Antimicrobial resistance Contents

Introduction

1.Antimicrobial resistance (AMR) poses a grave threat to health. Professor Dame Sally Davies, the Chief Medical Officer, told our inquiry quite simply that if action is not taken to address this growing threat, ‘modern medicine will be lost’.1

The “bedrock of modern medicine”

2.We heard that before the discovery of antibiotics and other antimicrobial2 treatments, 43% of people died from infections, and life expectancy was on average 20 years lower.3 Since antibiotics first came into widespread use in the 1940s, they have played an increasing role in underpinning modern medicine, being described as ‘the bedrock of many of the greatest medical advances of the 20th century’.4 Antimicrobial treatments have a key role in tackling infections–making common but previously life threatening illnesses such as TB, pneumonia and malaria treatable. Before their advent even a simple cut had the potential to kill if it became infected. Antimicrobials play a far wider supporting role in medicine than this, making it possible to carry out life-changing surgery safely–from hip replacements to organ transplants—and making childbirth far safer for both mother and baby. Cancer patients often depend on antimicrobial medicines to protect them whilst their immune systems are weakened by chemotherapy. Without effective antimicrobial treatments, we face a “being cast back into the dark ages of medicine”,5 where simple infections will once again kill people, and people will be faced with agonising decisions over whether or not to have cancer treatment or surgery, as risks of death through infection may outweigh the benefits of treatment.

What is AMR and what causes it?

3.Current antimicrobial treatments are becoming less effective because bacteria and other pathogens have evolved resistance to the medicines used to treat them, through processes of spontaneous genetic mutation and natural selection. The development of AMR is an inevitable and expected development–indeed it was predicted by Alexander Fleming, the scientist who discovered antibiotics, over 70 years ago.

4.The eventual development of resistance is inevitable, but the speed at which it develops is accelerated by excessive, inappropriate and unnecessary use of antimicrobial treatments. Antimicrobial use is rising across the world, with global consumption of antibiotics increasing by nearly 40% between 2000 and 2010, increasing the rate at which resistance is developing. International travel has created new opportunities for antimicrobial-resistant diseases to be spread globally.6 Evidence also suggests that far more antimicrobials are used than need to be, both in the UK and abroad. Although only 10 per cent of sore throats benefit from antibiotic treatment, as most are viral, antibiotics are still prescribed in as many as 60 per cent of cases.7 A recent study found that nearly a third of antibiotics prescribed by doctors in the US were prescribed for conditions that do not respond to antibiotics, translating to 47 million unnecessary prescriptions each year.8 In some countries, antimicrobial medicines are available without a prescription at all.

5.Antimicrobial resistance can also develop in animals and the environment. Over 40% of the UK’s total antibiotic use is in animals.9 In some countries antibiotics are widely used in farming both for growth promotion and to prevent infection, with antibiotics either being used to prevent infection developing, or being given to a whole herd or flock when one animal develops an infection, rather than isolating and treating only the affected animal.

6.Although antimicrobial resistance has been developing since the introduction of antimicrobial medicines, clinical problems have emerged relatively recently, and are escalating. Until the end of the 1980s, so many new types of antimicrobial medicines were being discovered that when an infection became resistant to one drug, alternatives were usually available. However, the era of rapid drug discovery has now come to an end, partly because the ‘easy discoveries’ have already been made and partly because the business model for antimicrobials does not incentivise the pharmaceutical companies to invest in drug discovery in this area. This issue is discussed in more detail in Chapter 2. Many of the medicines used to treat infections are based on chemical structures discovered 30 or more years ago.

7.Action to tackle the growing threat of AMR therefore needs to be on two fronts–firstly through reducing the inappropriate use of existing antimicrobials to preserve their effectiveness for longer and slow the development of AMR, through more targeted prescribing and action to prevent infections in the first place; and secondly through the development of new antimicrobial treatments.

