Open thread: Antibiotic resistance

I frequently see interesting stories about antibiotic resistance, and it seems to be quite an important issue. Back in 2008, I wrote about a Canadian initiative to try to deal with the dangerous bugs.

More recently, tuberculosis has progressed from extensively drug-resistant TB (XDR-TB) to “totally drug-resistant TB” (TDR-TB).

We are going to need some new antibiotics.

Author: Milan

In the spring of 2005, I graduated from the University of British Columbia with a degree in International Relations and a general focus in the area of environmental politics. In the fall of 2005, I began reading for an M.Phil in IR at Wadham College, Oxford. Outside school, I am very interested in photography, writing, and the outdoors. I am writing this blog to keep in touch with friends and family around the world, provide a more personal view of graduate student life in Oxford, and pass on some lessons I've learned here.

29 thoughts on “Open thread: Antibiotic resistance”

  1. Ancient antibiotic-resistant bacteria found in isolated cave

    Bacteria that have never before come in contact with humans, their diseases or their antibiotics, but are nevertheless resistant to a variety of antibiotics, have been discovered in a U.S. cave.

    “This supports a growing understanding that antibiotic resistance is natural, ancient,” and an integral part of the genetic heritage of microbes, suggest researchers from McMaster University in Hamilton, Ont. and the University of Akron in Akron, Ohio, in a new study published this week in the journal PLoS ONE.

    Scientists have long debated the relative roles of humans and nature in the evolution and spread of antibiotic-resistant bacteria, which can pose a serious problem in the treatment of diseases.

    In order to figure out how ancient and naturally widespread antibiotic resistance is, some researchers have been trying to study bacteria in environments highly isolated from human activity, such as a part of Lechuguilla Cave in Carlsbad Cavern National Park in New Mexico. It has been cut off from any input from the surface for four million to seven million years. The area is so deep and difficult to access that researchers had to camp there while collecting samples, said a news release from McMaster University.

  2. Untreatable gonorrhoea spreading around world: WHO

    (Reuters) – Drug-resistant strains of gonorrhoea have spread to countries across the world, the U.N. health agency said on Wednesday, and millions of patients may run out of treatment options unless doctors catch and treat cases earlier.

    Scientists reported last year finding a “superbug” gonorrhoea strain in Japan that is resistant to all recommended antibiotics and warned then that it could transform a once easily treatable infection into a global health threat.

    The World Health Organisation (WHO) said those fears are now reality, with many more countries around the world, including Australia, France, Norway, Sweden and Britain, reporting cases of the sexually transmitted disease resistant to cephalosporin antibiotics – normally the last option for drugs against gonorrhoea.

  3. Superbug Blog >> Drug-Resistant Gonorrhea: WHO Agrees It’s An Emergency

    The World Health Organization has weighed in on the growing threat from antibiotic-resistant gonorrhea, saying in a statement this morning (emailed, and apparently not online):

    “Millions of people with gonorrhoea may be at risk of running out of treatment options unless urgent action is taken, according to the World Health Organization (WHO). Already several countries, including Australia, France, Japan, Norway, Sweden and the United Kingdom are reporting cases of resistance to cephalosporin antibiotics — the last treatment option against gonorrhoea. Every year an estimated 106 million people are infected.”

    The statement arrived as an adjunct to the launch of the WHO’s new global action plan for controlling the spread of resistant gonorrhea.

    If you’ve been reading here for a while, the problem of resistant gonorrhea won’t be new to you. (Here are some past posts on data from the CDC and a call to action in the New England Journal of Medicine, along with a piece I wrote in Scientific American and a separate post by my SciAm editor Christine Gorman.) But in case you’ve just come in:

    Since the late 1990s, a very small group of researchers worldwide has been sounding the alarm about gonorrhea becoming resistant to the last group of drugs, cephalosporins, that can cure the disease in an outpatient setting. That is, the drugs can be given by mouth and usually take a single dose or a small number of doses to effect a cure. Those requirements are important because they are the conditions on which community-clinic STD control is based. Community programs — single visits to low-cost clinics where drugs are dispensed relatively quickly — is what keeps the cost of STD control from spinning into unaffordability.

  4. Drugmakers and antibiotics
    The path of least resistance
    Governments reckon that drug firms’ research efforts need a shot in the arm

    A GROWING worry in medicine is bugs’ increasing resistance to antibiotics. At AstraZeneca’s research centre near Boston, scientists toil to find new weapons. Machines screen thousands of drugs each year, robotic arms nimbly handling plates of compounds to test their effect on bacteria. But progress is slow. “It is not our hottest area in terms of commercial return,” admits Martin Mackay, AstraZeneca’s research and development chief.

