tag:theconversation.com,2011:/africa/topics/overusing-antibiotics-44068/articlesOverusing antibiotics – The Conversation2021-12-02T14:22:50Ztag:theconversation.com,2011:article/1727802021-12-02T14:22:50Z2021-12-02T14:22:50ZSwapping probiotics for antibiotics: how it could be a game changer for chickens, and us<figure><img src="https://images.theconversation.com/files/434375/original/file-20211129-25-2tx0tw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Even chickens need strong, healthy gut microbiomes.</span> <span class="attribution"><span class="source">Moonborne/Shutterstock</span></span></figcaption></figure><p>In 1928, microbiologist Alexander Fleming’s discovery of penicillin was <a href="https://www.nobelprize.org/prizes/medicine/1945/fleming/biographical/">hailed as a scientific breakthrough</a>. In the nearly 100 years since then, scientists have discovered numerous other antibiotics that have saved billions of lives.</p>
<p>However, bacteria have become <a href="https://www.cdc.gov/drugresistance/about.html">increasingly resistant</a> to these treatments. There are two reasons for this: the overuse and misuse of antibiotics by humans, and the introduction of <a href="https://www.sciencedirect.com/science/article/pii/S2666517421000110">antibiotics to agriculture</a>.</p>
<p>During 2021’s <a href="https://www.who.int/campaigns/world-antimicrobial-awareness-week/2021">World Antimicrobial Resistance Awareness Week</a>, the World Health Organisation (WHO) repeated a warning it had issued before: antibiotic resistance is rising to dangerously high levels globally. Globally <a href="https://theconversation.com/antibiotic-resistance-is-at-a-crisis-point-government-support-for-academia-and-big-pharma-to-find-new-drugs-could-help-defeat-superbugs-169443">it is estimated</a> that antibiotic-resistant bacteria kill between 700,000 and several million people every year.</p>
<p>Resistance to antibiotics leads to a situation in which previously treatable infections are becoming harder – and sometimes impossible – to treat. Without urgent action, the world is heading for a post-antibiotic era. Common bacterial infections could once again become frequent killers.</p>
<p>One way to address this crisis is to cut back on the unnecessary use of antibiotics. Some countries are doing this by banning the inclusion of antibiotics in animal feed as growth promoters. This is because when humans consume meat or chicken, we ingest not only the antibiotics added to animal feed, but also antibiotic resistant bacteria. </p>
<p>A 2018 <a href="http://apps.who.int/iris/handle/10665/273128">joint report</a> by the WHO, Food and Agriculture organisation and World Organisation for Animal Health found that only 42% of countries have limited their use as growth promoters. Most are in Europe; only a fraction of countries in Africa and the Americas have taken these steps. The agricultural sector desperately needs alternatives to maintain animal health without detrimental consequences to human health.</p>
<p>The term “antibiotic growth promoter” describes the administration of antibiotics at a low, sub therapeutic dose as a preventative measure. It’s not entirely clear why antibiotics influence livestock growth. However, research suggests that they possibly promote growth by depressing the growth of microbes that are toxic or that steal nutrients from the host, leading to increased nutrition utilisation and reducing the energy that must be invested in maintaining immune responses.</p>
<p>One alternative to this is the use of probiotics, rather than antibiotics, in animal feed. I am a microbiologist and have developed a probiotic for chickens. Most probiotics on the market are not developed for a specific host; ours is developed specifically for chickens and contains multiple bacterial strains, which each target different areas of the gut to strive for complete gut protection. </p>
<p><a href="https://link.springer.com/article/10.1007/s12602-020-09640-z">My research</a> shows that the probiotic has numerous beneficial characteristics – both for chickens and the humans who will ultimately eat them. The probiotic decreases the presence of pathogens in the animal’s gut and can be used safely on a daily basis.</p>
<h2>What are probiotics?</h2>
<p>Probiotics are health-promoting bacteria that naturally occur in the intestine of any animal with a gut. They have a mutually beneficial relationship with the host. A large body of research <a href="https://www.longdom.org/open-access/the-use-of-probiotics-in-animal-nutrition-2329-8901-1000132.pdf">has shown</a> that probiotics may <a href="https://www.intechopen.com/chapters/39589">improve animal health and growth performance</a>. They do so by modulating nutrition and digestion, changing the microbial composition in the intestine, and by stimulating the immune system. </p>
<p>Some probiotic strains also produce vitamins and regulate cholesterol blood levels. They also produce antioxidants – substances that protect your cells against free radicals – and regulate energy production.</p>
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Read more:
<a href="https://theconversation.com/antibiotic-resistance-is-at-a-crisis-point-government-support-for-academia-and-big-pharma-to-find-new-drugs-could-help-defeat-superbugs-169443">Antibiotic resistance is at a crisis point – government support for academia and Big Pharma to find new drugs could help defeat superbugs</a>
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<p>A chicken’s intestine, like a human’s, is home to a complex microbial ecosystem, the microbiome. It consists of trillions of microorganisms living in symbiosis with the host. These interactions are important for development, health, nutrition, and digestion. </p>
<p>Changes in the microbiome composition can be disruptive and lead to the emergence of pathogenic (harmful) microorganisms. Probiotics can prevent these disturbances by inhibiting the growth of pathogens and restoring the microbiome composition to a natural state. Probiotics can also prime the immune system to recognise pathogens in the gut.</p>
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Read more:
<a href="https://theconversation.com/probiotics-what-they-are-and-how-you-might-benefit-from-them-121587">Probiotics: What they are and how you might benefit from them</a>
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<img alt="A man in a white lab coat, shorts and boots, poses alongside a small flock of chickens." src="https://images.theconversation.com/files/434374/original/file-20211129-23-1shpsmi.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/434374/original/file-20211129-23-1shpsmi.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=507&fit=crop&dpr=1 600w, https://images.theconversation.com/files/434374/original/file-20211129-23-1shpsmi.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=507&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/434374/original/file-20211129-23-1shpsmi.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=507&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/434374/original/file-20211129-23-1shpsmi.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=637&fit=crop&dpr=1 754w, https://images.theconversation.com/files/434374/original/file-20211129-23-1shpsmi.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=637&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/434374/original/file-20211129-23-1shpsmi.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=637&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">The author with some of his probiotic testers.</span>
<span class="attribution"><span class="source">Stellenbosch University</span></span>
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<p>We developed a probiotic for chickens because they are <a href="https://storymaps.arcgis.com/stories/58ae71f58fd7418294f34c4f841895d8">the most farmed animal</a> in the world. There are <a href="https://storymaps.arcgis.com/stories/58ae71f58fd7418294f34c4f841895d8">about 135 chickens for every cow</a>, and three for every human. </p>
<p>The first step in developing a chicken probiotic was to obtain the guts of 25 free-ranging chickens. Free-range chickens were chosen rather than housing-reared birds because they are exposed to the environment and so acquire a natural gut microbiome. The guts were then mashed into a liquid and plated on several hundred Petri dishes. As you can imagine, the resulting smell made me very unpopular with my colleagues and I had to set up my lab in a separate room.</p>
<p>As soon as bacteria started growing, hundreds of different bacteria were isolated and identified to species level.</p>
<p>The isolates were then screened for various beneficial characteristics. These included ability to survive transit in the gut, ability to colonise the gut, production of enzymes that can assist with digestion, and production of antimicrobial compounds that can inhibit pathogens. After eight months, I identified six beneficial bacterial species. Over the next four years <a href="https://www.nature.com/articles/s41598-017-12866-7">I tested the multi-strain probiotic’s safety</a> and its ability to decrease the presence of pathogens in the gut of chickens. </p>
<p>We found that the multi-strain probiotic was safe, increased bird immune responsiveness, and was able to decrease pathogen levels in the gut.</p>
<h2>Environmentally friendly alternatives</h2>
<p>The resulting probiotic, ProbiGal™, is a water based probiotic additive administered in the animals’ drinking water. ProbiGal™ has been extensively tested in intensive rearing settings. It will be launched in South Africa after regulatory approval has been granted by the Department of Agriculture, Forestry and Fisheries. Thereafter, we plan to launch it in the US and Brazil, two of the world’s <a href="https://www.fao.org/poultry-production-products/production/en/">largest poultry producing countries</a>.</p>
