Antibiotics, used to treat bacterial infections, are often regarded as one of the most important discoveries of modern medicine. But they are slowly losing their potency.
This phenomenon, known as antibiotic resistance, is happening because bacteria can evolve to withstand the medicines. This leads to infections being harder to cure, sometimes even impossible to eradicate. Such “superbugs” cause several thousand deaths a year in the UK, and over a million worldwide.
Now a new report from the National Audit Office has warned that the UK is set to miss most of the targets that it set in 2019 to tackle the problem. While there was a goal to cut drug-resistant infections in England by 10 per cent between 2018 and 2025, in fact, rates had risen by 13 per cent in 2023. So, what can be done?
Antibiotic resistance arises because the medicines are usually based on natural molecules that kill bacteria, made by other bacteria, fungi or plants, said Professor Stefano Pagliara at the University of Exeter.
Bacteria have therefore evolved ways of defeating antibiotics in a biological arms race that has been going on for billions of years. “They are older than us, they are wiser than us,” said Professor Pagliara. “They have a big advantage.”
What has changed is that some of these antibiotics are now being manufactured and unintentionally released into the environment in unprecedented quantities, because of their use in medicine and farming.
Antibiotics and antibiotic-resistant bacteria can be in sewage that gets into a river, for instance. “In some cases, the levels of antibiotics that we can measure in sewage or in river water is around those concentrations where there’s a risk,” said Professor William Gaze, a microbiologist at the University of Exeter.
If those bacteria get into someone’s body, perhaps through outdoor swimming, they can set up home. Surfers who use beaches where there is antibiotic-resistant E. coli – a faecal bacterium that can cause diarrhoea – are more likely to have this superbug living inside their own gut, research has found.
In that study, the surfers’ health wasn’t assessed. The bacteria may not have caused an illness immediately, but they could have gone on to cause an antibiotic-resistant infection later.
Superbugs contribute to 35,000 deaths a year in the UK and directly cause 7,600 of those, according to the National Audit Office. People tend to be unaware of the toll, though, as illnesses and deaths involving antibiotic resistance are not always described as such – they may instead be recorded as deaths due to sepsis or pneumonia, for instance.
Sepsis is a real problem because it can kill so fast. Usually, if doctors see their first choice of antibiotic isn’t working, they will try a second one. That delay may not matter for most medical conditions, but for sepsis, it can be deadly. “You’ll have organ failure within hours if it’s untreated,” said Professor Adam Roberts, a microbiologist at the Liverpool School of Tropical Medicine.
Even if it is not fatal, antibiotic resistance contributes to thousands of people’s medical conditions being harder to treat, causing suffering and disability.
People with diabetes, for instance, are prone to foot ulcers because of poor blood circulation. If the ulcer becomes infected with antibiotic-resistant bacteria, the foot may need to be amputated. People can also have repeated painful urinary tract infections, where superbugs form a colony inside the bladder that just cannot be eradicated.
The government has multiple strategies to combat antibiotic resistance, set out in a policy paper last year. Some of them will not be much noticed by the public – such as health bodies carrying out better “surveillance” systems so that antibiotic-resistant infections are tracked.
One strategy certainly gets noticed, though. It involves trying to persuade doctors and patients to avoid using antibiotics when they are unnecessary. The more an antibiotic gets used, the more resistance to it will increase.
One of the key battlegrounds is over antibiotics being given for coughs and colds – with respiratory infections accounting for six in ten antibiotic prescriptions in primary care, worldwide. Yet most coughs and colds are caused by viruses, which are unaffected by antibiotics, as the medicines only work against bacteria.
A throat virus can sometimes lead to a further infection with bacteria, though. NHS guidelines say that if someone’s symptoms seem severe, for instance if they have red and swollen tonsils or a fever, then antibiotics may be appropriate.
But it’s hard for GPs to know whether anyone has a viral or bacterial infection. If unsure, they may want to err on the side of caution – and they may also be influenced by patients who are convinced they need an antibiotic. “If there is any doubt about whether a patient will benefit from an antibiotic, they will generally do what they feel is safest and prescribe,” said Professor Alastair Hay, a primary care researcher at the University of Bristol.
Yet trying to avoid unnecessary antibiotics isn’t just good for the community – it can also reduce your personal chances of getting colonised by a superbug. People who have used an antibiotic are more likely to carry bacteria resistant to that medicine up to a year later, Professor Hay has found. “There are definitely good reasons for individuals to be careful about taking antibiotics,” he said.
And as bacteria can be passed between people living in the same house, it makes sense to encourage your family members to be similarly cautious about only using antibiotics when necessary, said Professor Roberts. “If [there is] resistance within that particular individual, there’s more chance of that spreading within the household community.”
Reducing our antibiotic use can only do so much, though. Another vital, longer-term tactic is to boost the rate at which new antibiotics are developed.
Resistance among bacteria to one drug means doctors have to switch to a newer one. But the number of new medicines coming to market has slowed since the heyday of their discovery in the 1950s, 60s and 70s. The antibiotic pipeline is often described as dwindling.
That’s partly because drug firms have been moving their research efforts to more profitable areas. Antibiotics are usually only used for a few days, in contrast to medicines for obesity or heart disease, which may need to be taken over a patient’s whole life.
To make matters worse, if a firm succeeds in developing a new antibiotic, health systems may deliberately not use it, to keep it in reserve until it is really needed. That will help to avoid resistance emerging and spreading.
There are efforts to get round these problems, though. One approach involves incentivising drug companies to return to the antibiotic sector, by paying them a fixed amount for new antibiotics per year, regardless of how many doses are used. NHS England began one such deal with two companies, Pfizer and Shionogi, in 2022, one of the first in the world.
Another option is for governments and other bodies to fund antibiotic research to be done by universities. This month, three health charities – the Gates Foundation, Wellcome and the Novo Nordisk Foundation announced a $50 million fund for this purpose.
But these kinds of strategies will take many years to come to fruition. In the meantime, the main ways that the public can reduce their risk are to avoid unnecessary use of the medicines, to take them as prescribed when they are needed, and to never take antibiotics prescribed for someone else.
And the simplest measure of all, said Professor Roberts, is hand washing. “Prevention of infection is probably the best thing that healthy adults and children can do.”
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