E-DRUG: Antibiotic resistance: Inventing new ones or reviving old ones?
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Dear E-druggers,
It is an old story, the almost universal appeal to discover and market new
antibiotics because the old ones have become useless. For many years
industry has produced and pushed new and "me-too" antibiotics (i.e.,
cephalosporins) on a worldwide scale and now seems to have reached the end
of the line. Bacteria have become cleverer in developing resistance and new
problems (Klebsiella, Enterococci) replace the scare of MRSA. When one looks
back at the history of the development of antibiotics it is quite obvious
that the solution does not lie in producing more or different antibiotics.
There are many ways in which the situation can be changed for the better.
The keyword is prevention rather than cure. A number of sources of the
development of resistance can be defined. The first one is keeping powerful
antibiotics - perhaps even all available antibiotics out of the hands of
people who want quick results and have no idea of the havoc they are
creating by their ignorance. This automatically means educating all
practitioners authorized to prescribe drugs at a very early stage (when
students) what antibiotics can achieve and what these drugs cannot. It means
prohibiting delivery of antibiotics without proper prescription issued by an
accordingly educated physician. For pharmacists it means refusing providing
antibiotics to patients when no medical prescription can be submitted and
warning patients against hoarding outdated drugs. For hospitals it means
limiting the number of available antibiotics to those appropriate to the
local hygiene and bacterial sensitivity patterns.
It also means prohibiting the inappropriate inpatient use of antibiotics
outside strict protocols and formularies. An important source of resistance
is the inappropriate and random prophylactic use of powerful (especially
when "reserve") antibiotics in surroundings where infection prevention and
modern hospital hygiene are substandard. Antibiotics are no substitute for
cleanliness.
In the European context there are great differences between the countries in
the North and Northwest, and the Mediterranean countries, especially Greece,
Italy, Portugal, and to some extent Spain, where inappropriate and
indiscriminate use of antibiotics is still widespread. With the increase in
mass tourism - including tourists returning from the North and Northeast
African region, lately also Asia and parts of Africa and South America - the
threat of introducing new sorts of bacterial resistance to hospitals with no
appropriate facilities to cope with such problems. Often drastic and
expensive measures like isolation of patients coming from such regions have
to be taken.
The main keyword in preventing resistance is therefore education, preferably
by clinicians who not only have looked at Petri dishes, but also know from
practical experience what the consequences of untreatable, often lethal,
infections can be. Education "from the sideline" by laboratory
bacteriologists and pharmacists is simply not effective enough.
The second issue - fortunately increasingly in the focus of the media - is
the indiscriminate use of antibiotics in veterinary medicine as an important
source of producing and spreading dangerous and untreatable bacterial
strains. This is largely a political and financial issue, but governments to
tend to be too slow or even inert in tackling this problem. The Scandinavian
countries have shown that profitable agriculture is possible without such
misuse. Some countries now only admit pig farmers to hospitals when full
isolation facilities are available: Like putting the cart before the horse!
Why are chickens no longer safe foods unless properly cooked or roasted? Why
does industry continue selling tonnes of powerful antibiotics for this
purpose, but at the same time claiming that it is unable to provide new ones
for human use? I don't know the answer but as a medical practitioner one
feels rather powerless.
My own life has several times been saved by "old" antibiotics and I remain
grateful for the role industry has played in the past. Unfortunately a
proper pharmacological solution now seems out of reach. It is not too late
for the medical community to take up the gauntlet.
Regards
Dr. Leo Offerhaus,
Bussum,
the Netherlands
offerhausl@euronet.nl