1 Introduction
1. The substances used to treat infections caused
by micro-organisms, killing the micro-organisms with minimal impact
on the host, are termed antimicrobials. Antibiotics are those
antimicrobial substances that target bacterial infections rather
than infections caused, for example, by viruses and fungi and
they have become an essential tool in modern medicine. We note
that, despite its title, the UK Five Year Antimicrobial Resistance
Strategy 2013-2018 focused principally on "antibiotic"
resistance rather than antimicrobial resistance. In light of this,
our report also focuses largely on antibiotic resistance. Medical
procedures, such as chemotherapy for the treatment of cancer and
invasive surgery, rely on the use of antibiotics and without them
modern medicine would be impossible. Dame Sally Davies, Chief
Medical Officer, postulated that the apocalyptic scenario would
be "when I need a new hip in 20 years, I will die of a routine
infection because we have run out of antibiotics".[1]
Attempts to tackle antimicrobial
resistance
2. Alexander Fleming, in his 1945 lecture for the
Nobel Prize for discovering penicillin, warned that micro-organisms
could develop resistance to antibiotics.[2]
His prediction proved to be correct. Over the past two decades,
several attempts have been made to tackle the consequences of
antimicrobial resistance at both national and international levels.
In 1998, the House of Lords Science and Technology Committee conducted
an inquiry on Resistance to antibiotics and other antimicrobial
agents.[3] The Committee
described its inquiry as "an alarming experience, which leaves
us convinced that resistance to antibiotics and other anti-infective
agents constitutes a major threat to public health, and ought
to be recognised as such more widely than it is at present".[4]
3. Following this report, the Government produced
its UK Antimicrobial Resistance Strategy and Action Plan
in 2000.[5] This Strategy
had two key objectives:
i) to minimise the morbidity and mortality due
to antimicrobial resistant infection;
ii) to maintain the effectiveness of antimicrobial
agents in the treatment and prevention of microbial infections
in man and animals.
The 2000 Strategy document also set out three key
strategic aims:
i) Surveillance:
to monitor "how we are doing", and provide the data
on resistant organisms, illness due to them and antimicrobial
usage necessary to inform action;
ii) Prudent
antimicrobial use: to reduce the "pressure for resistance"
by reducing unnecessary and inappropriate exposure of micro-organisms
to antimicrobial agents in clinical practice, veterinary practice,
animal husbandry, agriculture and horticulture; and
iii) Infection
control: to reduce the spread of infection in general (and thus
some of the need for antimicrobial agents) and of antimicrobial
resistant micro-organisms in particular.
In a follow-up to its 1998 inquiry, published in
2001,[6] the House of Lords
Committee stated that it was "encouraged at the tangible
progress which has been made" but stressed that there remained
"much more to do, particularly in bearing down on MRSA [Methicillin
Resistant Staphylococcus Aureus] and other resistant infections
in hospitals and community settings, and in bridging gaps and
incompatibilities in surveillance".
4. In September 2013, under the sponsorship of the
CMO, the Department of Health and the Department for Environment,
Food and Rural Affairs jointly published the UK Five Year Antimicrobial
Resistance Strategy 2013 to 2018 ("the Strategy").[7]
This document set out action points in seven "key areas":
i) improving
infection prevention and control practices in human and animal
health;
ii) optimising
prescribing practice;
iii) improving
professional education, training and public engagement;
iv) developing
new drugs, treatments and diagnostics;
v) better
access to and use of surveillance data in human and animal sectors;
vi) better
identification and prioritisation of AMR research needs to focus
activity and inform our understanding of AMR; and
vii) strengthened
international collaboration.