<p>Much more – including an outright global ban of antibiotics in animal feed – remains to be done. But products like these are one step in the right direction: an example of an environmentally friendly alternative that’s good for animals and humans.</p><img src="https://counter.theconversation.com/content/172780/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Deon Neveling is a postdoctoral research fellow at the University of Stellenbosch he receives funding from the National Research Foundation and the University Technology Fund. In addition, he is the CEO of Biotikum (Pty) Ltd which develops microbial additives for the agricultural industry to promote sustainable farming.</span></em></p>The probiotic decreases the presence of pathogens in the animal’s gut and can be used safely on a daily basis.Deon Neveling, Postdoctoral researcher, Stellenbosch UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1357902020-04-20T13:31:01Z2020-04-20T13:31:01ZDrug-resistant superbugs: A global threat intensified by the fight against coronavirus<figure><img src="https://images.theconversation.com/files/328554/original/file-20200416-192731-1hcrz6l.jpg?ixlib=rb-1.1.0&rect=5%2C32%2C1272%2C848&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Methicillin-resistant Staphylococcus aureus (MRSA) bacteria (coloured yellow) enmeshed within a human white blood cell (coloured red). MRSA is a major cause of hospital-associated infections.</span> <span class="attribution"><a class="source" href="https://phil.cdc.gov/Details.aspx?pid=18125">(NIAID)</a></span></figcaption></figure><p>With the world’s attention on COVID-19, I believe that now is the time to talk about another pandemic that’s been happening right under our noses: antimicrobial resistance (AMR). </p>
<p>When infections caused by bacteria, parasites, viruses or fungi stop responding to the medicines designed to treat them, that’s AMR. Resistance builds over time through overexposure to antimicrobial drugs, such as antibiotics, or disinfectants. With ineffective treatments, these infections persist in the body and ultimately spread to others.</p>
<h2>A major public health and economic risk</h2>
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<img alt="" src="https://images.theconversation.com/files/327321/original/file-20200412-51445-1qir6kq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/327321/original/file-20200412-51445-1qir6kq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=628&fit=crop&dpr=1 600w, https://images.theconversation.com/files/327321/original/file-20200412-51445-1qir6kq.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=628&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/327321/original/file-20200412-51445-1qir6kq.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=628&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/327321/original/file-20200412-51445-1qir6kq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=789&fit=crop&dpr=1 754w, https://images.theconversation.com/files/327321/original/file-20200412-51445-1qir6kq.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=789&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/327321/original/file-20200412-51445-1qir6kq.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=789&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">Two methicillin-resistant Staphylococcus aureus (MRSA) bacteria, being enveloped by a white blood cell.</span>
<span class="attribution"><a class="source" href="https://phil.cdc.gov/Details.aspx?pid=18168">(NIAID)</a></span>
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<p>AMR is a slower-moving pandemic than COVID-19, but one that is worsening every day. A <a href="https://cca-reports.ca/reports/the-potential-socio-economic-impacts-of-antimicrobial-resistance-in-canada/">recent report by the Council of Canadian Academies</a> said that in 2018, more than a quarter of all infections in Canada were resistant to first-line drugs. In that one year alone, 5,400 people died as a direct result of resistant infections. </p>
<p>Drug-resistant infections lead to longer hospital stays and potentially greater complications. Doctors might need to use alternative medicines with more side effects. These issues cost the Canadian health-care system 1.4 billion dollars, and this will only increase.</p>
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<p>The <a href="https://www.un.org/press/en/2016/ga11825.doc.htm">United Nations</a>, the <a href="https://www.who.int/news-room/fact-sheets/detail/antimicrobial-resistance">World Health Organization</a> and even the <a href="https://www.worldbank.org/en/topic/health/publication/drug-resistant-infections-a-threat-to-our-economic-future">World Bank</a> recognize AMR as a public health and economic disaster waiting to happen. In 2016, United Kingdom economist Jim O’Neill and his team published <a href="https://amr-review.org">a report</a> stating that if we do not address the growing threat of AMR, by 2050 more people will die from drug-resistant infections than from cancer. </p>
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<img alt="" src="https://images.theconversation.com/files/327754/original/file-20200414-117587-rhjhzk.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/327754/original/file-20200414-117587-rhjhzk.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=480&fit=crop&dpr=1 600w, https://images.theconversation.com/files/327754/original/file-20200414-117587-rhjhzk.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=480&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/327754/original/file-20200414-117587-rhjhzk.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=480&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/327754/original/file-20200414-117587-rhjhzk.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=603&fit=crop&dpr=1 754w, https://images.theconversation.com/files/327754/original/file-20200414-117587-rhjhzk.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=603&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/327754/original/file-20200414-117587-rhjhzk.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=603&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">If left unsolved, AMR will cause more global deaths than cancer by 2050.</span>
<span class="attribution"><span class="source">(Christy Groves, Michael G. DeGroote Institute for Infectious Disease Research, McMaster University)</span>, <span class="license">Author provided</span></span>
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<p>If left unsolved, AMR will cost the health-care system trillions of dollars and, more importantly, it will cost millions of people their lives. </p>
<h2>Lessons from SARS-CoV-2</h2>
<p>We can learn from COVID-19. The current pandemic shows that despite all of our medical advances, we remain incredibly vulnerable to infections for which we have no therapies. However, it shows that if sufficiently motivated, we can make huge changes in short timeframes. </p>
<p>While there is inspiring work being done in different parts of the world to address the issues surrounding AMR — including here at <a href="https://iidr.mcmaster.ca">McMaster University’s Institute for Infectious Disease Research</a>, where my group is based — there is a long road ahead of us.</p>
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<img alt="" src="https://images.theconversation.com/files/327756/original/file-20200414-117573-1azvjmw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/327756/original/file-20200414-117573-1azvjmw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/327756/original/file-20200414-117573-1azvjmw.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/327756/original/file-20200414-117573-1azvjmw.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/327756/original/file-20200414-117573-1azvjmw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/327756/original/file-20200414-117573-1azvjmw.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/327756/original/file-20200414-117573-1azvjmw.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&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">The author at work in the lab at McMaster University’s Institute for Infectious Disease Research.</span>
<span class="attribution"><span class="source">(J.D. Howell, McMaster University)</span>, <span class="license">Author provided</span></span>
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<p>Despite significant efforts to educate policymakers and the public about the AMR crisis and offer possible solutions, it remains low on the priority list for many jurisdictions. On top of that, <a href="https://amr-review.org/sites/default/files/160525_Final%20paper_with%20cover.pdf">research on AMR is woefully underfunded compared to other areas of medicine</a>, such as cancer and cardiac disease. </p>
<p>Another major hurdle for the AMR response is loss of interest by big pharmaceutical companies. The need for expensive clinical trials and the risk of AMR rendering their products useless after a few years mean <a href="https://www.nytimes.com/2019/12/25/health/antibiotics-new-resistance.html">it’s challenging for them to recover their investment</a> into antibiotic research and development. </p>
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<img alt="" src="https://images.theconversation.com/files/327324/original/file-20200412-196246-g0e86m.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/327324/original/file-20200412-196246-g0e86m.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=464&fit=crop&dpr=1 600w, https://images.theconversation.com/files/327324/original/file-20200412-196246-g0e86m.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=464&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/327324/original/file-20200412-196246-g0e86m.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=464&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/327324/original/file-20200412-196246-g0e86m.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=583&fit=crop&dpr=1 754w, https://images.theconversation.com/files/327324/original/file-20200412-196246-g0e86m.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=583&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/327324/original/file-20200412-196246-g0e86m.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=583&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">Drug-resistant Salmonella serotype Typhi bacteria, from the Centers for Disease Control and Prevention publication <em>Antibiotic Resistance Threats in the United States</em>.</span>
<span class="attribution"><a class="source" href="https://phil.cdc.gov/Details.aspx?pid=23251">(Illustration by James Archer)</a></span>
