If we don’t treat antibiotics with respect, hoping to avoid resistance will be futile

The NHS wastes tens of millions of pounds each year on antibiotics, but the money is trivial compared to the problem of resistance.

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.

Patients infected with multidrug-resistant tuberculosis wear masks in Myanmar in 2012. Photo: Paula Bronstein/Getty.

This article first appeared in the 08 January 2014 issue of the New Statesman, The God Gap

Photo: Getty Images
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What do Labour's lost voters make of the Labour leadership candidates?

What does Newsnight's focus group make of the Labour leadership candidates?

Tonight on Newsnight, an IpsosMori focus group of former Labour voters talks about the four Labour leadership candidates. What did they make of the four candidates?

On Andy Burnham:

“He’s the old guard, with Yvette Cooper”

“It’s the same message they were trying to portray right up to the election”​

“I thought that he acknowledged the fact that they didn’t say sorry during the time of the election, and how can you expect people to vote for you when you’re not actually acknowledging that you were part of the problem”​

“Strongish leader, and at least he’s acknowledging and saying let’s move on from here as opposed to wishy washy”

“I was surprised how long he’d been in politics if he was talking about Tony Blair years – he doesn’t look old enough”

On Jeremy Corbyn:

"“He’s the older guy with the grey hair who’s got all the policies straight out of the sixties and is a bit of a hippy as well is what he comes across as” 

“I agree with most of what he said, I must admit, but I don’t think as a country we can afford his principles”

“He was just going to be the opposite of Conservatives, but there might be policies on the Conservative side that, y’know, might be good policies”

“I’ve heard in the paper he’s the favourite to win the Labour leadership. Well, if that was him, then I won’t be voting for Labour, put it that way”

“I think he’s a very good politician but he’s unelectable as a Prime Minister”

On Yvette Cooper

“She sounds quite positive doesn’t she – for families and their everyday issues”

“Bedroom tax, working tax credits, mainly mum things as well”

“We had Margaret Thatcher obviously years ago, and then I’ve always thought about it being a man, I wanted a man, thinking they were stronger…  she was very strong and decisive as well”

“She was very clear – more so than the other guy [Burnham]”

“I think she’s trying to play down her economics background to sort of distance herself from her husband… I think she’s dumbing herself down”

On Liz Kendall

“None of it came from the heart”

“She just sounds like someone’s told her to say something, it’s not coming from the heart, she needs passion”

“Rather than saying what she’s going to do, she’s attacking”

“She reminded me of a headteacher when she was standing there, and she was quite boring. She just didn’t seem to have any sort of personality, and you can’t imagine her being a leader of a party”

“With Liz Kendall and Andy Burnham there’s a lot of rhetoric but there doesn’t seem to be a lot of direction behind what they’re saying. There seems to be a lot of words but no action.”

And, finally, a piece of advice for all four candidates, should they win the leadership election:

“Get down on your hands and knees and start praying”

Stephen Bush is editor of the Staggers, the New Statesman’s political blog.