Shortly after I joined my practice, my senior partner gave me a memoir to read. It was written by a doctor called Kenneth Lane who had worked in the practice from the late 1920s. As I read stories from his 40-year career, I was struck by Lane’s detailed knowledge of the natural course of infectious diseases, something unfamiliar to my generation. In the case of a child with pneumonia, for instance, Lane would prepare the parents for each deterioration they could expect over the first eight to ten days, culminating in the “pneumonic crisis” – a crescendo of fever, hypoxia and delirium that would, in a quarter of cases, be fatal. Only once the crisis had been survived would Lane start to talk about the possibility of recovery.
Lane never lost the awe he experienced when, in the 1940s, the first antibiotics became available. Suddenly, feared diseases such as diphtheria, pneumonia and scarlet fever could be cured within days. To a doctor used to watching impotently as otherwise fit young people died, these new drugs were miraculous.
I wonder what he would make of how we use them today. Roughly 35 million prescriptions for antibiotics are issued each year in England, mostly for respiratory infections (coughs, colds, sore throats, sinusitis, earache). Studies have repeatedly shown that, in these scenarios, antibiotics do little or no good. The infections are going to get better anyway and antibiotics don’t reduce severe complications, which are, in any event, rare. They do shorten symptom duration by about half a day on average but up to 10 per cent of patients experience side effects. And there is good evidence that antibiotic use interrupts the development of a robust immune response, which makes people susceptible to contracting further infections. The more you use antibiotics, the more you will end up using them.
In the NHS this dismal situation wastes tens of millions of pounds each year but the money is trivial compared to the problem of resistance. Bacteria multiply extraordinarily quickly and in huge numbers. This large-scale, rapid reproduction ensures that, if exposed to an antibiotic, a gene mutation will soon arise that protects the bacterium from the drug’s mode of action.
The “resistant” organism that results will survive and reproduce, its progeny quickly replacing the susceptible strain that is dying all around it. The more antibiotics there are swilling around in the community, the more stimulus there is for resistance to arise. To compound matters, genes for resistance are transmitted by a process known as plasmid exchange: once one strain of bacteria has figured out how to evade a particular antibiotic, the capacity spreads rapidly.
Over the past 30 years, treatment failure – in which an infectious bacterium is no longer sensitive to the antibiotic prescribed – has gone from being an occasional phenomenon to something encountered routinely. And it’s becoming ever more common for bacteria to be multi-drug-resistant, so second- and even third-line antibiotics also fail to kill them. In these cases, there remain “last-line” drugs – agents whose use is permitted only when eradicating otherwise incurable organisms. Despite strict control over their use, resistance to these drugs started to appear around 2007 and is growing exponentially. We face the very real prospect of routinely encountering infectious diseases that we cannot treat – a situation that doctors such as Kenneth Lane were familiar with in the pre-antibiotic era. The threat is so alarming that in September 2013 the Department of Health launched a five-year strategy to tackle the problem.
One approach will be to give incentives to the pharmaceutical industry to develop new agents. Courses of antibiotics are short and new agents are usually reserved for last-line use. Because of this, the volume of sales is small, making research and development economically unviable under the present drugs patent system. A different model is needed.
As important as new drugs will be, the core of the Department of Health’s strategy is to promote the responsible “stewardship” of our existing antibiotics. Surgeries and pharmacies are currently festooned with posters advising against the casual use of antibiotics. Patients who habitually consult doctors with self-limiting infections can be persistent in their efforts to obtain antibiotics. Their beliefs usually have roots in years of inappropriate prescriptions. The reasons why doctors prescribe unnecessarily are complex: the desire to appear helpful, an aversion to conflict, blanket treatment “just in case” serious infection is brewing.
We need to emphasise the skills that were second nature to those like Kenneth Lane. His long experience observing infectious diseases enabled him readily to identify potentially grave cases amid the morass of self-limiting infections. We need to recover the respect Lane had for the antibiotic wonder drugs that transformed his practice. He would, I am sure, be aghast at the complacency with which we employ them and the mess we’ve got ourselves into as a result.