Antibiotics Back in the Spotlight
When the general public are asked to name a kind of medicine, antibiotics are likely to be the first thing they say. Antibiotics and specifically antibacterials are ubiquitous and are a cornerstone of improving health worldwide. Antibacterials have played a huge role in the doubling of life expectancy that has been witnessed worldwide since the early 20thcentury. In an age of personalised medicine and next-gen pharmaceuticals, it is perhaps surprising that they remain as relevant now as they were at their introduction.
In 2005 Barry Marshall received the Nobel Prize in Physiology or Medicine for his demonstration that stomach ulcers are caused by Helicobacter pylori and so stomach ulcers can be treated with a course of antibiotics. In 2013, a team from the University of Southern Denmark demonstrated that 20-40% of cases of chronic lower back pain are caused by bacterial infections (primarily Propionibacterium acnes, the bacterium linked to acne). These infections cause painful inflammation and small fractures in the spinal vertebrae. The treatment of chronic back pain can involve surgery, which this finding has shown may be unnecessary in some cases.
The group demonstrated that the infection (and consequently the pain) can be treated by a relatively long 100-day course of antibiotics. The location of the bacteria in a rather biologically inaccessible area requires this length of treatment to be effective. However there is some concern over the hot button issue of antibiotic resistance. There may be 500,000 or more cases just in the UK which will be amenable to antibiotic treatment. This will certainly result in many millions of people living better pain-free lives, but correct diagnosis must be considered paramount in ensuring that already over-prescribed antibiotics are not stretched even further.
This year the UK’s Chief Medical Officer Dame Sally Davies said that antibiotic resistance should be considered as a potential national emergency. Methicillin Resistant Staphylococcus aureus MRSA and Multi Drug Resistant Tuberculosis MDR-TB are already recognised as considerable risks, however lack of compliance during drug treatments and inappropriate treatment with antibiotics (e.g. for flu) continues to contribute to an already serious situation. In the UK government’s report on the subject Infections and the Rise of Antimicrobial Resistance, the top 10 tips for prescribing antibiotics:
- Institute antibiotic treatment immediately in patients with life-threatening infection.
- Prescribe in accordance with local policies and guidelines, avoiding broad-spectrum agents.
- Document in the clinical notes the indication(s) for antibiotic prescription.
- Send appropriate specimens to the microbiology lab; drain pus and remove foreign bodies if indicated.
- Use antimicrobial susceptibility data to de-escalate/ substitute/add agents and to switch from intravenous to oral therapy.
- Prescribe the shortest antibiotic course likely to be effective.
- Always select agents that minimise collateral damage (i.e. selection of multi-resistant bacteria/C. difficile).
- Monitor antibiotic levels when needed (e.g. vancomycin).
- Use single-dose antibiotic prophylaxis wherever possible.
- Consult your local infection experts.
In the report, emphasis is put not only on the development of new treatments, but also on the development of diagnostic and surveillance technologies and procedures to ensure that the full extent of the problem is known and to allow for better targeting of resources to tackle the problem.
Dame Sally Davies has called for greater research into creating new antibiotics and importantly, for this research to then be translated into commercially available treatments. Many groups around the world are working on creating new antimicrobial treatments, but the feeling is that there has been a lack of public-private partnerships to apply this research to drug development.
One intriguing piece of research published this year in the open access journal PLOS ONE may lead to a treatment which lowers the resistance of S. aureus to methicillin and other treatments. The group found that a complex found in human breast milk called Human Alpha-lactalbumin Made Lethal to Tumor cells (HAMLET) induced sensitisation of even resistant bacteria to treatment with antibacterials that they normally demonstrate resistance to.
This problem will not go fade away; it will only grow insidiously like the bacteria which cause it. A silver bullet will not be enough to fix it; only the coordinated efforts of governments, industry, researchers and healthcare services will be enough to prevent disaster.