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<p>Fortunately, antibiotics are only one strategy for fighting bacterial infections. Another common and highly successful approach is vaccination (think about routine <a href="https://link.springer.com/chapter/10.1007/978-94-007-7624-1_11">childhood immunizations against diphtheria</a> and <a href="http://www.health.gov.on.ca/en/pro/programs/immunization/docs/hcp_fact_sheets_hoemophilus_influenzae_typeb.pdf"><em>Haemophilus</em> <em>influenzae</em></a>), but vaccines are also challenging to develop and deliver in the face of a <a href="https://www.canada.ca/en/public-health/services/reports-publications/canada-communicable-disease-report-ccdr/monthly-issue/2020-46/issue-2-3-february-6-2020/article-5-best-practices-addressing-vaccine-hesitancy.html">growing hesitancy movement</a>. Novel treatments such as <a href="https://www.nature.com/articles/nrd.2017.162">immune boosters</a>, <a href="https://doi.org/10.1016/j.drudis.2019.03.002">therapeutic antibodies</a> or natural predators of bacteria called <a href="https://www.id-hub.com/2019/11/21/bacteriophages-2-0-old-solution-modern-problem/">bacteriophages</a> all show promise but are still in the early days of development.</p>
<h2>Antibacterial products contribute to AMR</h2>
<p>While the key players in the global response to AMR undoubtedly include researchers, food producers, policymakers and health-care professionals, the truth is every single person has a role to play.</p>
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<img alt="" src="https://images.theconversation.com/files/327317/original/file-20200412-32369-1kpxyl9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/327317/original/file-20200412-32369-1kpxyl9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/327317/original/file-20200412-32369-1kpxyl9.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/327317/original/file-20200412-32369-1kpxyl9.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/327317/original/file-20200412-32369-1kpxyl9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/327317/original/file-20200412-32369-1kpxyl9.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/327317/original/file-20200412-32369-1kpxyl9.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&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">Antibacterial soaps and disinfectant cleansers can contribute to antimicrobial resistance.</span>
<span class="attribution"><span class="source">(Kelly Sikkema/Unsplash)</span></span>
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<p>One thing we can all do to help combat the spread of AMR is to use regular — not “antibacterial” — soap. Good old-fashioned regular soap is antibacterial and antiviral; it dissolves the greasy membranes that surround bacteria and viruses such as SARS-CoV-2, killing them. </p>
<p>Conversely, antibacterial soaps usually contain additional chemicals that don’t add much in the way of hygiene, but can activate a microorganism’s efflux pumps. The pumps force disinfectants out before they can cause harm (picture someone bailing water out of a leaky boat so it doesn’t sink). They increase the ability of bacteria to fend off multiple types of toxic compounds, including antibiotics, and hasten the spread of AMR. </p>
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<img alt="" src="https://images.theconversation.com/files/327325/original/file-20200412-51445-16eao6a.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/327325/original/file-20200412-51445-16eao6a.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=628&fit=crop&dpr=1 600w, https://images.theconversation.com/files/327325/original/file-20200412-51445-16eao6a.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=628&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/327325/original/file-20200412-51445-16eao6a.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=628&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/327325/original/file-20200412-51445-16eao6a.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=789&fit=crop&dpr=1 754w, https://images.theconversation.com/files/327325/original/file-20200412-51445-16eao6a.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=789&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/327325/original/file-20200412-51445-16eao6a.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=789&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">Multidrug-resistant Klebsiella pneumoniae bacteria, which are known to cause severe hospital acquired nosocomial infections.</span>
<span class="attribution"><a class="source" href="https://phil.cdc.gov/Details.aspx?pid=18170">(David Dorward/NIAID)</a></span>
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<p>While COVID-19 in its own right is indeed terrifying, its implications for the future of AMR might be even worse. Widespread use of antibacterial soaps and disinfectants aside, <a href="https://doi.org/10.1016/S0140-6736(20)30566-3">early studies out of China</a> show that almost all severely ill COVID-19 patients were given antibiotics (sometimes multiple antibiotics) to prevent or treat the secondary bacterial infections to which many ultimately succumbed. Unfortunately, the more antibiotics we use, the more we select for AMR. </p>
<p>But I choose to be an optimist. I hope that COVID-19 is a learning experience. I hope it will open the eyes of many to the life-altering power of microbes. I hope it teaches us that we need better (and faster) surveillance infrastructure for outbreaks. I hope it highlights the need for the rapid development, approval and scale up of effective diagnostics and new therapies.</p>
<p>To me, these steps would be encouraging progress in the global response to AMR.</p><img src="https://counter.theconversation.com/content/135790/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Lori L. Burrows receives research grants from the Canadian Institutes of Health Research, the Natural Sciences and Engineering Research Council of Canada, Glyconet, and the Ontario Research Fund. </span></em></p>Antimicrobial resistance is a public health and economic disaster waiting to happen. If we do not address this threat, by 2050 more people will die from drug-resistant infections than from cancer.Lori L. Burrows, Professor of Biocchemistry and Biomedical Sciences, McMaster UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1230812019-12-02T05:30:44Z2019-12-02T05:30:44ZWe can reverse antibiotic resistance in Australia. Here’s how Sweden is doing it<figure><img src="https://images.theconversation.com/files/301676/original/file-20191114-77305-qhax3s.jpg?ixlib=rb-1.1.0&rect=35%2C17%2C5955%2C3655&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">More stringent use of antibiotics is needed to curb antibiotic resistance. But how can we achieve this?</span> <span class="attribution"><span class="source">From shutterstock.com</span></span></figcaption></figure><p>The antibiotic resistance threat is real. In the years to come, we will no longer be able to treat and cure many infections we once could.</p>
<p>We’ve had no new classes of antibiotics in decades, and the development pipeline is <a href="https://www.who.int/news-room/detail/20-09-2017-the-world-is-running-out-of-antibiotics-who-report-confirms">largely dry</a>. Each time we use antibiotics, the bacteria in our bodies become more resistant to the few antibiotics we still have.</p>
<p>The problem seems clear and the solution obvious: to prescribe our precious antibiotics only when absolutely needed. Implementing this nationally is not an easy task. But Australia could take cues from other countries making significant progress in this area, such as Sweden.</p>
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Read more:
<a href="https://theconversation.com/antibiotic-resistant-superbugs-kill-32-plane-loads-of-people-a-week-we-can-all-help-fight-back-125813">Antibiotic resistant superbugs kill 32 plane-loads of people a week. We can all help fight back</a>
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<h2>The Swedish example</h2>
<p>Antibiotic use was rising steadily in Sweden during the 1980s and 1990s, causing an increase in antibiotic resistant bacteria. A group of doctors mobilised to tackle this threat, and brought together peak bodies across pharmaceuticals, infectious diseases and other relevant areas to form a national coalition. </p>
<p>The Swedish Strategic Programme Against Antibiotic Resistance (<a href="https://www.ncbi.nlm.nih.gov/pubmed/19021951">Strama</a>) was founded in 1995.</p>
<p>Since then, Strama has been working on a national and regional level to reduce antibiotic use. Between 1992 and 2016, the number of antibiotics prescriptions <a href="https://www.ncbi.nlm.nih.gov/pubmed/29147057">decreased by 43%</a> overall. Among children under four, antibiotics prescriptions <a href="https://www.ncbi.nlm.nih.gov/pubmed/29147057">fell by 73%</a>.</p>
<p>Levels of antibiotic use and resistance in Sweden are now among the lowest of all OECD countries, both in humans and animals.</p>
<iframe title="Antibiotics prescriptions in OECD countries" aria-label="Column Chart" src="https://datawrapper.dwcdn.net/iPsiJ/1/" scrolling="no" frameborder="0" style="border: none;" width="100%" height="500"></iframe>
<h2>What has Australia done so far – and what more can we do?</h2>
<p>In 2017, Australia’s chief medical officer sent a letter to all high-prescribing general practitioners. Over the following six months, this resulted in <a href="https://www1.health.gov.au/internet/main/publishing.nsf/Content/Nudge-vs-Superbugs-behavioural-economics-trial-to-reduce-overprescribing-antibiotics-June-2018">around a 10% reduction</a> in antibiotic prescriptions among those GPs.</p>
<p>While an excellent start, this is just one of <a href="https://onlinelibrary.wiley.com/doi/abs/10.5694/mja17.00574">several interventions</a> needed to avert the looming antibiotic crisis.</p>
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Read more:
<a href="https://theconversation.com/drug-resistance-how-we-keep-track-of-whether-antibiotics-are-being-used-responsibly-82446">Drug resistance: how we keep track of whether antibiotics are being used responsibly</a>
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<p><strong>Audit and feedback</strong></p>
<p>The idea of audit and feedback sees GPs provided with a summary of their antibiotic prescribing rates over a specified period of time.</p>
<p>In Australia, antibiotic prescribing data are currently collected by the Pharmaceutical Benefits Scheme (PBS) and periodically used by the National Prescribing Service (NPS MedicineWise) to provide feedback to some GPs.</p>
<p>In Sweden, <a href="https://www.ncbi.nlm.nih.gov/pubmed/29147057">regular meetings</a> between local Strama members and primary health care clinics serve to reinforce treatment guidelines. Strama representatives review individual doctors’ antibiotic prescribing as well as trends across the area, and discuss targets for optimal prescribing.</p>
<p>This results in <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(16)00215-4/fulltext">some decrease in antibiotic use</a>; a small but desirable effect if combined with other interventions.</p>