The Strategy was informed by the World Health Organisation
(WHO)'s "Global Strategy for the Containment of Antimicrobial
Resistance"[8] (2001),
and its 2012 follow-up "Options for Action"[9]
document, which focused on "five of the most important areas
for the control of antibiotic resistance as recognized in the
WHO 2001 strategy, which are: surveillance, rational use in humans,
rational use in animals, infection prevention and control, and
innovations".[10]
The "Action plan against the rising threats from Antimicrobial
Resistance", published by the European Commission in November
2011, also served to inform the Government's Strategy.[11]
5. While this report was being drafted the Prime
Minister announced an independent review to "explore the
economic issues surrounding antimicrobial resistance". The
review will be co-funded by the Government and the Wellcome Trust
and the Prime Minister said that he wanted "to see a stronger,
more coherent global response, with nations, business and the
world of science working together to up our game in the field
of antibiotics". The review, to be conducted by Jim O'Neill,
an economist who, until 2013, was Chairman of Goldman Sachs Asset
Management will present its initial findings in 2015 with a final
report and recommendations to follow in 2016. The review will
set out a plan for encouraging and accelerating the discovery
and development of new generations of antibiotics, and will examine:
The development, use and regulatory environment
of antimicrobials, especially antibiotics, and explore how to
make investment in new antibiotics more attractive to pharmaceutical
companies and other funding bodies.
The balance between effective and sustainable
incentives for investment, and the need to conserve antimicrobial
drugs so they remain effective for as long as possible.
How governments and other funders can stimulate
investment in new antimicrobials and timeframes and mechanisms
for implementation.
Increasing international cooperation and
support for action by the international community, including much
closer working with low and middle income countries on this issue.
We welcome this review and the leadership shown by
Dame Sally Davies. We comment later in the report on our own
conclusions about the economic difficulties associated with the
production of new antimicrobial treatments. We look forward to
hearing more detail on the review and how it will be conducted.
Our inquiry
6. When the Strategy was published by the Government
in September 2013,[12]
we wanted to ensure that it would be fit for purpose and sought
written evidence on the following terms of reference:
· How
has antimicrobial resistance developed in the past decade?
· What
are the gaps in our knowledge about antimicrobial resistance?
· Is there
sufficient research and investment into new antibiotics or other
treatments and methods to ensure continued protection against
infection? If not, how could this be rectified?
· What
measures (including behavioural change) have been most effective
in controlling the spread of resistant pathogens, and could such
measures be used to control other pathogens?
· What
global coordination and action is required to fight antimicrobial
resistance and is the UK contributing enough towards cross-border
initiatives?
· What
are the strengths and weaknesses of the Government's 2013-2018
strategy for tackling antimicrobial resistance? What changes might
be made to further strengthen the Government's action plan?
We received 70 submissions of written evidence and
held five oral evidence sessions with themed sessions focusing
on the science of antimicrobial resistance, clinical issues, alternative
approaches, animals, research and development of antimicrobials,
culminating in a final evidence session with civil servants and
the Ministers from the Department of Health and Department for
the Environment, Food and Rural Affairs. We would like to thank
everyone for their contribution to this inquiry.
1 Oral evidence taken before the Science and Technology
Committee on 23 January 2013, HC 921-i (2012-13), Q44 Back
2
Alexander Fleming, Penicillin, Nobel Lecture, 11 December
1945, accessed June 2014 http://www.nobelprize.org/nobel_prizes/medicine/laureates/1945/fleming-lecture.pdf Back
3
House of Lords, Resistance to Antibiotics, Seventh Report
of the Select Committee on Science and Technology, Session 1997-98,
HL 151 Back
4
House of Lords, Resistance to Antibiotics, Seventh Report
of the Select Committee on Science and Technology, Session 1997-98,
para 11.1 Back
5
Department of Health, UK Antimicrobial Resistance Strategy
and Action Plan, June 2000, p.5-6 Back
6
House of Lords, Resistance to Antibiotics, Third Report
of the Select Committee on Science and Technology, Session 2000-2001,
HL 56, para 36 Back
7
Department of Health, Department of Rural Affairs, UK Five
Year Antimicrobial Resistance Strategy 2013 to 2018, September
2013, para 3.10 Back
8
World Health Organization, Global Strategy for Containment
of Antimicrobial Resistance, 2001 Back
9
World Health Organization, The evolving threat of antimicrobial
resistance. Options for action, 2012 Back
10
World Health Organization, The evolving threat of antimicrobial
resistance. Options for action, 2012, p.2 Back
11
European Commission, Communication from the Commission to the
European Parliament and the Council, Action plan against the
rising threats from Antimicrobial Resistance, November 2011 Back
12
Department of Health, Department of Rural Affairs, UK Five
Year Antimicrobial Resistance Strategy 2013 to 2018, September
2013 Back
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