The scale of the problem

8.Antimicrobial-resistant infections currently claim at least 50,000 lives each year across Europe and the US alone, and 700,000 lives globally–but these figures are set to rise dramatically over the next 30 years. The estimate of global mortality from AMR across the world by 2050 is a staggering 10 million per year. This would represent a greater death toll than cancer and diabetes combined.10

9.While in developed health systems it is currently often possible to access alternative second or third line treatments when patients develop a resistant infection, mortality rates and costs of treatment are likely to be approximately double for a drug-resistant infection, generating an estimated cost to the NHS of £180 million per year.11 Especially in poorer countries there is a growing prevalence of drug resistant strains of TB and malaria, increasing danger to individuals and communities as well as the cost burden of dealing with those critical diseases.12

10.Public Health England publishes data on resistance rates in key infections, including E coli, K. pneumonia, K. oxytoca and Pseudomonas SPP.13 The most recent data shows that for all of these, the percentage of cases involving antibiotic resistance was higher in 2016 than 2012:

11.Gonorrhoea has developed resistance to all classes of antibiotics used to treat the infection.

In the past year cases of multi-drug resistant gonorrhoea—for which there is no effective treatment—have been detected in the UK and elsewhere.

Previous action to tackle AMR

12.The Government launched its five year UK strategy to tackle antimicrobial resistance in September 2013.14 The strategy takes a ‘one health’ approach, addressing AMR in humans, animals and the environment. A number of Government departments and agencies are involved in steering and delivering the strategy, which is led by PHE, DHSC and DEFRA. The Government’s assessment of its progress against seven key areas for future action is set out in its written evidence.15 Around the same time as the strategy was published, the House of Commons Science and Technology Committee launched an inquiry into AMR, focusing on whether the proposals would contribute enough to tackling this threat. Its report16 and the Government’s response to its recommendations were published in 2014.17 Also in 2014, the then Prime Minister announced an independent review of the issue, chaired by Lord O’Neill of Gatley. This report, published in 2016, looked beyond the UK and took a global view, made ten recommendations, many of which dovetail with the aims of the UK strategy. In response to the report, the Government set out five new ambitions, listed in their written evidence.18

Our inquiry

13.The Government’s updated AMR strategy, due to be published early in 2019, will be an opportunity to renew the impetus for tackling this extremely serious threat. We therefore call not just on the Department of Health and Social Care, but on the Government as a whole, to incorporate the recommendations of this report within the strategy. We intend to take follow up evidence from the Government shortly after publication of its strategy. This report makes recommendations in five key areas:


1 Q4

2 Antimicrobials refer to all chemicals (including heavy metals) and drugs that can kill microorganisms (bacteria, fungi, parasites and viruses). Antibiotics are a subset of antimicrobial drugs that kill or inhibit the growth of bacteria.

3 Q2

4 The Review on Antimicrobial Resistance (launch paper), Lord Jim O’Neill, December 2014, p3.

6 The Review on Antimicrobial Resistance (launch paper), Lord Jim O’Neill, December 2014, p4

7 What if antibiotics were to stop working? King’s Fund blog authored by Professor Dame Sally Davies, 2017

8 What if antibiotics were to stop working? King’s Fund blog authored by Professor Dame Sally Davies, 2017

9 Reducing UK antibiotic use in animals, Parliamentary Office of Science and Technology, October 2018

10 The Review on Antimicrobial Resistance (launch paper), Lord Jim O’Neill, December 2014, p5

11 Q2

12 The Review on Antimicrobial Resistance (launch paper), Lord Jim O’Neill, December 2014, p4

13 These are gram-negative bacteria that can cause septicaemia and pneumonia, and which are increasing in incidence in healthcare settings.

14 The UK strategy was developed collaboratively with the devolved administrations of the UK, and each of the devolved administrations has responsibility for its implementation within their own jurisdictions in relation to human health. The control of veterinary medicines, including is antimicrobials, is currently a reserved power, and the Department for Environment and Rural Affairs (Defra) has UK-wide responsibilities in relation to animal health

15 Department of Health and Social Care (AMR0043) paras 7–57

16 Science and Technology Committee, Ensuring Access to Working Antibiotics, July 2014

17 Government response, September 2014

18 Department of Health and Social Care (AMR0043) para 5




Published: 22 October 2018