<p><strong>Restrict access to specific antibiotics</strong></p>
<p>The health department keeps a list of antibiotics that should only be used as a <a href="https://www.amr.gov.au/resources/importance-ratings-and-summary-antibacterial-uses-human-and-animal-health-australia">last line of defence</a>. An example is <a href="https://www.nps.org.au/australian-prescriber/articles/meropenem">meropenem</a>, which is commonly used to treat infections with multidrug-resistant organisms such as septicaemia.</p>
<p>Current restrictions stipulate these antibiotics can only be used in hospitals under the supervision of a hospital antimicrobial stewardship team. This team usually consists of an infectious disease specialist, a microbiologist and a pharmacist. The team reviews the request and either approves it or recommends using another antibiotic.</p>
<p>Strama takes a similar approach.</p>
<p>But the way this is enforced differs between Australian hospitals. We may need to strengthen these restrictions if resistance continues to increase. </p>
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<img alt="" src="https://images.theconversation.com/files/301679/original/file-20191114-77315-kgmkan.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/301679/original/file-20191114-77315-kgmkan.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/301679/original/file-20191114-77315-kgmkan.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/301679/original/file-20191114-77315-kgmkan.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/301679/original/file-20191114-77315-kgmkan.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/301679/original/file-20191114-77315-kgmkan.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/301679/original/file-20191114-77315-kgmkan.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&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">Doctors can educate patients about when antibiotics are and aren’t appropriate.</span>
<span class="attribution"><span class="source">From shutterstock.com</span></span>
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<p><strong>Stop default repeat prescriptions</strong></p>
<p>Prescriptions which include a “repeat” could leave patients believing another course of antibiotics is needed, when this is not always the case. They may hold on to the prescription with a “just in case” attitude to take when they feel it’s necessary, or even give the prescription to someone else.</p>
<p>In Sweden, there are no default repeat prescriptions for antibiotics and this is reinforced by appropriate package size.</p>
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Read more:
<a href="https://theconversation.com/why-the-health-and-agriculture-sectors-need-to-work-together-to-stop-antibiotic-resistance-69031">Why the health and agriculture sectors need to work together to stop antibiotic resistance</a>
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<p>Pleasingly, Australia’s Pharmaceutical Benefits Advisory Committee <a href="https://www.theaustralian.com.au/nation/politics/war-on-superbugs-to-end-repeat-scripts/news-story/648b1316b0098d61883b84a2cc000362">has recently recommended</a> the removal of default repeat options for a range of common antibiotics in high usage, where no repeats are deemed clinically necessary.</p>
<p><strong>Delayed prescribing</strong></p>
<p>Delayed prescribing is when a GP provides a prescription during the consultation, but advises the patient to see if the symptoms will resolve first before using it (a “wait-and-see” approach).</p>
<p>GPs use delayed prescribing in situations of uncertainty as a safety measure, or when patients appear anxious and require additional assurance antibiotics are accessible in case the infection gets worse.</p>
<p>A systematic review found delayed prescribing resulted in <a href="https://www.ncbi.nlm.nih.gov/pubmed/28881007">31% of people taking the course of antibiotics</a> compared to 93% who were prescribed them normally.</p>
<p>In <a href="https://www.tandfonline.com/doi/abs/10.1080/00365540801932439?journalCode=infd19">Sweden</a>, national treatment guidelines for common infections in primary health care support GPs delaying antibiotic prescribing. </p>
<p><strong>Public engagement</strong></p>
<p>To change public attitudes around antibiotic use and preservation, it’s important to communicate the negative effects of the unnecessary use of antibiotics and the risk of antibiotic resistance for the individual as well as the community. </p>
<p>Continuous awareness campaigns are essential (for example, via the media) to keep the public tuned in to the issue. The French campaign “<a href="http://resistancecontrol.info/2016/government-engagement/the-french-approach-to-fighting-antibiotic-resistance-a-constant-and-coordinated-effort-since-2000/">antibiotics are not automatic</a>” is a good example.</p>
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Read more:
<a href="https://theconversation.com/why-gps-prescribe-too-many-antibiotics-and-why-its-time-to-set-targets-80550">Why GPs prescribe too many antibiotics and why it's time to set targets</a>
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<p>Further, enabling patients to be involved in the decision of whether to use antibiotics or not encourages discussion between the doctor and the patient around the benefits and harms of potential treatments. Using shared decision making in consultations has proven effective in reducing antibiotic prescribing by <a href="https://www.ncbi.nlm.nih.gov/pubmed/26560888">about one-fifth</a>. </p>
<p>Each of these strategies contributes a small amount to improving antibiotic usage. Like the <a href="https://www.ncbi.nlm.nih.gov/pubmed/29147057">Swedish Strama program</a>, the combination will need to be sustained and reinforced over many years to reach levels of antibiotic use comparable to the lowest prescribing OECD countries, like Sweden.</p>
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<p><em>Correction: this article originally stated the list of last-line antibiotics was kept by the Australian Commission on Safety and Quality in Health Care.</em></p><img src="https://counter.theconversation.com/content/123081/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Chris Del Mar is the chief investigator of a A$2.4M National Health and Medical Research Council grant for research on antibiotic prescribing and resistance in primary care.</span></em></p><p class="fine-print"><em><span>Helena Kornfält Isberg receives funding from the Southern Regional Health Care Committee, Sweden.</span></em></p><p class="fine-print"><em><span>Mina Bakhit 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>Antibiotic resistance is one of the greatest health challenges we face today. But making a few small changes to the way antibiotics are prescribed could make a big difference in Australia.Mina Bakhit, Postdoctoral Research Fellow, Bond UniversityChris Del Mar, Professor of Public Health, Bond UniversityHelena Kornfält Isberg, MD, General practitioner, PhD-student, Lund UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1055202018-11-13T10:57:03Z2018-11-13T10:57:03ZWhy you shouldn’t take antibiotics for colds and flu<figure><img src="https://images.theconversation.com/files/245067/original/file-20181112-83564-5ho4bz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">And don't infect everyone else in the office either.</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>Winter is well and truly on its way. For many, this conjures up images of log fires, mistletoe and festive feasts. But it can also mean cold, damp mornings, short hours of daylight and the dreaded cold and flu season. </p>
<p>Tickly throats, headaches, fevers and generally feeling rotten are the warning signs that many of us fear. Pressures of work and personal commitments often lead people to seek a quick fix from their GP or other healthcare professional. This usually takes the form of antibiotics. </p>
<p><a href="http://www.who.int/antimicrobial-resistance/en/">Evidence</a> suggests the use of antibiotics is on the increase, which is a cause for concern as the overuse of antibiotics has been linked to <a href="http://www.who.int/antimicrobial-resistance/en/">antimicrobial resistance</a>. This is the ability of microorganisms – such as bacteria and viruses – to evolve so that antimicrobials (antibiotics and antivirals) become less effective at killing or working against them. </p>
<p>Antibiotic resistance results in standard treatments – such as many of the commonly prescribed antibiotics – becoming ineffective. And this leaves people who need antibiotics for serious infections vulnerable. </p>
<p>This issue has been recognised as a problem on a global scale in a <a href="https://amr-review.org/sites/default/files/160525_Final%20paper_with%20cover.pdf">UK government commissioned review</a>. These findings led to the National Institute of Clinical Excellence (NICE) publishing <a href="https://www.nice.org.uk/guidance/qs121">quality standards</a> to help clinicians when prescribing antibiotics to slow the rise in antimicrobial resistance. </p>
<h2>Antibiotic expectations</h2>
<p>The <a href="https://www.cochrane.org/CD012406/AIRWAYS_macrolide-antibiotics-bronchiectasis">Cochrane review</a>, on which I worked, found that many vulnerable patients have an increased risk of developing microbial resistance. This includes people with chronic respiratory illness – many of whom have “rescue packs” which include antibiotics at home. These repeat prescriptions are often issued without enough education to support their use or <a href="https://www.pcrs-uk.org/sites/pcrs-uk.org/files/UseofRescuePacksinCOPD_5_1_2018.pdf">highlight their drawbacks</a> – so unnecessary prescribing practices continue.</p>
<p>Beliefs and expectations by patients, healthcare professionals and society have been found to be the main drivers of the <a href="http://erj.ersjournals.com/content/40/1/1.long">overuse of antibiotics</a>. From a patient’s perspective, the desire to get better is often more important than any external considerations such as publicity campaigns. And for healthcare professionals, the greater good of society occurs outside the immediate consultation and is therefore <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1325265/">often overlooked</a> – <a href="https://onlinelibrary.wiley.com/doi/abs/10.1197/j.aem.2007.07.011">along with existing evidence</a>. This breeds a cycle of expectation and self-interest which serves both clinician and patient but neglects wider societal issues. </p>
