LanceGary
11-11-2010, 22:53
Life without antibiotics
SARAH BOSELEY | LONDON - Nov 09 2010 10:15
http://www.mg.co.za/article/2010-11-09-life-without-antibiotics
Just 65 years ago Dr David Livermore's paternal grandmother died after
an
operation to remove her appendix. It didn't go well, but it wasn't the
surgery that killed her. She succumbed to a series of infections that
the
pre-penicillin world had no drugs to treat. Welcome to the future.
The era of antibiotics is coming to a close. In just a few generations
what
once appeared to be miracle medicines have been beaten into
ineffectiveness
by the bacteria they were designed to knock out.
Once scientists hailed the end of infectious diseases. Now the
post-antibiotic apocalypse is within sight.
Hyperbole? Unfortunately not. The highly serious journal, Lancet
Infectious
Diseases, in August posed the question itself, revealing the rapid
spread of
multidrug-resistant bacteria. "Is this the end of antibiotics?" it
asked.
Doctors and scientists have not been complacent, but the paper by
Professor
Tim Walsh and colleagues takes the anxiety to a new level.
The discovery of NDM 1
Last September, Walsh published details of a gene he had discovered,
called
NDM 1, which passes easily between types of bacteria called
enterobacteriaceae such as E coli and klebsiella pneumoniae and makes
them
resistant to almost all the powerful, last-line group of antibiotics
called
carbapenems.
A recent paper revealed that NDM 1 is widespread in India and arrived
there
as a result of global travel and medical tourism for, among other
things,
transplants, pregnancy care and -cosmetic surgery.
"In many ways, this is it," Walsh said. "This is potentially the end.
There
are no antibiotics in the pipeline that have activity against NDM
1-producing enterobacteriaceae. We have a bleak window of maybe 10
years,
where we are going to have to use the antibiotics we have very wisely,
but
also grapple with the reality that we have nothing to treat these
infections
with."
And this is the optimistic view, based on the assumption that drug
companies
can and will get moving on discovering new antibiotics to throw at the
bacterial enemy.
Since the 1990s, when pharma found itself twisting and turning down
blind
alleys, it has not shown a great deal of enthusiasm for difficult
antibiotic
research. And besides, because, unlike heart medicines, people take
the
drugs for a week rather than for life and because resistance means the
drugs
become useless after a while, there just isn't much money in it.
Livermore, whose grandmother died for lack of infection-killing drugs
in
1945, is far from sanguine about the future. "A lot of modern medicine
would
become impossible if we lost our ability to treat infection," he says.
He is
talking about transplant surgery, for instance, where patients' immune
systems have to be suppressed to stop them rejecting a new organ,
leaving
them prey to infections and the use of immuno-suppressant cancer
drugs.
But it isn't just an issue in advanced medicine. Antibiotics are vital
to
abdominal surgery. "You safeguard the patient from bacteria leaking
into the
body cavity," he said. "If you lose the ability to treat these
infections,
far more people would die of peritonitis." Appendix operations would
carry
the same risk as they did before Fleming discovered penicillin in
1928.
Finding effective antibiotics
It may not be over yet, he said, but "we are certainly scraping the
bottom
of the barrel to find antibiotics that are effective against some of
the
infections caused by bacteria."
Studies show that the chances of dying from hospital pneumonia or
septicaemia (blood poisoning) are twice as high if the bacteria are
drug-resistant, rising in the case of pneumonia from 20% to 40%. For a
long
time now doctors have known they were in a race to stay a few steps
ahead of
the rapidly growing resistance of bacterial infections to antibiotics.
Ten years ago the so-called superbug MRSA caused front-page panic in
the
United Kingdom. Hospital patients were picking up Staphylococcus
aureus
infections that were resistant to the hitherto powerful antibiotic
methicillin.
All-out war, led by the UK government's former chief medical officer
Sir
Liam Donaldson, against MRSA and also C diff (Clostridium difficile)
has
reduced the threat of what are known as Gram-positive bacteria.
Hospital hygiene has been massively improved and, in response in part
to
public anxiety, pharmaceutical companies have put money into finding
new
antibiotics for those infections.
