Published: 28 March 2019
Despite very significant optimism in the 1950-70s that ‘It’s time to close the books on infectious diseases, declare the war against pestilence won,’ (a quote erroneously attributed to the US Surgeon General in 1967) we now find ourselves on the brink of a so-called ‘post-antibiotic era’ where our armamentarium of antimicrobial drugs may no longer be adequate to treat even common infections.
This is down to the ability of micro-organisms to develop resistance when exposed to antimicrobials, and to potentially pass this resistance onto other microbes. Such antimicrobial resistance (AMR) has been acknowledged as one of the major threats to health globally and we are likely to increasingly encounter organisms that have no effective treatments in future years.
Most of the focus, and most of the concern, has been based upon antibacterial resistance. We are increasingly having to treat patients with second and third-line drugs , and fourth or even further line therapies in those individuals with significantly resistant organisms. This is not a long-term solution.
Not only are these drugs often more toxic and expensive, but we are also encouraging these organisms to develop resistance to these antibiotics (when they are increasingly becoming a last resort) - and hence we are actively, but perhaps unavoidably, worsening the multi-drug resistance we encounter.
There are several ways to attempt to combat this.
The first is to try and steward and control our use of antibiotics: so that the correct drugs are used (if required at all), for the shortest possible periods, perhaps in combination. This will hopefully slow the development of further resistance but is unlikely to fully correct the situation and trajectory we have found ourselves in.
This could be supported by better diagnostics – informing clinicians and others of when antimicrobials are indicated, which ones, and when it is appropriate to de-escalate or stop them. Finally we need to develop new antibiotics, preferably novel classes, but also ensure these are subsequently ‘saved’ for when they are really needed.
This is a global imperative, and requires a global collaboration – and we all have our roles to play. The NIHR is a vital component of this. It is well positioned to help develop the diagnostics and interventions we require, and evaluate their utility and importance. It can significantly assist in the development and evaluation of newer drugs, other supportive therapies and diagnostics.
In fact there are several advantages that the NIHR and the UK have in undertaking this work. We have a unified public health system, with similar standards and protocols throughout. We have fairly standardised antimicrobial protocols and have tended not to jump to utilise the newer drugs as soon as licensed. Our laboratory system is effectively networked and unified. We have a broad and homogeneous infrastructure to perform robust clinical studies and interventions.
The NHS and the NIHR are well positioned to play a role in the collaborations and partnerships required to help combat AMR – with a very large and diverse population of potential patients interacting in a fairly standardised way within a uniform and connected health system.
So are we doing enough or can we do more?
The answer is, of course, that we can and should do more. We need to pursue better collaborations with industry and others, we need to make sure that we are optimally contributing to any partnership – and we can improve.
We need to provide realistic feasibility assessments and feedback on study and intervention designs and protocols. We need to further speed up our research approval processes and subsequent pathways, so that we can deliver quickly, robustly, and to time and target. We also need to listen more and be more responsive to our partners in this fight against AMR.
And the good news is we are actively making steps in all these directions. We are becoming more responsive, leaner, quicker and more effective. We can therefore assist as perhaps no one else can, and offer unique insights and contributions in this fight against AMR.
So my message to current and future partners in this struggle is work with us. Help us and direct us to become better yet.
This is a fight, that together, we must win.
Dr Andy Ustianowski, NIHR Greater Manchester Specialty Lead for Infection
Find out more: Tackling antimicrobial resistance
The views and opinions expressed in this blog are those of the authors and do not necessarily reflect those of the NIHR, NHS or the Department of Health and Social Care.