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<p>It is possible, then, that much antibiotic prescribing, particularly in the flu season, is driven by these expectations – from both patients and healthcare professionals. But this is not unique to antibiotic prescribing. Our previous research found similar behaviours with oxygen therapy. Despite emerging evidence and guidelines, poor prescribing and administration of oxygen therapy persists – and it is often given routinely for <a href="https://onlinelibrary.wiley.com/doi/full/10.1111/crj.12571">breathlessness to patients</a>. </p>
<h2>A medical priority</h2>
<p>A UK parliamentary health and social care committee <a href="https://publications.parliament.uk/pa/cm201719/cmselect/cmhealth/962/962.pdf">report on antimicrobial resistance</a> has called for the issue to be regarded as “top five policy priority” for government – stressing the need to support the pharmaceutical industry to develop new antibiotics. </p>
<p>How Brexit will affect this investment and commitment is <a href="https://www.independent.co.uk/news/business/news/brexit-uk-pharmaceutical-research-drug-investment-select-committee-review-a8087161.html">unclear</a>. But there remains an urgent need to promote responsible and appropriate prescribing through education, research, guidelines and campaigns. </p>
<p>Current UK prescribing levels are reported as double that of other countries such as <a href="https://publications.parliament.uk/pa/cm201719/cmselect/cmhealth/962/962.pdf">Sweden, Netherlands and the Baltic States</a>. This presents a challenge for primary care and hospitals who need to reduce both the number of antibiotics prescribed and the length of time that they are administered.</p>
<h2>Antibiotic efficacy</h2>
<p>A recent <a href="https://amr-review.org/sites/default/files/160525_Final%20paper_with%20cover.pdf">government report</a> has called for the use of rapid <a href="https://www.ncbi.nlm.nih.gov/pubmed/28973636">diagnostic testing</a> to inform all antibiotic prescriptions. This approach should take the <a href="https://theconversation.com/theres-a-test-that-shows-doctors-if-antibiotics-will-work-or-not-so-why-isnt-it-being-used-72892">guesswork out of prescribing</a> antibiotics by testing for blood markers that signify the presence of infection. <a href="http://www.pace-study.co.uk/">Findings from a large trial</a> based in the UK are expected soon. </p>
<p>Sometimes though, the prescribing of general use antibiotics is not only expected, but cheaper and easier. So it will require a concerted effort to promote responsible prescribing and educate all healthcare professionals, patients and the public to refrain from using antibiotics. </p>
<p>So as winter approaches, rather than rushing out to your doctors at the first sign of a sniffle, try and ride it out. <a href="https://www.nhs.uk/conditions/flu/">Get lots of sleep</a>, keep <a href="https://theconversation.com/take-a-chill-pill-if-you-want-to-avoid-the-flu-this-year-53027">stress to a minimum</a> and up your fluid intake – all of which have been shown to help in the treatment and staving off of colds and flu. It’s also worth being extra vigilant with <a href="https://theconversation.com/shaking-hands-is-disgusting-heres-what-else-you-can-do-98097">hand washing</a> to help keep those germs at bay and stop them from developing into something more nasty in the first place.</p><img src="https://counter.theconversation.com/content/105520/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Dr Carol Kelly is affiliated with ARNS (Association for Respiratory Nurse Specialists) </span></em></p>The overuse of antibiotics puts vulnerable patients and society at risk.Carol Ann Kelly, Reader Respiratory Care, Edge Hill UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1007992018-08-20T10:30:59Z2018-08-20T10:30:59ZThree reasons the US is not ready for the next pandemic<figure><img src="https://images.theconversation.com/files/232140/original/file-20180815-2897-16tpvs7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A poster from a world summit in Hong Kong on preparing for worldwide pandemics in June 2010. Despite efforts to develop plans, none is yet in place. </span> <span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Hong-Kong-Next-Pandemic/95011033061a403bb7257e8f1f8786b8/100/0">Vincent Yu/AP Photo</a></span></figcaption></figure><p><strong>Note: This article was published in 2018</strong></p>
<p>Over a hundred years after the Great Influenza pandemic of 1918, global health leadership stands at a crossroads. The United States continues to expand its <a href="https://www.washingtonpost.com/news/to-your-health/wp/2018/02/01/cdc-to-cut-by-80-percent-efforts-to-prevent-global-disease-outbreak/">policy of isolationism</a> at a time when international cooperation in health could not be more important. The state of pandemic preparedness and the necessary steps for protecting the people throughout the world was the topic of The Scowcroft Institute for International Affairs’ <a href="http://issuu.com/tamuvetmed/docs/2018pandemicwhitepaper?e=10250889/61709576">2nd Annual White Paper</a>. </p>
<p>As pandemic policy scholars, with two of us spending the majority of our career in the federal government, we believe that it is essential to prepare the country and the world for the next pandemic. It is not a matter of if, but when, the next disease will sweep the world with deadly and costly consequences. </p>
<p>There are many topic areas that national leaders must address to create better preparedness and response capabilities, but we believe three are most urgent. These include targeting the resistance to antimicrobial agents that has come about because of overuse and misuse of antibiotics; ensuring continuity of supply chains; and improving and strengthening leadership. </p>
<h2>Overuse of a wonder drug</h2>
<p>Prior to Alexander Fleming’s <a href="https://www.pbs.org/newshour/health/the-real-story-behind-the-worlds-first-antibiotic">discovery of penicillin</a>, even the smallest scratch could be deadly. Its discovery, however, helped contribute to the perception that man had conquered disease, despite Fleming’s <a href="https://www.businessinsider.com/alexander-fleming-predicted-post-antibiotic-era-70-years-ago-2015-7">warning</a> that “the thoughtless person playing with penicillin treatment is morally responsible for the death of a man who succumbs to infection with the penicillin resistant organism.” Now, 70 years later, society is quickly reaching the precipice of that reality.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/232143/original/file-20180815-2903-1kvi3me.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/232143/original/file-20180815-2903-1kvi3me.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/232143/original/file-20180815-2903-1kvi3me.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/232143/original/file-20180815-2903-1kvi3me.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/232143/original/file-20180815-2903-1kvi3me.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=504&fit=crop&dpr=1 754w, https://images.theconversation.com/files/232143/original/file-20180815-2903-1kvi3me.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=504&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/232143/original/file-20180815-2903-1kvi3me.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=504&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Penicillin fungi growing in petri dishes.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/penicillin-fungi-petri-dishes-263963465?src=an__v-iSSNGB2o6mr3E8jw-1-7">science photo/Shutterstock.com</a></span>
</figcaption>
</figure>
<p>The problem of antibiotic overuse and misuses is extensive. In fact, in the United States, <a href="https://www.ncbi.nlm.nih.gov/pubmed/26464037">80 percent of all antibiotic use</a> occurs in the agricultural sector and the majority of this use is nontherapeutic, meaning it is not medically necessary. Misuse of antibiotics also occurs frequently in the human health sector, however. The Review on Antimicrobial Resistance estimated that if changes are not made, the world could witness <a href="https://amr-review.org/sites/default/files/AMR%20Review%20Paper%20-%20Tackling%20a%20crisis%20for%20the%20health%20and%20wealth%20of%20nations_1.pdf">10 million deaths annually</a> due to antimicrobial resistant infections. </p>
<p>To help prevent this public health threat from reaching that level of crisis with potential catastrophic implications, we recommend four actions. </p>
<p>First, an increase of investment needs to be made by the federal government and the private sector into research, development and production of new antimicrobials. In 2014, WHO also called for <a href="http://www.who.int/phi/implementation/consultation_imnadp/en/">greater investment</a> in discovering new antimicrobials, but in the last 50 years, <a href="https://www.sciencedirect.com/science/article/pii/S1198743X16300271">only one new class</a> of antibiotics has been discovered. </p>
<p>Second, governments throughout the world need to create stronger internationally harmonized regulatory systems for agriculture production and veterinary use of antimicrobials. For example, in the United States, antibiotics cannot be purchased without a prescription from either a medical doctor or a veterinarian (for the agricultural sector). But many countries in the developing world have no oversight for animal or human use of antibiotics. In some places, particularly African countries, many antibiotics can be purchased <a href="https://aricjournal.biomedcentral.com/articles/10.1186/s13756-017-0208-x">over the counter</a>.</p>
<p>You may already have experienced the third recommendation, if your doctor has sent you home from an appointment without an antibiotic prescription because your illness was viral. Health care providers and consumers need to decrease misuse and overuse of antimicrobials in human health by only prescribing antibiotics in cases of bacterial infection. The Centers for Disease Control and Prevention has issued guidelines for this, including <a href="https://www.cdc.gov/antibiotic-use/community/improving-prescribing/index.html">recommendations for patients</a>. </p>
