found that at least 45% of Australians took at least one course of antibiotics during that year.</p>
<p>Unfortunately, only a few countries report their primary care antibiotic prescription numbers per head of population. These are shown in the chart below, taken from the report.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/147141/original/image-20161123-19692-inipmo.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/147141/original/image-20161123-19692-inipmo.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/147141/original/image-20161123-19692-inipmo.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=803&fit=crop&dpr=1 600w, https://images.theconversation.com/files/147141/original/image-20161123-19692-inipmo.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=803&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/147141/original/image-20161123-19692-inipmo.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=803&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/147141/original/image-20161123-19692-inipmo.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1009&fit=crop&dpr=1 754w, https://images.theconversation.com/files/147141/original/image-20161123-19692-inipmo.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1009&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/147141/original/image-20161123-19692-inipmo.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1009&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Comparison of community antimicrobial use in Australia and other countries (prescriptions dispensed per 1000 inhabitants).</span>
<span class="attribution"><a class="source" href="https://www.safetyandquality.gov.au/publications/aura-2016-first-australian-report-on-antimicroibal-use-and-resistance-in-human-health/">AURA 2016 – First Australian report on antimicrobial use and resistance in human health, using data from Pharmaceutical Benefits Scheme (Australia); CIPARS (Canada); ESPAUR (England); SAPG (Scotland); SWEDRES (Sweden); NARMS (United States)</a></span>
</figcaption>
</figure>
<p>Overall, the point of the minister’s quote is clear: Australia’s antibiotic use in the community is unnecessarily high. </p>
<p>Evidence from Australia’s <a href="http://www.nps.org.au/medicines/infections-and-infestations/antibiotics/for-individuals/what-is-antibiotic-resistance">NPS MedicineWise</a>, presented in the <a href="https://www.safetyandquality.gov.au/publications/aura-2016-first-australian-report-on-antimicroibal-use-and-resistance-in-human-health/">AURA report</a>, makes it clear that antibiotics are often prescribed for infections when they’re not needed, particularly with respiratory viral infections like cold and flu. </p>
<h2>Verdict</h2>
<p>The data Sussan Ley quoted is a bit out of date – to be accurate, the statement should have said 10% above the OECD average, not 20% – and it refers to antibiotic use in all sectors, not just prescriptions by GPs. </p>
<p>But her broader message about Australia’s antibiotic use still being high compared to the OECD average is correct – and it’s an important point to make. Overuse of antibiotics is dangerous, as it can lead to situations where antibiotics that once worked effectively no longer do. <strong>– John Turnidge</strong></p>
<hr>
<h2>Review</h2>
<p>This analysis of Sussan Ley’s comments is accurate. I would further note that:</p>
<p>1) Government initiatives are helping to reduce antibiotic usage in other countries. For example, England just <a href="https://www.gov.uk/government/news/use-of-antibiotics-decreases-across-all-healthcare-settings-for-the-first-time">announced</a> its first decrease in usage.</p>
<p>2) While this FactCheck focuses on antibiotic usage in humans, usage in animals is much less clear, often poorly documented, and also contributes to the increase in antimicrobial resistance. In the United States, <a href="https://amr-review.org/sites/default/files/Antimicrobials%20in%20agriculture%20and%20the%20environment%20-%20Reducing%20unnecessary%20use%20and%20waste.pdf">70% of antibiotics are consumed by animals</a>.</p>
<p>Australia appears to have significantly lower antibiotic use in animals than other countries, as indicated in Australia’s first national antimicrobial resistance <a href="http://health.gov.au/internet/main/publishing.nsf/Content/1803C433C71415CACA257C8400121B1F/$File/amr-strategy-2015-2019.pdf">strategy</a>. <strong>– Mark Blaskovich.</strong></p>
<hr>
<p><div class="callout"> Have you ever seen a “fact” worth checking? The Conversation’s FactCheck asks academic experts to test claims and see how true they are. We then ask a second academic to review an anonymous copy of the article. You can request a check at checkit@theconversation.edu.au. Please include the statement you would like us to check, the date it was made, and a link if possible.</div></p><img src="https://counter.theconversation.com/content/68657/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>John Turnidge is a member of the Australian Society of Antimicrobials, the Australian Society of Infectious Diseases, and the Australian Society for Microbiology, which have all been active in the public debate about antibiotic resistance in Australia. He sits on the Australian Government's Australian Scientific Technical Advisory Group on antimicrobial resistance on behalf of the Commission noted above. Any opinion expressed is entirely his own.