    Help is on the way. On May 8th the European Commission and Europe’s pharmaceutical association gave details of a plan to boost antibiotics research by up to €590m ($760m). The same day in America, a congressional committee weighed measures with a similar goal. The attention is welcome. Its effect is less clear.

  5. The report is more worrying on the subject of antibiotics. These wonder-pills have saved more lives than almost any other invention. But there are signs that they are losing some of their potency, thanks in part to rampant overuse. The number of infections that are resistant to treatment by antibiotics is on the rise, a problem that may cost America’s health system between $21 billion and $34 billion a year. And the pace of development of new antibiotics is slowing, as drug firms shift their attention to chronic illnesses such as diabetes and hypertension or to new technologies such as nanotechnology.

    The report argues that it should be much harder to get hold of antibiotics. Consider China, where many hospitals make much of their income from selling the drugs they prescribe. One study found that 98% of children with the common cold at a Beijing hospital were given antibiotics—which are useless for treating viral infections. In India strong antibiotics are sold without a prescription. Almost everywhere antibiotics are overused in farming fish and livestock. The WEF also argues that companies and non-profits need to collaborate more to develop more drugs. GlaxoSmithKline and the Bill & Melinda Gates Foundation have both acted as pioneers here through their “open lab” approach to research. Glaxo has opened its Tres Cantos research facilities to academic and government scientists in order to collaborate on discovering new antibiotics. The Gates Foundation has organised an accelerator programme that brings together research teams from academia and private companies such as Abbott Laboratories, AstraZeneca, Bayer, Eli Lilly and Glaxo.

  6. Neisseria gonorrhoeae is another bug that has repeatedly developed resistance to antibiotics. When penicillin was first introduced it worked very well against gonorrhoea. When its effectiveness began to fall, it was replaced by tetracyclines. Those gave way to fluoroquinolones, and those, in turn, to cephalosporins. Now, some strains can be tackled only with a combination of ceftriaxone, a cephalosporin, and azythromicin, an azalide. There is nothing else in the locker.

    Humans are not the first of Earth’s creatures to want to kill bugs. Fungi don’t make penicillin for fun, they do it to protect themselves from certain bacteria. The existence of these natural bug-killers has been a great help to human medicine; many of the 20-odd classes of antibiotic used medically are derived from them. But it also means that today’s bugs are not facing entirely new threats. There are often resistance genes tailored to abiding threats lurking, at a low level, in bacterial populations, waiting for their hour to come.

    There are reasons for drug firms not to invest in antibiotics. Such companies increasingly prefer treatments for chronic diseases, not acute ones; the customers stick around longer. And despite the growing problem of resistance, most antibiotics still work for most things most of the time. Given that the incumbents are also cheap, because they are off-patent, new drugs cannot earn back their development costs. Even if they could, it would be poor public policy to let them; much better for new drugs to be used only sparingly, to forestall the development of further resistance. That further puts the kibosh on sales.

  7. Losing antibiotics is a global threat

    THE UNITED Nations General Assembly will hold its first high-level meeting Wednesday on the growing problem of antimicrobial resistance — the tendency of bacteria to fight back against antibiotics. This is a rare example of the world body devoting time to a public-health issue, and though concrete results may be a long way off, the event itself suggests a stirring awareness that it is a global threat.

  8. Doctors are warning that the rise of an almost untreatable superbug, immune to some of the last-line antibiotics available to hospitals, poses a serious threat to patients.

    The number of lab-confirmed cases of the bug, called carbapenemase-producing Enterobacteriaceae (CPE), rose from three to nearly 2,000 in the 12 years to 2015, according to Public Health England (PHE). But that may be far short of the real number because hospitals are not compelled to report suspected cases. PHE admits it does not know where the infections are coming from or how many people are dying.

  9. CPE, dubbed the “nightmare bacteria” by Tom Frieden, former head of the Centers for Disease Control and Prevention in the USA, has developed resistance to the carbapenems, a group of “last resort” antibiotics that are used in serious infections when other drugs will not work. They include KPC (Klebsiella pneumoniae carbapenemase) and NDM (New Delhi Metallo-beta-lactamase)

  10. In India the average consultation lasted three minutes, a quarter as long as in OECD countries. A third lasted less than a minute and involved no examination and just one question from the clinician: “What’s wrong with you?” The correct treatment was given in 30% of cases, and unnecessary or harmful treatment in 42%.

    Patients fare little better in China. A team led by Sean Sylvia of Renmin University of China sent standardised patients to clinics in Shaanxi province. Health workers spent an average of 96 seconds with patients. They gave a correct diagnosis in just 26% of cases, and an outright wrong one in 41%. Inept treatment is not because providers are too busy. According to the World Bank, in India, Kenya, Senegal and Tanzania each one sees just eight to ten patients a day. Those in India spent just 40 minutes a day on average seeing patients.