<p>Last, governments throughout the world need to understand that fighting antimicrobial resistance requires a collaboration between animal health, human health and environmental health. This idea, known as One Health, works to bring together researchers and professionals from these three areas to address disease-related challenges. While these actions require monetary and time investments, they are essential. Without taking these actions society may find itself in a post-antibiotic world. This world, as former Director-General of the World Health Organization <a href="http://www.who.int/dg/speeches/2012/amr_20120314/en/">Margaret Chan explained in 2012</a>, means “the end of modern medicine as we know it. Things as common as strep throat or a child’s scratched knee would once again kill.”</p>
<h2>Will global supply chains collapse?</h2>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/232145/original/file-20180815-2921-1qtc7d.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/232145/original/file-20180815-2921-1qtc7d.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=361&fit=crop&dpr=1 600w, https://images.theconversation.com/files/232145/original/file-20180815-2921-1qtc7d.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=361&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/232145/original/file-20180815-2921-1qtc7d.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=361&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/232145/original/file-20180815-2921-1qtc7d.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=454&fit=crop&dpr=1 754w, https://images.theconversation.com/files/232145/original/file-20180815-2921-1qtc7d.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=454&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/232145/original/file-20180815-2921-1qtc7d.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=454&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Global supply chains involve complicated logistics of getting goods to and from trucks, ships and jets all around the world. If one piece is interrupted, disaster can sometimes strike.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/logistics-transportation-container-cargo-ship-plane-722794939?src=NnOEq7mY82YB80SYGV3EKg-1-1">Travel Mania/Shutterstock.com</a></span>
</figcaption>
</figure>
<p>Modern society is able to function and flourish in large part because of the global <a href="http://www.businessdictionary.com/definition/supply-chain.html">supply chains</a> transporting parts, equipment and supplies with speed, efficiency and <a href="https://financial-dictionary.thefreedictionary.com/Just-In-Time+Delivery">just-in-time delivery</a>, which allows business to keep carrying costs low because they can order what they need and have it shipped quickly, or “just in time.” Global supply chains, which consist of production specialization through comparative advantage, has enabled great economic development, but their just-in-time structure also leaves them exceedingly vulnerable. Components of the critical medical infrastructure, such as components essential to running life support machines or insulin for diabetics, are<a href="https://www.amazon.com/Deadliest-Enemy-Against-Killer-Germs/dp/B06XKQLD4X"> always in transit</a>. </p>
<p>This means that even a localized disease could deprive people of needed medical supplies. For example, if an epidemic hits a town in Asia where <a href="https://www.health.ny.gov/publications/2805/index.htm">N95 masks</a>, which are used to protect people from hazardous substances, are manufactured, there may no longer be any N95 masks to be shipped to the United States or elsewhere. The United States experienced supply chain breakdown when Hurricane Maria caused a <a href="https://www.smithsonianmag.com/innovation/saline-shortage-this-flu-season-exposes-flaw-in-our-medical-supply-chain-180967879/">disruption in the supply</a> of small bag IV saline. A manufacturer in Puerto Rico that produces <a href="https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2681062">nearly half of all the saline</a> utilized in the U.S. had to halt production because of the hurricane. </p>
<p>This interconnectedness of the global economy and the expansiveness of medical supply chains means that a disruption anywhere along the line could spell disaster worldwide. To help prevent such a disaster, the federal government needs to understand the United States’ critical supply chains. The federal government and private sector should be aware of likely points of breakdown. </p>
<p>Once there is understanding, the U.S. must implement new policies that enable private sector innovation to diversify production and transportation where possible. Diversification of production and transportation means that there is not just one production source for critical supplies. Thus, a disruption in one geographical location would not cripple the entire supply chain. </p>
<h2>Centralized, involved leadership</h2>
<p>Diseases do not respect borders, and for this reason, pandemics are a global threat. Therefore, the U.S. must address the threat of pandemics in cooperation with all other nations and with multilateral institutions such as the World Health Organization, the U.N. Security Council, UNICEF and more. We believe that investment in global health security, such as the establishment of a permanent fund for influenza preparedness and response, and remaining engaged with the international community to prevent an outbreak from becoming a pandemic is the best way to protect the American people.</p>
<p>Additionally, we believe that the U.S. should commit to pandemic preparedness by creating a position of authority within the White House that transcends administrations and elevates pandemics as existential threats to a national security priority. There is a need to have decision-making authority and oversight vested at the highest levels of government.</p>
<p>In the midst of a pandemic, decisions must be made quickly. Quick decision-making can often be hindered by the absence of high-level leadership. The need for high-level leadership, coordination and a new strategy are essential to mitigate the <a href="http://www.biodefensestudy.org/a-national-blueprint-for-biodefense">threat of pandemics</a>, but these fundamental <a href="http://bush.tamu.edu/scowcroft/white-papers/The-Growing-Threat-of-Pandemics.pdf">pandemic preparedness gaps persist</a>.</p>
<p>The next great pandemic is coming. The true question is: Will we be ready when it does? Right now, that answer is no, because the country lacks the sufficient safeguards we have outlined. But if the United States chooses to elevate the issue of pandemic preparedness and biosecurity as a national security priority, we could be. Outbreaks are inevitable, but pandemics are not if we take action now.</p><img src="https://counter.theconversation.com/content/100799/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Andrew S.Natsios I sit on the board of directors and own shares in Canadian-based Fio Corporation, a hitech startup which works in developing countries in remote diagoses of malaria, HIV/AIDS, and other infectious diseases.</span></em></p><p class="fine-print"><em><span>Christine Crudo Blackburn and Gerald W Parker do not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>It’s not a matter of if, but when, the next deadly pandemic will strike. Will the world be ready?Christine Crudo Blackburn, Deputy Director, Pandemic & Biosecurity Policy Program, Scowcroft Institute of International Affairs, Bush School of Government and Public Service, Texas A&M UniversityAndrew Natsios, Director of the Scowcroft Institute of International Affairs and Executive Professor, Texas A&M UniversityGerald W Parker, Associate Dean For Global One Health, College of Veterinary Medicine & Biomedical Sciences; and Director, Pandemic and Biosecurity Policy Program, Scowcroft Institute for International Affairs, Bush School of Government and Public Service, Texas A&M UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/943022018-04-05T06:41:03Z2018-04-05T06:41:03Z‘Super gonorrhoea’ raises the stakes in the war against superbugs<figure><img src="https://images.theconversation.com/files/213320/original/file-20180405-189798-nbplrq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Antibiotic resistance is not new but recent developments increase the urgency for action.</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>There has been a lot of news over the past few weeks about the rise of superbugs and antibiotic overuse, including a <a href="https://www.theguardian.com/commentisfree/2018/mar/30/super-gonorrhoea-antibiotic-crisis-drug-resistant-bugs">nasty sexually transmitted infection</a> in the United Kingdom. A British man is the first in the world to be diagnosed with a strain of gonorrhoea resistant to all strains of antibiotics used to treat the infection. </p>
<p>Superbugs have tended to pose the greatest risk to people with compromised immune systems, such as cancer patients, and those who were injured or underwent surgery. But the sexual transmission of these bugs means antibiotic resistant infections can spread much more widely.</p>
<p>So what exactly are superbugs, and how scared should we be?</p>
<h2>Super but not new</h2>
<p>“Superbugs” aren’t the bug equivalent of superheroes. The term describes bacteria that have become resistant to antibiotics. How “super” they are depends on how many antibiotics they have become resistant to. </p>
<p>“Antibiotic resistance” and “drug-resistant infections” also refer to the same phenomena. They describe microorganisms that have evolved to become impervious to being killed by treatment with antibiotics. </p>
<p>There is a common misconception that antibiotic resistance means your body has become resistant to antibiotics. This is not true.</p>
<p>Antibiotic resistance is nothing new. Alexander Fleming’s 1945 <a href="https://www.nobelprize.org/nobel_prizes/medicine/laureates/1945/fleming-lecture.pdf">Nobel Prize acceptance speech for the discovery of penicillin</a> discusses the development of resistance. He includes a scenario of Patient X, who:</p>
<blockquote>
<p>buys some penicillin and gives himself, not enough to kill the streptococci but enough to educate them to resist penicillin. He then infects his wife. Mrs. X gets pneumonia and is treated with penicillin. As the streptococci are now resistant to penicillin the treatment fails.</p>
</blockquote>
<p>Indeed, resistance has been reported for <em>every</em> antibiotic ever introduced – <a href="https://antimicrobialresistance101.files.wordpress.com/2015/04/antibiotic-resistance-history-graph.png">generally within a few years</a> of deployment.</p>
<h2>How do they become resistant?</h2>
<p>Bacteria are able to fight antibiotics by a variety of methods:</p>
<ul>
<li>They build stronger cell walls to stop the drugs from entering</li>
