Antibacterials - Back to the Future.

Back to the Future - Antibacterials in 2010.

Back to the Future. What will happen in 2010?

As we entered the new millennium full of hope and optimism for the
future, we saw the warning signs but chose to ignore them. The dawn
of the new millennium was to be the beginning of a new and much
improved era. But scientists were already sounding alarm bells that our
misuse of antibiotics in the 20th Century would result in problems for the
future. We ignored those signals and today we are paying the price.

As this year’s bout of influenza reaches epidemic proportions, the
Government has issued an official quarantine announcement.

‘No person shall after 12 hours after the publication of this notice be
permitted to enter into or leave their respective counties on any rail
network, by road or in any manner whatsoever by any conveyance, on
foot or otherwise without first obtaining a permit from their local health
department.’

The government authorities have today closed all schools and forbidden
all public meetings and gatherings, including funerals, in an attempt to
isolate the epidemic. Spanish flu, also known as the ‘Spanish Lady’ is
believed to have reached our shores via the increased number of
holidaymakers that have visited Spain over the recent winter months.
The Costa resorts in Spain have been making a comeback as the most
popular European holiday destinations. They are cheap, cheerful and
only a two hour flight away. But it seems that as a nation, we are now
paying the price for people’s winter sojourns.

The repercussions of this disease are not just stopping at killing our
loved ones. The ramifications stretch much further. Today, the
Government has issued a statement that the Euro is at its all time lowest
value since it was introduced. Productivity has reached a virtual
standstill, the workforce is on sick leave in record numbers and has
today reached the 30 million mark.

In a short time the influenza virus has made its way here and is killing
people throughout Europe. More than 1.3 million people in Britain alone
have died in the last two months and a further 20 million people are
currently seriously ill, desperately fighting to stave off this killer flu.

Medical experts are ordering people to go straight to bed and stay quiet,
eat plenty of nourishing food and try and maintain your strength to fight
off the illness. There is no cure for influenza. The disease must run its
course. Evidence seems to prove that this is a disease which is
principally spread by human contact, for example by coughing, sneezing
and spitting. It is therefore important that if you have any symptoms
resembling the common cold, you should remain in your home until they
have subsided.

Influenza weakens bodily resistance and there are grave warnings from
the medical world that there is an increased danger of bronchitis and
pneumonia developing. But we are today learning that there are an
increasing number of reported cases of pulmonary tuberculosis which is
attacking people whose immune system has been weakened by
influenza. The country now offers the perfect condition to encourage the
spread of tuberculosis, and this is where an even bigger danger lies.

As early as 1945 Sir Alexander Fleming who brought us penicillin,
predicted that the more antibiotics people take or feed their animals, the
faster bacteria will become resistant. But we didn’t heed this warning.
Throughout the 1980's and 90's, rich people, and particularly women,
throughout the world visited the doctor with minor ailments and were
given antibiotics like children are handed out smarties. The more that
people paid for medical care, the more antibiotics they were given. If the
doctor had given them nothing, they would have simply gone elsewhere
to a doctor who would.

But when one person takes an antibiotic, it is not just an act of an
individual seeking a cure from infection, instead it is a social act that
stimulates resistance to the whole world of bacteria which implicates us
all. It affects everybody and not just the individual who took the pill. Of
course we need the drugs, surgery would be impossible without them
and people would have died anyway. But the drug has its limitations, as
we are now learning at our cost.

Antibiotics were never intended to be given for viruses; they were
always known not to be effective against them. Antibiotics were
intended to be used to fight infection. In the United States of America in
the year 2000, one third of all antibiotics were mis-prescribed. They
were administered for viral infections against which they were
powerless. Today we are paying the price of the recklessness of our
predecessors.

In Britain it was always a slightly different story. As a nation we only
accounted for 4% of the world’s antibiotic consumption. This was due to
the fact that we had at that time a National Health Service, controlled by
Government spending, and whilst there was medical treatment offered
free to everyone, there were certainly far fewer antibiotics handed out
than in the private medical sector, where people effectively paid for that
‘luxury.’ Britain was a stark contrast to other countries. For example in
the USA, Japan and Spain, antibiotics were sold over the counter in
pharmacies without the necessity of prescriptions signed by doctors and
the rich took them like common aspirin.

So today why do we have no effective antibiotics that are able to fight
the bacteria that surround us? There are many reasons. The most
fundamental is that ever since scientists invented antibiotics, the bugs
they were designed to combat have been one step ahead of the game.
Their introduction has lulled two generations into a false sense of
security, people believing that there will always be pills to fight any
infection we get. However, unless humans develop a solid immunity to
bacteria, our ability to treat infections will always be doomed to failure,
just as it is right now. We are now living in an era where the bugs are
winning, and people are dying because of it.

Dr Stuart Levy of the Alliance for the Prudent Use of Antibiotics, Boston
gave his first warning in 1981. He told us that the misuse of the drugs
will, without a shadow of doubt, cause problems for infections in the
future. He campaigned to a medical establishment that was not listening.
No one would accept that there would ever be a problem.

