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World Health Day on April the 7th highlighted the need for the development of new antibiotics to combat the ever-growing trend in drug resistance. In an exclusive interview for Govtoday, Director of antibiotic resistance at the Health Protection Agency, Dr David Livermore, speaks to Editor Scott Buckler about the increasing need to conserve antibiotics and the emergence of a new superbug

David can you explain more about the importance of conserving antibiotics?


Antibiotics have revolutionised medicine, curing classical diseases and protecting medical procedures that once would have been unthinkable owing to the infection risk.  The trouble is that as we use antibiotics we select the bacteria that have become resistant to them. In other words, we kill the sensitive bacteria and the resistant ones go on and infect further patients. For about 55 years, from the mid 1940s onwards, we managed to develop new antibiotics as quickly as bacteria were developing resistance.  More recently we have not done so well. ‘Gram-negative’ bacteria such as E. coli, Klebsiella and Acinetobacter- are developing resistance faster than we are creating new drugs. Against MRSA we have done rather better and there are treatment options becoming available. I believe there are two ways in which we can stop bacteria from becoming more resistant; firstly, we need to try to use our current antibiotics better, leading to less selection of resistance. This means not using an antibiotic when one isn’t needed and using the right one when one is needed. Secondly, we need to try to revitalise antibiotic discovery in order to develop new antibiotics.


Could you tell us more about the co-authored paper the HPA conducted with Cardiff University on the emergence of NDM-1?


The most powerful group of antibiotics are the carbapenems. For nearly twenty years now these antibiotics have worked effectively as a last line of defence. Gradually, though, we are seeing bacteria with resistance mechanisms which destroy carbapenems starting to emerge. One such type of resistance is NDM-1, an enzyme that destroys carbapenems.
Bacteria with NDM-1 are widespread in India and a few people who have travelled to India –mostly people who were hospitalised there– carried bacteria with NDM-1 back to the UK. This led us to collaborate with researchers in India and Pakistan looking at the distribution of NDM in their countries. The recent paper you are referring to, which was co-authored with Cardiff University, has been published in the Lancet Infectious Diseases and shows that, in New Delhi, bacteria carrying the gene that codes for NDM-1 can be found outside of hospitals in drains and within public water taps. What this means is that more people going into hospitals will be carrying resistant bacteria.
The big issue, with regards to India, is that it is a country undergoing rapid economic development and this is increasing healthcare expectations. Modern hospitals and complicated medical procedures are being carried out, however, this medical sophistication balances on an infrastructure where the sewers are not working. A hospital cannot isolate itself from the environment where the patients, staff and food are all coming in from outside, potentially carrying resistant bacteria.


Antibiotic resistance has risen sharply up on the World Health Organisation agenda. In India, there has been interest over NDM-1, and antibiotic resistance has entered the public and political arenas. It has now been decided that hospitals in India should have an antibiotic policy so that the most powerful antibiotics will be reserved on those with the most serious cases. The Indian government also are proposing to stop people being able to buy antibiotics over the counter.  All this is to be welcomed, for it should reduce the selection for resistance.
Not only is there research showing that there are bacteria with NDM-1 in the drainage system in Delhi, there is also evidence, from a recent study by the Health committee of the Delhi Municipal Council, that 20% of the tap water is also unfit for human consumption. There is also hard evidence, from a Swedish study, that tourists travelling to the Indian subcontinent return back home with antibiotic resistant bacteria in their gut, which fuels concern over the wider spread of resistance.


What guidance is been given to UK hospitals on the emergence of new infections?


Hospital laboratories that find bacteria resistant to carbapenems –and so likely to have NDM or something similar- are asked to refer them to the Health Protection Agency and we make a risk assessment from a public health point of view.  We then issue advice via our website on how best to detect the resistance, what infection control to use and what treatments should be used. We work together with the government’s Antibiotic Resistance and Healthcare Associated Infections advisory committee on these matters.


David are you concerned at the over-usage of antibiotics?


You can find, in any country, many examples of the inappropriate use of antibiotics, for instance when people are given antibiotics for infections that are very mild or are due to viruses -for which antibiotics are not effective.  And then there are patients in a hospital who are given a series of antibiotics unnecessarily and those in intensive care who are given four antibiotics at one time. Another example is that, on average, people in France and Greece consume three times more antibiotics than the Dutch. Why?   The French and Greeks are no sicker than the Dutch.   The main reason is that it is easier to get antibiotics from a general practitioner in these countries than in the Netherlands
Doctors need to be able to refuse people an antibiotic prescription if it is not warranted, this becomes difficult in countries where residents can go from one doctor to another.


Coming back to India, there is a further issue around patent protection which either does not apply or applies to recently discovered drugs.   The result is that many competing companies may make the same antibiotic; if any one encourages responsible use it just gives up market share to the others.  This is very different to the situation where a company has a patent to protect since it then has some interest in responsible use so that it does not destroy the usefulness of its own compound.

Written by Dr David Livermore
Friday, 19 August 2011 11:11

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