<li>They actively spit them out so the antibiotic can’t reach a lethal concentration inside the cell</li>
<li>They produce enzymes that modify and inactivate the antibiotics and</li>
<li>They alter the target of the antibiotic so it no longer interacts with the drug.</li>
</ul>
<p>One or more of these resistance mechanisms may already be naturally present in a very small fraction of the millions of bacteria exposed to an antibiotic. This is called “innate resistance”. Most of the bacteria are killed, but this small population survives and grows. </p>
<p>In other cases, resistance develops through evolution (a process known as “induced resistance”). Bacteria grow rapidly. Under optimal conditions the population can double in as few as 15-30 minutes. </p>
<p>When exposed to sub-lethal doses of antibiotic, bacteria can become tolerant. They accumulate beneficial mutations over multiple generations. They then pass on this resistance to their progeny when they divide.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/we-know-why-bacteria-become-resistant-to-antibiotics-but-how-does-this-actually-happen-59891">We know _why_ bacteria become resistant to antibiotics, but _how_ does this actually happen?</a>
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</em>
</p>
<hr>
<p>Bacteria are also very promiscuous. They exchange pieces of genetic material (plasmids) that carry the codes for resistance. This allows for the rapid spread of resistance between different types of bacteria. </p>
<p>An example is highlighted by <a href="https://www.theaustralian.com.au/news/world/the-times/drug-resistance-spreads-to-humans-at-shocking-rate/news-story/fc0d3487e6f353a1f4569c1770721d34">recent news reports</a> of resistance to a “last resort” antibiotic, colistin. A gene called mcr-1 (mobilized colistin resistance) was found to be contained in plasmids in <em>E. coli</em> bacteria collected from Chinese pig farms in 2011 (<a href="http://www.thelancet.com/journals/laninf/article/PIIS1473-3099(15)00424-7/fulltext">though it was not reported until 2015</a>). </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/213326/original/file-20180405-189816-h2h0lq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/213326/original/file-20180405-189816-h2h0lq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/213326/original/file-20180405-189816-h2h0lq.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/213326/original/file-20180405-189816-h2h0lq.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/213326/original/file-20180405-189816-h2h0lq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/213326/original/file-20180405-189816-h2h0lq.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/213326/original/file-20180405-189816-h2h0lq.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A gene that makes bugs resistant to antibiotics of ‘last resort’ was found in Chinese pig farms.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/1060871903?src=8TKC8hWSjSmYq38tXIvwjw-1-22&size=medium_jpg">Zawinul/Shutterstock</a></span>
</figcaption>
</figure>
<p>While colistin resistance was already known, the potential for resistance to be quickly spread by this new mechanism is of great concern. For some infections, colistin is the only antibiotic that still works. Indeed, the mcr-1 gene has now been found in <a href="https://www.nature.com/articles/s41467-018-03205-z">multiple types of bacteria in more than 30 countries</a> (including a <a href="http://www.cidrap.umn.edu/news-perspective/2016/05/highly-resistant-mcr-1-superbug-found-us-first-time">patient in the United States in 2016</a>).</p>
<p>The <a href="http://www.searo.who.int/mediacentre/releases/2015/1612/en/">World Health Organisation is now warning</a> that we face a return to a “pre-antibotic era”. It warns:</p>
<blockquote>
<p>Common infections and minor injuries which have been possible to treat for decades may once again kill millions. Resistance to antibiotics will make complex surgeries and management of several chronic illnesses like cancer extremely difficult.</p>
</blockquote>
<p>Before antibiotics, 40% of deaths were due to infection. If we do not act, <a href="https://amr-review.org/sites/default/files/160525_Final%20paper_with%20cover.pdf">a review commissioned by the United Kingdom government</a> predicts that by 2050 drug-resistant infections could cause 10 million annual deaths.</p>
<h2>How did we get here?</h2>
<p>This rise in resistance is largely driven by excessive antibiotic use. The same UK report indicates that up to two-thirds of the world’s antibiotics are not used to treat humans, but are given to animals grown for food. This animal use is often as a food additive, not as therapeutic treatment for an infection. </p>
<p>Of the remaining antibiotics used in humans, up to two-thirds may be inappropriately prescribed. </p>
<p>This huge overuse of antibiotics inevitably drives the development of resistance by unnecessarily exposing a much greater population of bacteria to antibiotics. Sub-lethal concentrations, such as in waste water from farms, fosters resistance. </p>
<p>Alarmingly, <a href="http://www.pnas.org/content/early/2018/03/20/1717295115">a recent study</a> shows that <a href="https://www.theguardian.com/science/2018/mar/26/calls-to-rein-in-antibiotic-use-after-study-shows-65-increase-worldwide">our use of antibiotics is increasing even more</a>.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/why-the-health-and-agriculture-sectors-need-to-work-together-to-stop-antibiotic-resistance-69031">Why the health and agriculture sectors need to work together to stop antibiotic resistance</a>
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</p>
<hr>
<p>So, given we already have <a href="https://www.statnews.com/2017/01/12/nevada-woman-superbug-resistant/">people dying from bacteria resistant to all known antibiotics</a>, and these bacteria are <a href="https://apnews.com/afcee30eb24848d38f9b855fbcc9a4ba">becoming increasingly prevalent</a>, what’s stopping a global pandemic tomorrow? </p>
<p>It really comes down to the fact that, unless you’re immunocompromised or have an injury allowing the bacteria to get into your body, most bacteria aren’t particularly effective at spreading infections. </p>
<p>This is why the <a href="https://news.nationalgeographic.com/2018/03/gonorrhea-evolving-untreatable-spd/">reports</a> of a <a href="https://www.theguardian.com/commentisfree/2018/mar/30/super-gonorrhoea-antibiotic-crisis-drug-resistant-bugs">“super-gonorrhea” case in the UK </a> are alarming. The sexually transmitted bacteria (<em>Neisseria gonorrhoeae</em>) <a href="http://www.who.int/mediacentre/news/releases/2017/Antibiotic-resistant-gonorrhoea/en/">causes nearly 80 million infections a year</a>. This bacteria now has the potential to carry and spread high levels of antibiotic resistance through a much larger population of both people and other bacteria.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/213325/original/file-20180405-189821-p2j2no.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/213325/original/file-20180405-189821-p2j2no.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/213325/original/file-20180405-189821-p2j2no.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/213325/original/file-20180405-189821-p2j2no.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/213325/original/file-20180405-189821-p2j2no.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/213325/original/file-20180405-189821-p2j2no.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/213325/original/file-20180405-189821-p2j2no.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Super-gonorrhea has the potential to spread antibiotic resistance to many more people.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/white-mattress-after-waking-morning-sun-1058016380?src=idJzfv5Tw4DqSyPgT08sBA-1-42">The Five Aggregates/Shutterstock</a></span>
</figcaption>
</figure>
<h2>Fight against superbugs</h2>
<p>It’s not all doom and gloom. Nations and international organisations are increasingly devoting attention and resources to fight the rise of antibiotic resistance. Strategies include more sparing use of existing antibiotics, and <a href="https://longitudeprize.org/">investment and incentives to develop diagnostics</a> that can decide when antibiotics are needed.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/when-the-drugs-dont-work-how-we-can-turn-the-tide-of-antimicrobial-resistance-71711">When the drugs don’t work: how we can turn the tide of antimicrobial resistance</a>
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</p>
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<p>Non-antibiotic approaches, such as vaccines, phage therapy, and microbiome manipulation, are garnering increased consideration. </p>
<p>Initiatives to re-invigorate the discovery of new antibiotics include efforts such as <a href="https://www.gardp.org/">The Global Antibiotic Research & Development Partnership</a>, the <a href="http://www.carb-x.org/">Combating Antibiotic Resistant Bacteria Biopharmaceutical Accelerator</a>, and Australia’s own global effort to crowdsource antibiotics from international chemists, <a href="http://www.co-add.org">The Community for Open Antimicrobial Drug Discovery</a>. </p>
<p>We must keep our attention on the threat posed by drug resistant infections and invest in antimicrobial research to keep the potential global catastrophe at bay.</p><img src="https://counter.theconversation.com/content/94302/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Mark Blaskovich receives funding from the NHMRC, Australian Academy of Technology and Engineering, the Aiustralian Department of Industry, Innovation and Science, and the Wellcome Trust for antibiotic-related research. He works for the Community for Open Antimicrobial Drug Discovery, an initiative to discover new antibiotics. He is an inventor on several patents describing new antibiotics.</span></em></p>Superbugs used to pose the greatest risk to people with compromised immune systems and those who had surgery. But their sexual transmission means antibiotic resistance can spread much more widely.Mark Blaskovich, Senior Research Officer, The University of QueenslandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/824462017-10-02T00:44:51Z2017-10-02T00:44:51ZDrug resistance: how we keep track of whether antibiotics are being used responsibly<figure><img src="https://images.theconversation.com/files/184852/original/file-20170906-9846-2usz92.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Some patients may be prescribed antibiotics as preventatives, rather than to treat infections.</span> <span class="attribution"><span class="source">from www.shutterstock.com.au</span></span></figcaption></figure><p>While we know increasing numbers of bacteria all over the world are becoming more resistant to existing antibiotics, we need to learn more about how antibiotics are being used in healthcare settings.</p>