But it's like putting a finger in a hole in the dam, only to find the
water
surges out somewhere else. Bacteria are great survivors. The biggest
threat
now, experts believe, is from multi-drug-resistant Gram-negative
bacteria,
such as NDM 1-producing enterobacteriaceae and an enzyme called KPC
that has
spread in the United States (and in Israel and Greece) that also gives
bacteria resistance to the carbapenems, the most powerful group of
antibiotics we (once) had.
"It is a war of attrition. It is naive to think we can win," said
Livermore.
Controlling bacteria
The game now is to keep bacteria at bay. Hygiene is an obvious weapon.
Better cleaning, hand gels and stern warnings to staff and public
alike have
helped reduce infection rates in hospitals. But Professor Richard
James, the
director of the centre for healthcare associated infections at the
University of Nottingham in central England, warned that bugs don't
stay in
hospitals (indeed, the NDM 1-producing bacteria appear to be
widespread in
the community in India, passed on through contaminated water, in which
people bathe, wash clothes and also defecate).
"The worry is once these organisms are out in the community," said
James.
"There probably is some need for public education about infection and,
for
instance, kitchen hygiene."
Beyond that, there is a real need to conserve those antibiotics we
have. "To
me, it has many parallels with the problems of energy in economies
around
the world," he said. Carbon trading was dreamed up to try to conserve
oil
and reduce its pollutant effects.
There have now been a few papers suggesting a Pigouvian tax -- which
he
defined as one levied on an agent causing an environmental problem as
an
incentive to mitigate that problem -- for antibiotics.
Like oil, he said, antibiotic usefulness is finite. And the cost of
drug
resistance is not reflected in the price of the drug.
Such a tax would be worldwide and the proceeds could fund new drug
development. But should you tax life-saving drugs, especially in poor
countries? "If you don't do anything, there won't be any antibiotics
anyway," said James.
In the battle for survival of the fittest between humans and bacteria,
it
looks as though the best we are going to get is a draw -- if we are
lucky.
-- C Guardian News & Media 2010
SARAH BOSELEY | LONDON - Nov 09 2010 10:15
http://www.mg.co.za/article/2010-11-09-life-without-antibiotics
Just 65 years ago Dr David Livermore's paternal grandmother died after
an
operation to remove her appendix. It didn't go well, but it wasn't the
surgery that killed her. She succumbed to a series of infections that
the
pre-penicillin world had no drugs to treat. Welcome to the future.
The era of antibiotics is coming to a close. In just a few generations
what
once appeared to be miracle medicines have been beaten into
ineffectiveness
by the bacteria they were designed to knock out.
Once scientists hailed the end of infectious diseases. Now the
post-antibiotic apocalypse is within sight.
Hyperbole? Unfortunately not. The highly serious journal, Lancet
Infectious
Diseases, in August posed the question itself, revealing the rapid
spread of
multidrug-resistant bacteria. "Is this the end of antibiotics?" it
asked.
Doctors and scientists have not been complacent, but the paper by
Professor
Tim Walsh and colleagues takes the anxiety to a new level.
The discovery of NDM 1
Last September, Walsh published details of a gene he had discovered,
called
NDM 1, which passes easily between types of bacteria called
enterobacteriaceae such as E coli and klebsiella pneumoniae and makes
them
resistant to almost all the powerful, last-line group of antibiotics
called
carbapenems.
A recent paper revealed that NDM 1 is widespread in India and arrived
there
as a result of global travel and medical tourism for, among other
things,
transplants, pregnancy care and -cosmetic surgery.
"In many ways, this is it," Walsh said. "This is potentially the end.
There
are no antibiotics in the pipeline that have activity against NDM
1-producing enterobacteriaceae. We have a bleak window of maybe 10
years,
where we are going to have to use the antibiotics we have very wisely,
but
also grapple with the reality that we have nothing to treat these
infections
with."
And this is the optimistic view, based on the assumption that drug
companies
can and will get moving on discovering new antibiotics to throw at the
bacterial enemy.