One particular bug staphylococcus aureus (SA) has always been
scientists primary target in the battle against antibiotic resistance. It is
probably the world’s most infectious agent. At any one time, one third of
us carry SA, usually in our noses, but most of the time it has no effect on
our health. However, SA was the main reason that until 1945 modern
surgery was almost impossible. Almost any operation would push SA
deep into the human tissue and lead to a potentially fatal infection.
Penicillin made surgery less risky because it killed SA and with that came
the saving of lives.

Within eighteen months of penicillin’s first use, the bacteria SA had
developed a system for chopping up the penicillin molecule. By the late
1950's, 90% of all SA strains were already resistant to penicillin.

In 1959, the new antibiotic ‘methicillin’ was introduced which also
effectively killed SA, but the same thing happened again. Within eighteen
months, SA was resistant to it. The proteins in the outer coat of SA had
changed to such an extent that the antibiotic couldn’t bind to it. This we
know as MRSA (methiciliin resistant SA).

It’s interesting that MRSA wouldn’t exist as a bacteria we cannot control
if it weren’t for the antibiotic SA being invented in the first place. The
possibility of contracting MRSA has, since the turn of the century, been
overwhelming. Hospitals provide a near-perfect environment for the bug
to live and breed; they are full of patients with wounds whose immune
systems are suppressed.

This resistance compromises our ability to conduct modern medicine. St
Thomas’s Hospital, one of the most keenly aware hospitals and the one
with perhaps the best infection control systems in the country has 80
cases of MRSA cases a month, double the figure of 10 years ago. It is
still unclear how many people MRSA kills. Death certificates give the
cause as cancer or heart attack and never MRSA because it is difficult
to isolate this as being the sole reason for death.

Most MRSA strains could be treated with some form of antibiotics and in
the year 2000, the most powerful antibiotic called ‘vancomycin’ had been
discovered. Scientists believed that it could be used to conquer any
infection. It was almost always effective but like its predecessors,
bacteria began to evolve that could eat ‘vancomycin.’ By the year 2003
cases of VRSA (vancomycin resistant SA) were appearing across the
world. Scientists had been defeated yet again by what had been
heralded as the drug to fight all bugs.

Scientists believed that ‘vancomycin’ had won the battle but even they
should have realised that whilst man has been on this planet for
thousands of years, bugs have been here for millions, vying for their
survival the whole time, and more importantly always winning. The
dilemma has always been how to get one step ahead of the bacteria.

By the last millennium, the pneumonia bug was acquiring multiple
resistance. Food poisoning bacteria such as E-coli and salmonella had
also acquired multiple resistance. But we were lucky, the number of
fatalities was never as high as it could have been. The Government took
an early initiative and stepped in to ban home cleaning agents that had
been designed to combat kitchen bacteria. Chemical anti-bacterial
cleaners were found to be extremely harmful. They killed the bacteria
that were necessary to prevent food poisoning. Our habits were forced
to change and we all reverted to the rather primitive method of using
good old hot soapy water. The cleaners were believed to play a large
part in increasing resistance to antibiotics.

As a result of that ban, Unilever was faced with huge class actions,
namely groups of people who joined forces to bring one of the most
costly lawsuits of our generation. David took on Goliath and won.
Families had lost loved ones to the deadly food poisoning infections and
the lawsuit was their only means to fight back. Unilever had been
producing anti-bacterial agents for years and we had unknowingly
changed our cleaning habits because of this wonder cleaner, believing it
to be the most hygienic way to clean the kitchen worktops. Unilever, as a
result of the costly lawsuit was forced into bankruptcy.

Potentially the most lethal of all, is the strain of multiple resistant
Tuberculosis which emerged at the turn of the century. At first it mainly
attacked in the United States, mostly drug addicts and sufferers of AIDS
and to a lesser extent people in less well-developed countries. Because
it largely affected this relatively small group of people, nobody took any
real notice. Today of course, we know that it is sweeping through our
populations afflicting those that are still weak after the current flu
epidemic.

As we look back to the year 2000 with our 20-20 hindsight vision, we
should have been better able to anticipate the potential of the spread of
tuberculosis. But we probably thought that we fixed tuberculosis in the
1950's and were confident that it wouldn’t return. However, we only
have to look at history to see that it has a nasty habit of repeating itself.
Look back at the Spanish influenza epidemic of 1918 and 1919 and it
bears a striking resemblance to what we are experiencing now, a little
under a hundred years later.

The flu epidemic of 1918 killed millions of people as the illness swept
across the world. The American troops, who came home after the First
World War, were believed to have come into contact with the bug when
they were shipped overseas to Europe to help with the war. When they
began to return home, the epidemic hit the East coast ports like wildfire.
In a short time the flu made its way to 46 states killing more than 500,000
people in its wake. At the same time, ports in South Africa, Cape Town
and Durban, were also decimated.

