A year without antibiotics

Antibiotics have been one of the most transformational discoveries in mankind’s history. Few drugs can make the impressive claims that antibiotics, which we have taken for granted, can. Antibiotics have slashed infant mortality and contributed to prolonging life and increasing life expectancy. They have been the catalyst for advances in medicine and surgery. Today antibiotics underpin the cornerstones of modern clinical medicine, providing prophylaxis during surgery; from the pioneering to the routine. Antibiotics underwrite the use of indwelling medical devices and prosthetics on which an ageing population increasingly rely. They facilitate scientific advances in disparate fields. Human and animal health, agricultural productivity, life expectancy, the global economy, directly or indirectly, is influenced by and reliant on accessible, effective antibiotic therapy. Antibiotics save lives.

So, what would a year without antibiotics be like? If we lose antibiotics, all this could potentially be lost. One by one, the doors thrown open by effective antibiotic therapies slam firmly shut. In a year without antibiotics, we can expect to see the beginning of a backslide in human health and economic productivity that takes us right back to the pre-antibiotic era. Infant mortality rises, life expectancy falls, patients die from routine surgical operations, which eventually become too risky even to attempt. And not just the ‘big ticket’ procedures like organ transplantation, childbirth or hip replacements, but also routine surgery for appendicitis, tonsillitis or cosmetic surgery will all carry a hefty rick of life-threatening infections. Without antibiotics, clinical medicine will be very, very different. For some, a year without antibiotics is not some distant shore; it’s a reality in the here and now. For the 25,000 patients in Europe, for the hundreds of thousands worldwide, who die every year from resistant infections, which no antibiotic can treat, the scenario is a reality. Already the chances of dying from hospital acquired septicaemia or pneumonia are twice as high if the pathogens are antibiotic resistant. In reality, we don’t have to look back far to learn lessons from the history of the ‘pre-antibiotic’ era. Events at the dawn of the antibiotic era hold an important lesson for us regarding what happens when transition from having effective antibiotics to having none. Among the very first patients to be treated with penicillin was Albert Alexander, an Oxfordshire police constable in his forties who had developed a severe topical infection and sepsis following a scratch while tending to his rose garden. By 1940 Florey and Chain had worked out a purification method for penicillin, as Alexander was not responding to the sulfa drugs being used to treat the septicaemia and facing death. Florey and Chain’s penicillin was used for five days before it eventually ran out (the penicillin was even recrystallized from his urine to conserve the precious stocks). Alexander, who had responded well to treatment with penicillin up to that point, eventually succumbed to the infection in the absence of antibiotic and died.

A future without antibiotics won’t happen overnight, but we are slipping towards it with increasing pace. Nor did it creep up on us and catch us unawares, and whilst there is plenty of blame to go around for why we got here, only concrete action to incentivize the industry, implement root and branch reform of regulation and boost discovery and research by training the next generation of antibiotic pioneers, can we hope to recover the ground lost.

Without antibiotics, patient and physician alike will seek alternatives. There is little doubt that there are alternatives out there, unfortunately none yet at the stage of supplanting antibiotics altogether. Many still rely on helping old antibiotics work better. As in times of war, scientific advances will no doubt be accelerated and innovative steps taken, but at a predictably terrible cost of human suffering and death. It would be easy with such an emotive issue to succumb to hyperbole or to paint some apocalyptic, dystopian image of what the world might look like without antibiotics. However, antibiotics have only been in clinical use for around 75 years. In the course of human history great civilizations have risen and fallen without them, the foundations of science, culture and the arts laid in their absence. That said, modern medicine stands on their shoulders. We need them, and we need more - urgently. But more isn’t the only answer. We need to value them and use them appropriately.

Last week marked the WHO World Antibiotic Awareness Week and on 16 November the European Center for Disease Prevention and Control’s European Antibiotic Awareness Day. These important efforts to highlight the importance both of antibiotics and good antibiotic stewardship in the general public coincided with the first worrying report of the emergence of plasmid-mediated colistin resistance in E. coli isolated from food animals in China. Polymyxins are often the drug of last choice for a number of serious Gram negative infections, so the discovery that resistance to these last line of defence antibiotics may horizontally transferred via plasmids carrying the mcr-1 gene represents a significant loss in the battle against antibiotic resistance. Again, the seemingly relentless march of antibiotic resistance reminds us that urgent, globally coordinated action is necessary to avoid complete depletion of our antibiotic arsenal. We cannot afford a day without antibiotics, let alone a year.