<p>We know overuse and inappropriate use of antibiotics contribute to resistance, so it’s important we monitor antimicrobial use and develop strategies to improve practice. Australia now has a <a href="http://www.health.gov.au/internet/main/publishing.nsf/Content/1803C433C71415CACA257C8400121B1F/%24File/amr-strategy-2015-2019.pdf">national strategy</a> to do so.</p>
<p>Importantly, a <a href="https://www.safetyandquality.gov.au/antimicrobial-use-and-resistance-in-australia/what-is-aura/">national surveillance report</a> provides an overview of annually-updated data and analyses from relevant <a href="https://www.safetyandquality.gov.au/antimicrobial-use-and-resistance-in-australia/resources-page/">programs</a>. This covers <a href="http://www.sahealth.sa.gov.au/wps/wcm/connect/public+content/sa+health+internet/clinical+resources/clinical+programs/antimicrobial+stewardship/national+antimicrobial+utilisation+surveillance+program+nausp">drug consumption in participating hospitals</a>, <a href="https://www.naps.org.au/Default.aspx">appropriateness of use in participating hospitals</a>, and prescribing <a href="https://www.nps.org.au/">data from GPs</a> and <a href="https://www.safetyandquality.gov.au/publications/antimicrobial-prescribing-and-infections-in-australian-residential-aged-care-facilities-results-of-the-2015-aged-care-national-antimicrobial-prescribing-survey-pilot/">residential aged-care facilities</a>. </p>
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Read more:
<a href="https://theconversation.com/we-know-why-bacteria-become-resistant-to-antibiotics-but-how-does-this-actually-happen-59891">We know _why_ bacteria become resistant to antibiotics, but _how_ does this actually happen?</a>
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<p>While some programs provide representative estimates of drug consumption, the National Antimicrobial Prescribing Survey (<a href="https://www.naps.org.au/Default.aspx">NAPS</a>) is unique, in that it assesses the quality of individual patient prescriptions. This means it looks at whether prescriptions were compliant with clinical practice guidelines for the given indications (including drug choice and dose), and whether the overall drug use was appropriate and safe.</p>
<p>Assessing these factors helps to identify areas of inappropriate use and inform changes in clinical practice.</p>
<h2>What the surveys found</h2>
<p>In <a href="https://www.safetyandquality.gov.au/wp-content/uploads/2014/11/Web-Accessible-2013-NAPS-Report.pdf">2013-14</a>, 151 hospitals (132 public and 19 private) from all states and territories participated in the NAPS. From that, 12,800 prescriptions for antimicrobial drugs were analysed. In <a href="https://www.naps.org.au/Resources/Antimicrobial-prescribing-practice-in-Australian-hospitals-Results-of-the-2015-National-Antimicrobial-Prescribing-Survey.pdf">2015-16</a>, 281 hospitals (213 public and 68 private) participated in the audit, and 22,021 prescriptions for antimicrobial drugs were analysed. </p>
<p>In 2015, on average, 40% of patients in hospitals were administered an antibiotic. Of these, 72% were found to have needed them as they were prescribed, and 35% had a review- or stop-date documented.</p>
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<a href="https://images.theconversation.com/files/184856/original/file-20170906-9830-izvrfr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/184856/original/file-20170906-9830-izvrfr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/184856/original/file-20170906-9830-izvrfr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/184856/original/file-20170906-9830-izvrfr.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/184856/original/file-20170906-9830-izvrfr.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/184856/original/file-20170906-9830-izvrfr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/184856/original/file-20170906-9830-izvrfr.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/184856/original/file-20170906-9830-izvrfr.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">A survey found 22% of antibiotic use in hospitals was inappropriate.</span>
<span class="attribution"><span class="source">from www.shutterstock.com</span></span>
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<p>Overall, 23% of prescriptions for antibiotics for hospitalised patients were deemed to be non-compliant with prescribing guidelines (40% in 2013-14), and 22% were assessed as inappropriate (29% in 2013-14).</p>
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Read more:
<a href="https://theconversation.com/factcheck-is-australias-use-of-antibiotics-in-general-practice-20-above-the-oecd-average-68657">FactCheck: Is Australia’s use of antibiotics in general practice 20% above the OECD average?</a>
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<p>Specific areas that needed attention were identified. In 2015, 40% of prescriptions for the prevention of surgical site infections were assessed as inappropriate. This was mainly because of incorrect duration (30%) and incorrect dose or frequency (28%), or because they were given for a procedure that does not require antibiotics to be used as preventatives (22%). Knowing these common errors means we can give feedback to doctors and, in some cases, help clarify guidelines or develop new ones.</p>
<h2>Why does over-prescribing happen?</h2>
<p>There are complex reasons why therapeutic drugs, including antibiotics, are sometimes inappropriately prescribed. These can include institutional or systemic cultures that have been in place for a long time. Knowledge gaps are an issue. Despite access to good-quality prescribing guidelines in hospitals, guidelines may not be consulted frequently. The fear of missing infections or adverse outcomes may contribute to excessive or inappropriate treatment.</p>
<p>Sometimes, a lack of resources means staff don’t have the time to review a diagnosis and adjust treatments in a timely way. Some staff may recognise inappropriate use but are fearful about speaking up or contradicting another doctor. Cultural factors such as medical hierarchies can define the workflow in hospitals.</p>
<p>Until recently, there may have been a view that antibiotics “do no harm” and that prescribing “just in case”, or giving more than is necessary, has no consequence.</p>
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Read more:
<a href="https://theconversation.com/long-courses-confusion-and-culture-why-were-losing-the-fight-against-antibiotic-resistance-49300">Long courses, confusion and culture: why we're losing the fight against antibiotic resistance</a>
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<h2>What can we do about it?</h2>
<p>There are no quick fixes when it comes to improving antibiotic prescribing, but concerted efforts can lead to change. Much progress has already been made in several countries, and <a href="https://www.doctorportal.com.au/mjainsight/2017/2/milestones-challenges-in-antimicrobial-stewardship/">Australia has been a leader</a> in initiatives aimed at using antibiotics properly and responsibly in hospitals. </p>
<p>Programs aimed at improving antibiotic use are referred to as “antimicrobial stewardship”. Australian hospitals were early adopters and initiators of antimicrobial stewardship programs. </p>
<p>It’s widely recognised that alongside education and training for individual doctors, setting up systems that support better decision-making within hospitals is key to enhancing patient safety and care. Many Australian hospitals have <a href="https://www.doctorportal.com.au/mjainsight/2017/26/evidence-based-solutions-for-antimicrobial-stewardship/">decision-support and approval systems</a> to monitor and control when and how antibiotics are used. This is sometimes coupled with post-prescription reviews by teams of experts, <a href="https://www.doctorportal.com.au/mjainsight/2017/32/antimicrobial-stewardship-hospital-standards-update-in-2018/?platform=hootsuite">although this should happen more</a>.</p>
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Read more:
<a href="https://theconversation.com/use-them-and-lose-them-finding-alternatives-to-antibiotics-to-preserve-their-usefulness-48655">Use them and lose them: finding alternatives to antibiotics to preserve their usefulness</a>
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<p>Regular auditing and feedback allow problem areas to be identified and strategies to be developed. The NAPS enables pharmacists and doctors in one facility to compare their performance with that of similar facilities.</p>
<p>In addition to providing a national overview of hospital prescribing and helping facilities monitor their performance over time, the NAPS serves to increase awareness of guidelines and appropriate prescribing in hospitals.</p>
<p>Through regular surveillance and the adoption of stewardship programs, we know we can improve antibiotic prescribing and patient care in hospitals.</p>
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<p><em>Dr. Rod James, Caroline Chen, Sonia Koning, and Robyn Ingram of the National Antimicrobial Prescribing Survey program, and Dr. Arjun Rajkhowa from the National Centre for Antimicrobial Stewardship, contributed to this article.</em></p><img src="https://counter.theconversation.com/content/82446/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Kirsty Buising is the deputy director of the National Centre for Antimicrobial Stewardship (University of Melbourne) and director of the Guidance Group (Royal Melbourne Hospital).</span></em></p><p class="fine-print"><em><span>Karin Thursky is the director of the National Centre for Antimicrobial Stewardship (University of Melbourne) and the Guidance Group (Royal Melbourne Hospital). The National Centre for Antimicrobial Stewardship is an Australian National Health and Medical Research Council (NHMRC) Centre of Research Excellence.</span></em></p>We know overuse and inappropriate use of antibiotics contribute to resistance, so it’s important we develop strategies to improve practice.Kirsty Buising, Associate Professor, The Peter Doherty Institute for Infection and ImmunityKarin Thursky, Professor, The Peter Doherty Institute for Infection and ImmunityLicensed as Creative Commons – attribution, no derivatives.