Since the 1990s, when pharma found itself twisting and turning down
blind
alleys, it has not shown a great deal of enthusiasm for difficult
antibiotic
research. And besides, because, unlike heart medicines, people take
the
drugs for a week rather than for life and because resistance means the
drugs
become useless after a while, there just isn't much money in it.
Livermore, whose grandmother died for lack of infection-killing drugs
in
1945, is far from sanguine about the future. "A lot of modern medicine
would
become impossible if we lost our ability to treat infection," he says.
He is
talking about transplant surgery, for instance, where patients' immune
systems have to be suppressed to stop them rejecting a new organ,
leaving
them prey to infections and the use of immuno-suppressant cancer
drugs.
But it isn't just an issue in advanced medicine. Antibiotics are vital
to
abdominal surgery. "You safeguard the patient from bacteria leaking
into the
body cavity," he said. "If you lose the ability to treat these
infections,
far more people would die of peritonitis." Appendix operations would
carry
the same risk as they did before Fleming discovered penicillin in
1928.
Finding effective antibiotics
It may not be over yet, he said, but "we are certainly scraping the
bottom
of the barrel to find antibiotics that are effective against some of
the
infections caused by bacteria."
Studies show that the chances of dying from hospital pneumonia or
septicaemia (blood poisoning) are twice as high if the bacteria are
drug-resistant, rising in the case of pneumonia from 20% to 40%. For a
long
time now doctors have known they were in a race to stay a few steps
ahead of
the rapidly growing resistance of bacterial infections to antibiotics.
Ten years ago the so-called superbug MRSA caused front-page panic in
the
United Kingdom. Hospital patients were picking up Staphylococcus
aureus
infections that were resistant to the hitherto powerful antibiotic
methicillin.
All-out war, led by the UK government's former chief medical officer
Sir
Liam Donaldson, against MRSA and also C diff (Clostridium difficile)
has
reduced the threat of what are known as Gram-positive bacteria.
Hospital hygiene has been massively improved and, in response in part
to
public anxiety, pharmaceutical companies have put money into finding
new
antibiotics for those infections.
But it's like putting a finger in a hole in the dam, only to find the
water
surges out somewhere else. Bacteria are great survivors. The biggest
threat
now, experts believe, is from multi-drug-resistant Gram-negative
bacteria,
such as NDM 1-producing enterobacteriaceae and an enzyme called KPC
that has
spread in the United States (and in Israel and Greece) that also gives
bacteria resistance to the carbapenems, the most powerful group of
antibiotics we (once) had.
"It is a war of attrition. It is naive to think we can win," said
Livermore.
Controlling bacteria
The game now is to keep bacteria at bay. Hygiene is an obvious weapon.
Better cleaning, hand gels and stern warnings to staff and public
alike have
helped reduce infection rates in hospitals. But Professor Richard
James, the
director of the centre for healthcare associated infections at the
University of Nottingham in central England, warned that bugs don't
stay in
hospitals (indeed, the NDM 1-producing bacteria appear to be
widespread in
the community in India, passed on through contaminated water, in which
people bathe, wash clothes and also defecate).
"The worry is once these organisms are out in the community," said
James.
"There probably is some need for public education about infection and,
for
instance, kitchen hygiene."
Beyond that, there is a real need to conserve those antibiotics we
have. "To
me, it has many parallels with the problems of energy in economies
around
the world," he said. Carbon trading was dreamed up to try to conserve
oil
and reduce its pollutant effects.
There have now been a few papers suggesting a Pigouvian tax -- which
he
defined as one levied on an agent causing an environmental problem as
an
incentive to mitigate that problem -- for antibiotics.
Like oil, he said, antibiotic usefulness is finite. And the cost of
drug
resistance is not reflected in the price of the drug.
Such a tax would be worldwide and the proceeds could fund new drug
development. But should you tax life-saving drugs, especially in poor
countries? "If you don't do anything, there won't be any antibiotics
anyway," said James.
In the battle for survival of the fittest between humans and bacteria,
it
looks as though the best we are going to get is a draw -- if we are
lucky.
-- C Guardian News & Media 2010