Combatting antimicrobial resistance: a doctor’s perspective

There are 46 antibiotics in the development pipeline. It’s likely that only around 28 of these will be significantly effective against the common priority pathogens. The pipeline is tiny compared to that for drugs for diabetes, coronary artery disease and high blood pressure. 

Antibiotics are essentially single-use products. Someone with high blood pressure will take their drugs for life. Antibiotics are for acute illnesses. The profits are low and development costs are high. There are no significant commercial incentives to develop antimicrobial medicines.

Absolutely. Professor Dame Sally Davies (former chief medical officer) is on record as saying that AMR is a more immediate threat than climate change. The message the public gets is that AMR is a future threat, but it’s affecting thousands of people in our hospitals today. We need action now. 

The UK and other countries have been examining how we can incentivise the antimicrobial pipeline. The National Institute for Health and Care Excellence has a subscription pilot that reimburses pharmaceutical companies almost according to the societal value of their new medicines. This only applies to two medicines. We’re hopeful it will be extended.

Sepsis is the way the body can respond to infection. The immune system goes into overdrive, causing organ damage. Sepsis can be triggered by a seemingly benign urinary tract infection, but it’s the immune system’s response that’s harmful. 

Globally, there are about 49 million sepsis cases every year. In the UK, there are an estimated 245,000 cases and 48,000 deaths each year. To put that into context, sepsis is a more common reason for UK hospital admission than heart attacks and claims more lives than breast cancer, bowel cancer and prostate cancer combined. But this relationship is not black and white. These conditions can coexist. For example, somebody having chemotherapy for breast cancer may have a weakened immune system, putting them at risk of sepsis.

Governments have focused on heart attacks and cancer for a lot longer. There was significant progress in the 1960s with heart attacks, but sepsis was only defined from a medical perspective in the mid-1990s. It’s had less lead time. 

Also, sepsis doesn’t have a common touch point. If you have a heart attack, you see a cardiologist. If it’s cancer, you see an oncologist. Sepsis touches every point of the healthcare system. There’s no specific set of health professionals routinely dealing with it. But once organ failure occurs, we admit patients to intensive care.

This depends upon infection management. This is not about AMR or sepsis in isolation. It’s about infection prevention in all of its forms, including access to clean water, sanitation, hygiene and vaccines. It’s about disease surveillance, pathogen surveillance, pandemic preparedness and antimicrobial stewardship. 

Stewardship is not about measuring how many antibiotics doctors prescribe and assuming that an increased prescription rate compared with the average is bad practice. We need a culture where infection management is seen to be as important as that of trauma, heart attacks and cancer. Every doctor and every patient should expect excellence. 

We need everybody to understand that antibiotics are for treating bacterial infection, and, in very high-risk patients, preventing it. They’re not for self-limiting viral illness. Health professionals also have to prescribe responsibly.

They have to understand what their local antimicrobial flora is, how likely it is that an organism is going to be therapy-resistant and tailor treatment accordingly. In many UK hospitals, there is a significant lag time between the prescribing clinician attending the patient’s bedside and receipt of antimicrobial prescription information.

Animals account for about a third of UK antibiotic consumption. We’re concerned about the routine use of antibiotics in intensive farming to compensate for poor animal husbandry. 

There’s evidence that you can have a direct transfer of genetic material from a microbe that has developed resistance in a farm animal to pathogens that can infect humans. Most UK meat reared with antibiotics is laid down for some time before consumption, reducing the risk of direct ingestion of antibiotics. But meat from overseas is often not laid down for so long. So, ready meals from overseas may contain antibiotics. And, of course, animals fed antibiotics excrete them, contaminating the environment.

Although sepsis affects 49 million people, we have a ‘single size fits all’ definition. We apply the same physiological and laboratory thresholds to all sepsis patients – from athletic 18-year-olds to 88-year-olds with severe cardiovascular disease. This is illogical. 

What does it mean? We’re probably significantly over-treating some patient cohorts and significantly under-treating others. Some sepsis patients can comfortably wait six to 8 hours before receiving antimicrobials – some can’t wait six to eight minutes. 

The intelligence doesn’t allow us to prioritise patients who need treatment most urgently. We need to build national registries to map which people develop sepsis. We need to apply pattern recognition to establish which patients need antibiotics and assessment within an hour and which can wait. We have much to do.