</span></em></p><p class="fine-print"><em><span>Mark Blaskovich is affiliated with The Community for Open Antimicrobial Drug Discovery. He receives funding from theNHMRC, NIH and Wellcome Trust grants, and is an inventor on several patent applications related to antibiotics. </span></em></p>Health minister Sussan Ley said Australia’s use of antibiotics in general practice is 20% above the OECD average. Is that right?John Turnidge, Affiliate Professor of Molecular and Biomedical Science, University of AdelaideLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/647582016-09-05T14:06:22Z2016-09-05T14:06:22ZTo avoid antibiotic apocalypse, we need to diagnose infections faster<figure><img src="https://images.theconversation.com/files/136594/original/image-20160905-4765-9j2299.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Chop, chop. </span> <span class="attribution"><a class="source" href="https://www.google.co.uk/search?hl=en&authuser=0&site=imghp&tbm=isch&source=hp&biw=1440&bih=762&q=studying+microbes+in+the+lab&oq=studying+microbes+in+the+lab&gs_l=img.3...1139.7736.0.8023.30.14.1.14.14.0.170.1413.9j5.14.0....0...1ac.1.64.img..1.16.1417...0j0i24k1j0i10i24k1j0i30k1j0i8i30k1.LPaj_b0hpfI#q=studying+microbes+in+the+lab&hl=en&authuser=0&tbm=isch&tbs=sur:fc&imgrc=oHwxzFGE-Tg4DM%3A">USFDA</a></span></figcaption></figure><p>You will have heard of the “antibiotic apocalypse” – the nightmare scenario in which we run out of treatments for bacterial infections because too many bacteria have acquired antibiotic resistance. </p>
<p>It has been the subject of a <a href="http://www.resistancethefilm.com">major documentary</a> and endless books and articles. David Cameron, when prime minister of the UK, commissioned a <a href="http://amr-review.org">major review</a> on the subject, led by the distinguished economist Lord Jim O'Neill. England’s chief medical officer, Dame Sally Davies, <a href="https://www.theguardian.com/society/2016/may/19/englands-chief-medical-officer-warns-of-antibiotic-apocalypse">warned</a> that the apocalypse may already be upon us. I <a href="http://codi.beltanenetwork.org/event/codi-2016-the-antibiotic-apocalypse-threatens-us-all/">discussed it</a> at the Edinburgh Fringe recently as part of the Cabaret of Dangerous Ideas.</p>
<p>Being able to diagnose bacterial infections more quickly is seen as a key to the problem, as highlighted in the ten-point plan in O'Neill’s <a href="http://amr-review.org/sites/default/files/160518_Final%20paper_with%20cover.pdf">final report</a> in May. At the moment, diagnoses take a number of days. If we could do them in minutes, it would reduce the need for “just in case” antibiotics and ensure that the correct antibiotic is given for the infection. It would also mean we stopped using them to treat infections caused by viruses. </p>
<p>Use fewer antibiotics and it would reduce the pressure on bacteria that results in them developing resistance. This would help our already limited range of antibiotics remain effective for longer. To incentivise the research community, the UK government set up the £10m <a href="https://longitudeprize.org">Longitude Prize</a> a couple of years ago. So how are we getting on?</p>
<h2>Diagnosing <em>Salmonella</em></h2>
<p>To give a sense of the challenge, take <em>Salmonella</em>. This bacteria can frequently cause gastroenteritis (food poisoning) from people eating contaminated meat, eggs and chicken, among other things. </p>
<p>In some countries, different types of <em>Salmonella</em> can cause more serious infections such as <a href="http://www.nhs.uk/Conditions/Typhoid-fever/Pages/Introduction.aspx">Typhoid fever</a>. This can be life-threatening to the elderly, newborns and those with defective immune systems – another reason why rapid diagnosis is important. </p>
<p>In the UK, clinical laboratories identify bacteria that cause infections according to the <a href="https://www.gov.uk/government/collections/standards-for-microbiology-investigations-smi">Standards for Microbiology Investigations (SMI)</a>. For <em>Salmonella</em>, the <a href="https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/443443/ID_24i3.pdf">standard practice</a> is to do four tests. </p>
<p>You start by growing a bacterial culture from a sample of blood or another bodily product in a petri dish – this scales up the bacteria and makes it easier to identify. Next the technician has to first analyse the bacterial cells under a microscope; then mix <em>Salmonella</em>-specific antibodies with a blood sample to look for signs of clumps forming (agglutination); then carry out biochemical tests that identify bacteria by revealing what kind of enzymes they possess. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/136595/original/image-20160905-4758-eew4bk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/136595/original/image-20160905-4758-eew4bk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/136595/original/image-20160905-4758-eew4bk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=503&fit=crop&dpr=1 600w, https://images.theconversation.com/files/136595/original/image-20160905-4758-eew4bk.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=503&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/136595/original/image-20160905-4758-eew4bk.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=503&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/136595/original/image-20160905-4758-eew4bk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=632&fit=crop&dpr=1 754w, https://images.theconversation.com/files/136595/original/image-20160905-4758-eew4bk.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=632&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/136595/original/image-20160905-4758-eew4bk.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=632&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Your friendly neighbourhood Salmonella.</span>
<span class="attribution"><a class="source" href="https://commons.wikimedia.org/wiki/File:Salmonella_NIH.jpg">Wikimedia</a></span>
