AMR: tragedy or trivia?

21st November, 2015 marked the end of antibiotic awareness week, which passed with barely a mention in Australia. I spent the day manning a public science information stand at a local village Spring festival, encouraging passers-by to make AMR* history. It was a personal triumph of hope over experience, since even the local pharmacist had not heard of the national Antibiotic Awareness Week. Our small band of hopefuls found encouragement in a handful of small victories, when likeminded professionals or concerned people-in-the-street stopped by to share their stories of antibiotic over-prescription.

It was a bit different overseas. The Centers for Disease Control in Atlanta circulated a series of arresting infographics. In the UK; the epicentre of AMR official activism, Prime Minister Cameron concluded his speech in a security debate by naming antibiotic resistance as a threat to public safety. So at least one G20 leader has the intestinal fortitude to put the growing problem of AMR in the same bracket as organised terrorism. Not that it was a flash in the pan. When polled for priorities for the UK government’s Longitude Prize, the British public were sufficiently concerned to place AMR above terrorism. On this side of the planet we have yet to develop that perspective. Here, we are still fixated on kinetic threats. We are not quite sophisticated enough to understand the sinister gathering of microscopic forces whose bridgehead in Europe already has health administrators planning for a future without antibiotics. But in Europe those administrators have the data to show that deaths from antibiotic resistant infections already outnumber deaths from terrorist action many times over

Classic tragedy

The tragedy is not the lack of sophistication, scientific literacy or unified political action. The real tragedy is that the growing international disaster of antibiotic resistance has occurred under our noses. It has been compared with the tragedy of the commons; an economist’s parable of what happens when all seek benefit from a common good in public ownership but none accept responsibility for its care. The story has been applied in recent years to environmental and sustainment issues, which explains why some biologists see the parallels with the use and abuse of antibiotics. At the risk of sounding a little picky, we need to remember that the recent promulgation of the tragedy of the commons was in an economic context, and we have yet to see a truly informed debate about the antibiotic value chain. In the UK a government review has put broad figures on the loss to the global economy through rising levels of AMR. While their estimates are an important part of the clamour for action, they gloss over the stark realities of lengthy value chains from pharmaceutical manufacturer, to prescriber, retail pharmacist and patient – not to mention the role of antibiotics in the informal economies of many developing communities. If you want to play the economist’s ‘tragedy of the commons’ card, you need to look at the wider context of the poker game we’ve been playing. But then, if we look beyond the first application of the tragedy of the commons in modern times, to the etymology of ‘the commons’ you can see themes associated with use of the word that resonate with the current AMR problem including responsibility and shared ownership.

The tragedy then, is that we are losing something of global worth much faster than we thought possible only a few years ago. And we have nothing comparable to replace it. One statistic is worth a mention: the World Health Organisation estimates that antibiotics have given the developed world an average of 20 additional years of life expectancy. As that gift of two extra decades is being steadily eroded by antibiotic resistance, the next generation are entitled to be grumpy about their inheritance. When you translate the direct consequences of AMR into downstream effects, you understand why European health services are starting to plan for hospitals without antibiotics. The stark reality will be that cancer treatment, elective surgery and other critical components of modern medicine will be too risky to continue in their current form. The O’Neill Review has put figures on it. In a generation’s time, they estimate the death toll due to AMR will have overtaken cancer as the biggest killer and over ten million people will die per year due to antibiotic resistant infections.

At the trivial end

Despite these gloomy predictions, there is reason for hope. At the senior end of town, national leaders and international organisations are mobilising for coordinated action. Philanthropic foundations and research funds are promoting an unprecedented quest for new AMR preventive and diagnostic measures. New antibiotics are in vogue again after several decades without significant new additions to the pharmacopeia. Perhaps we will get lucky with a great new antibiotic that kills 99% all known germs, without promoting further AMR. But that would go against an overwhelming body of prior experience that argues for more prudent use of exciting new antibiotic treatments. For the meantime, we will have to learn to make the best use of what we have, use it more sparingly, and return to some of the old lessons from the pre-antibiotic era when hygiene wasn’t a personal choice, but rather a matter of necessity.

Sweating over the small stuff of microbes, their resistance to antibiotics and commonplace human activities that assist their programme of survival at our expense is no trivial matter. The geeks and nerds that dwell in the murky world of microbial mass murder may look like sure-fire trivia quiz winners. Somewhere among them are the discoverers and inventors of the survival toolkit we need to cope with AMR. Their efforts in the lab may become the diagnostic test or new antibiotic that tips the balance in your future infection.

So as we plan to make AMR history, consider what you can do to make our job that little bit easier.

  • AMR: antimicrobial resistance

Tim Inglis is a Medical Microbiologist in Perth, Western Australia and also writes for the Micrognome blog.

Figure. A film of Klebsiella pneumoniae bacteria growing on a layer of nutrients in agar is inhibited by antibiotics in paper disks. This strain of bacteria can break down antibiotics, making the halo effect or inhibition zone smaller. But when an inhibitor of resistance is added (right hand side of the black line) the antibiotics work better, producing a larger inhibition zone or halo. This test for antibiotic resistance requires the bacteria to grow for several hours – often overnight.