    A better explanation starts with the fact that many clinicians have received little training and do not know what they are doing. In India and China more medical training is (reassuringly) associated with making fewer mistakes. And a recent Kenyan study using standardised patients found that clinicians in Nairobi made “significantly better” diagnoses than Indian and Chinese ones, who had less training.

    In China, for example, until recently doctors often shared in the revenues from prescriptions. That led to rampant overuse of antibiotics. Chinese studies by Janet Currie, of Princeton University, and Wanchuan Lin, of Peking University, used standardised patients with flu-like symptoms who, since their symptoms suggested they were suffering from a virus, did not need antibiotics. Yet 63% of doctors prescribed them. That fell to 43% when patients mentioned that they had read that antibiotics are not always suitable in such cases—and to 12% when they said they would buy the antibiotics from a relative’s pharmacy.

  11. Why Dutch hospitals are so good at beating superbugs

    The hospital has yet to see its first Ebola case. Isolation rooms like this one, sprinkled through its wards, have long been used for the kinds of patients who in other European countries are often in open-plan wards: those who harbour superbugs like mrsa (short for methicillin-resistant Staphylococcus aureus), a bacterium resistant to several widely used antibiotics. Here, as in other Dutch hospitals, some patients are even quarantined pre-emptively until tests for such bacteria come back negative. Suspects include workers on animal farms and those who have recently stayed in a hospital abroad. When an unexpected mrsa case is found on a ward, everyone who has been near that patient, including health workers, is tested.

    This “search and destroy” approach to superbugs is a Dutch speciality, though variations are also used in the Nordic countries. It helps explain why the Netherlands has the second-lowest mortality from infections resistant to antibiotics in the eu, after Estonia (see chart). As Rosa van Mansfeld, who oversees infection prevention at vumc, points out, when mrsa outbreaks sweep through German hospitals, they stop at the Dutch border. That is no small feat. In 2016 about 30,000 patients crossed that border to get health care.

    The rest of Europe is looking to the Netherlands as superbugs scarier than mrsa, once rare, are spreading fast. They include cre (for carbapenem-resistant Enterobacteriaceae), gut bacteria resistant to the last-resort antibiotics that are deployed when all else has failed. cre blood infections are deadly in about 50% of cases, compared with 10-30% for mrsa. In Europe, the prevalence of superbugs is particularly high in Greece, Italy and Romania, but international travel has put other countries on notice. Even in the Netherlands, which has used antibiotics prudently for decades, the prevalence of some superbugs in the general population has almost doubled in the past five years.

  12. But the most promising idea is for drugs firms to change how they charge governments and health insurers for antibiotics, by switching to a Netflix-style subscription model. Just as Netflix subscribers pay the same each month, whether they binge-watch boxsets all day or watch nothing at all, so health-care providers would pay a flat rate for access to an antibiotic, regardless of the volume. When the drug is new and being saved as a last line of defence, the drugs company still gets paid. And if the antibiotic has to be more widely used, the price does not go up. It may sound crazy, but subscriptions are already being tried in America to pay for hepatitis c drugs. Using this model for antibiotics can square the circle of incentivising drugs companies to develop a treatment that doctors will then try to use as little as possible.

    This will not solve antibiotic resistance all on its own. Reducing the misuse of existing antibiotics, in medicine and agriculture, is also necessary. And more could be done to improve sanitation and processes, in hospitals and elsewhere, to minimise the risk of infection in the first place. Fixing the pricing model is not a silver bullet, then. But it is a vital part of the answer.

  13. At the moment, the standard treatment for drug-resistant tb involves taking highly toxic medicaments for as long as two years. A patient may have to swallow as many as 20 pills a day, and receive injections with nasty side-effects, such as permanent deafness. Even this regime, however, has a cure rate of only 25-50%. But shorter and safer drug combinations tested in recent years are now being introduced.

    They may get shorter still. In August America’s drug regulator approved pretomanid, a medicine developed by the tb Alliance, a non-profit organisation with a research centre in South Africa’s capital, Pretoria, after which the drug is named. Used in combination with other drugs, pretomanid shortens treatment of the most drug-resistant forms of tb to just six months, with an 89% success rate and no injections. Trials are now under way to check whether simpler regimens that include pretomanid can work for strains of tb that are resistant to fewer of the standard drugs.

  14. Tests on bacteria collected from patients showed that halicin killed Mycobacterium tuberculosis, the bug that causes TB, and strains of Enterobacteriaceae that are resistant to carbapenems, a group of antibiotics that are considered the last resort for such infections. Halicin also cleared C difficile and multidrug-resistant Acinetobacter baumannii infections in mice.

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