</figcaption>
</figure>
<p>Before any of this can begin, a patient needs to present at the clinic or hospital and provide a suitable sample. This may be a number of hours after the onset of infection. Growing a culture can take at least 24 hours. The microscope study and the agglutination only take minutes, but the enzyme testing will take another 24 hours. </p>
<p>Sometimes another prior step is necessary to make the bacteria easier to identify. In a blood sample, for example, bacteria might be present in low numbers which can affect test sensitivity. Or where it’s a faecal sample, there will be other bacteria present which could affect the sensitivity of any tests done. </p>
<p>This extra step can involve various ways of enriching the bacteria – for instance subjecting the sample to conditions that will favour the bacteria in question to the detriment of others. This will normally add another 24 hours. Put everything together and you’re talking about between two and five days from infection to diagnosis. </p>
<p>Other more rapid tests that have become possible in recent years. <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3943139/">Nucleic acid amplification tests</a> (NAATs) can identify bacteria based on the presence of their specific DNA within hours; and <a href="http://www.jove.com/video/50635/matrix-assisted-laser-desorptionionization-time-flight-maldi-tof-mass">MALDI-TOF mass spectometry</a> can identify bacteria in minutes from the protein components of their cells. Yet these require specialist equipment that is too expensive for many laboratories. Both still require a cultured sample, which again adds 24 hours. And NAATs in particular have limitations which can produce false results and inaccuracies.</p>
<h2>The way forward</h2>
<p>So where do we go from here? The Holy Grail is something analogous to a pregnancy test in terms of simplicity and speed. Such a test could be administered by a doctor or nurse at the point of first consultation and provide a diagnosis before your appointment is finished. </p>
<p>There is precedent for rapid disease diagnosis with the release of a <a href="http://hivselftest.co.uk/">self-test for HIV</a>, where you can obtain a result in about 15 minutes. Producing an equivalent test for bacterial infection is more complex, however. Where the HIV self-test works by detecting HIV antibodies, with bacterial infection it can take time for antibodies to be produced while the onset of symptoms can be rapid. Some bacteria are also covered in molecules which can fool the immune system so that no antibodies are produced. </p>
<p>Another hurdle that would need to be overcome is that any test would need to be able to distinguish the bacteria causing the infection from the <a href="http://www.gutmicrobiotaforhealth.com/en/glossary/commensal-bacteria/">harmless bacteria</a> we normally find in the body.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/136597/original/image-20160905-4760-1klsgu3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/136597/original/image-20160905-4760-1klsgu3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/136597/original/image-20160905-4760-1klsgu3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=367&fit=crop&dpr=1 600w, https://images.theconversation.com/files/136597/original/image-20160905-4760-1klsgu3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=367&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/136597/original/image-20160905-4760-1klsgu3.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=367&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/136597/original/image-20160905-4760-1klsgu3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=461&fit=crop&dpr=1 754w, https://images.theconversation.com/files/136597/original/image-20160905-4760-1klsgu3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=461&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/136597/original/image-20160905-4760-1klsgu3.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=461&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">‘I told you I’d be quick’.</span>
<span class="attribution"><a class="source" href="https://en.wikipedia.org/wiki/Midwife#/media/File:US_Navy_midwife_checks_on_a_mom.jpg">Wikimedia</a></span>
</figcaption>
</figure>
<p>In short, the development of a new rapid method of diagnostics is by no means an easy task. I think it unlikely that either MALDI-TOF mass spectrometry or NAATs are the answer. In my laboratory we are trying to use our knowledge of bacterial physiology to think beyond these methods to design microbial sensors that can detect the harmful bacteria, but without the need for culture. I am aware that others are exploring developing a diagnostic that can sense whether an infection is present by identifying specific molecules produced by the body in response to infection. </p>
<p>Either way, I am optimistic that we will find a solution within the next five to ten years, and that it will come from a multidisciplinary approach from scientists, engineers and industry working in partnership. With £10m Longitude Prize on offer too, it’s a great incentive. For most working towards this, however, the real reward will be contributing to averting one of the most serious threats that humanity currently faces.</p><img src="https://counter.theconversation.com/content/64758/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Clare is General Secretary of the Society for Applied Microbiology.</span></em></p>How slow diagnosis of bacterial infections is exacerbating our antibiotics problem.Clare Taylor, Senior Lecturer in Medical Microbiology, Edinburgh Napier UniversityLicensed as Creative Commons – attribution, no derivatives.