Ensuring access to working antimicrobials - Science and Technology Committee Contents

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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Prepared 7 July 2014