It takes five to ten years to develop an antibiotic from the first stages
through to production and to the ultimate sale of the final product.
Unfortunately in the 1990's drug companies failed to see the development
of antibiotics as a lucrative enough field of research. They lost interest
and switched to more profitable areas. This ultimately led to a lull and
indeed a gap between old antibiotics that were SA resistant and new
ones that could possibly combat the bacteria.
In 2003 ‘Linezolid’ was heralded as the drug to save the world and was
even successful against MRSA. It was seen as the drug to supersede
‘vancomycin’ - the ultimate antibiotic to continue where its predecessor
had ceased to be effective. But by 2006, it was already struggling in its
effectiveness and the battle was still being fought to find a drug that
was MRSA resistant.

Supercomputers began producing millions of possible compounds. The
experiments were changing to a more genetic means of testing which
enabled scientists to target bacteria more precisely. In 2006, with the aid
of computer technology, we believed that we were for the first time in
history half a step ahead of the game in the battle against MRSA
resistant bacteria.

How wrong could we have been? The next wave of resistance was
due to come in the year 2020 or possibly 2025 which would have been
completely predictable, but it is here now in 2010. The problem is: we
have no new drugs ready and tested to fight the deadly bacteria.

The size of cities, the increase in Britain’s population and the longevity of
people’s lives have all added to the necessity of our health service
infrastructure changing, and changed it has. Gone are the days when
we had free health service for all. Admittedly there were always queues
and waiting lists for operations and consultations with the medics but the
most important thing was that it was free at the point of service for all
who needed it. There has nearly always been an alternative private
health service for those that could afford it or for those who simply
wanted to pay for a better service and a private room with baskets of
fruit.

Today of course, it is a completely different story. The National Health
Service, already beginning to lose favour at the turn of the century, no
longer exists at all. Today, we have only one, the Government private
health service. Today everybody needs to have some sort of private
health cover to pay for their medical bills. People used to think that we
would never end up with a health service that mirrored America’s, but
here we are with exactly that. Most of us grew up with a national health
service, and people assumed that the Government would always need
to find the funding for the service, no matter what. Votes, would be lost
if a Government lost the national health service altogether. But we were
wrong.

Of course, if people are so desperately poor that they can’t afford health
cover then there is emergency cover available, but it is a standard that is
indifferent and in a separate part of the hospital. People are left waiting
for great lengths of time or sometimes they simply die waiting. Doctors
attend their private patients first. It is a sad cry from the days of our once
beloved National Health Service.

Variations of the ‘Linezolid’ drug have constantly been updated, but to no
avail. Nothing seems adequate to combat tuberculosis. Back in the year
2000, St Thomas’s hospital began screening patients for resistant
infections before allowing them into the hospital. Ten years ago, it
seemed overly sensitive and viewed as something that would never be
the normal way of accepting admissions. Today of course it is the norm.
Everybody is screened before they are admitted.

In every hospital in the country there are isolation wards. We have been
forced to go back to a drug-free era, back to a life before penicillin was
ever invented. Before penicillin, hygiene was of paramount importance
but once it was discovered it led to a complacency that was always
inevitably going to lead to problems.

In the days of Florence Nightingale, hospitals were spotlessly clean with
doctors and nurses acutely aware of the perils of infection. As penicillin
became more widely used, doctors failed to even wash their hands as
they went from patient to patient doing their daily rounds. Germs were so
easily transferred between bedding. Nurses were more aware of the
spread of germs, always diligently washing their hands between
patients but doctors on the other hand seemed to rely and act in a
manner that suggested that if any disease spread it would be okay;
antibiotics would look after the problem. It is attitudes such as these that
led to a heavy reliance on the drugs in the first place.

Today, the Government have issued the warning that nobody is to leave
their respective county without a permit for fear of spreading the
influenza bug. But the reality is a little different. The spread of
Tuberculosis is proving to be the bigger threat to us.

We no longer have a penicillin drug that is tuberculosis multiple resistant.
We had the drug and abused it and now we find ourselves living in a
time that few people thought would ever come. The gap in the research,
when no new drugs were being discovered, has hit us harder than we
might have imagined. If it hadn’t been for this latest flu epidemic, perhaps
a new drug might have been found in time.

Without the effectiveness of penicillin to fight tuberculosis, what are we
left with? We have the rather archaic method of cutting out the damaged
lung caused by the disease, followed by the waiting - will they die or
won’t they? We have reverted to the wait and see method. Today, all we
can do is isolate our victims to prevent the unnecessary spread of the
disease. But with the isolation, comes the division of the family unit,
children forced into the care of social services to pray for sick relatives,
hoping they will recover from the killer disease.

Before we had penicillin all we could do was wait and pray, and today
as I watch people die, all I can do is observe the irony of how we have
come full circle.

©YVETTE BARNETT 2000

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