An­tibi­otics that work

Financial Mirror (Cyprus) - - FRONT PAGE -

From the dis­cov­ery of peni­cillin in 1928 to the in­tro­duc­tion of the last of the main groups of an­tibi­otics in the 1960s, hu­man­ity’s ca­pac­ity to fight path­o­genic bac­te­ria has been trans­for­ma­tive. But, over time, the num­ber of an­tibi­otics to which bac­te­ria are sus­cep­ti­ble has been dwin­dling, and some pathogens have be­come re­sis­tant to most or all ex­ist­ing drugs. As a re­sult, once-treat­able in­fec­tions are be­com­ing deadly again.

Al­ready, an­tibi­otic re­sis­tance is lead­ing to an es­ti­mated 700,000 deaths per year, with fi­nan­cial costs reach­ing tens of bil­lions of dol­lars. As an­tibi­otic re­sis­tance con­tin­ues to un­der­mine our abil­ity to treat can­cers, trans­plant or­gans, and im­plant pros­the­sis, these fig­ures will only rise.

Many fac­tors have con­trib­uted to ris­ing an­tibi­otic re­sis­tance. Bac­te­ria can re­pro­duce and mu­tate rapidly, and they can es­tab­lish some­thing of a “ge­netic In­ter­net” that en­ables cer­tain path­o­genic bac­te­ria to “down­load” an­tibi­oti­cre­sis­tant genes. More­over, most an­tibi­otics are nat­u­ral prod­ucts of soil bac­te­ria, in which an­tibi­otic re­sis­tance can oc­cur nat­u­rally. When hu­man-made an­tibi­otics were in­tro­duced on a mas­sive scale, the bac­te­ria with re­sis­tance be­came the most preva­lent.

To­day, hu­mans re­lease about 100,000 tons of an­tibi­otics per year. If those an­tibi­otics were be­ing used prop­erly and sav­ing lives, a rea­son­able cost-ben­e­fit anal­y­sis might be pos­si­ble. But about 70% of them are used to make farm an­i­mals to grow a bit faster. The other 30%, while used to treat peo­ple, are of­ten pre­scribed in­cor­rectly or need­lessly. And, be­cause a sub­stan­tial share of the used drugs are re­leased into the en­vi­ron­ment with waste­water and ma­nure, bac­te­rial com­mu­ni­ties in soils, wa­ters, and wildlife are also ex­posed.

If this abuse of an­tibi­otics does not end, we will soon find our­selves with­out drugs to treat bac­te­rial in­fec­tions ef­fec­tively. But while some steps are be­ing taken – a high­level United Na­tions meet­ing last Septem­ber pro­duced pro­pos­als for some from ad­e­quate.

What is re­ally needed is an im­me­di­ate world­wide ban on the agri­cul­tural use of an­tibi­otics. More­over, guide­lines for the clin­i­cal use of an­tibi­otics, which the med­i­cal com­mu­nity now fol­lows as closely as those con­cern­ing how to pick a neck­tie, must be re­viewed and strongly en­forced. These two mea­sures alone – both of which could be en­acted by gov­ern­men­tal reg­u­la­tory agen­cies – would re­duce the use of an­tibi­otics by nearly 80%, slow­ing the rise of an­tibi­otic re­sis­tance sub­stan­tially.

Of course, get­ting gov­ern­ments to im­ple­ment such mea­sures will not be easy, be­cause they run counter to pow­er­ful eco­nomic in­ter­ests, the most ob­vi­ous be­ing the phar­ma­ceu­ti­cal in­dus­try, which sells $40 bil­lion worth of an­tibi­otics each year. While Big Pharma has a strong in­ter­est in con­tin­ued an­tibi­otic abuse, it has lit­tle in­ter­est in de­vel­op­ing new an­tibi­otics to tackle drug-re­sis­tant bac­te­ria. Drugs for chronic ill­nesses and can­cer are bet­ter for their bot­tom line.

So Big Pharma is seek­ing “in­cen­tives” to pur­sue re­search and de­vel­op­ment of new an­tibi­otics, such as ex­tended patents or tax breaks; the al­ter­na­tive would be to charge as­tro­nom­i­cal prices for new drugs. But the ben­e­fits of such in­cen­tives for phar­ma­ceu­ti­cal com­pa­nies would far ex­ceed the cost of the ac­tual R&D pur­sued; they would be in­stru­ments to fun­nel public funds into pri­vate hands – the very hands that caused the prob­lem.

Be­yond all of these car­rots, how­ever, so­ci­eties should con­sider us­ing some sticks. I pro­pose an ini­tia­tive that rates phar­ma­ceu­ti­cal com­pa­nies ac­cord­ing to their con­tri­bu­tion to solv­ing the an­tibi­otic-re­sis­tance prob­lem; those that do not con­trib­ute should be pun­ished with fewer sales. I call it NANBU (No An­tibi­otics, No Busi­ness).

NANBU would grant points to com­pa­nies with vig­or­ous re­search pro­grammes or with new an­tibi­otics in the de­vel­op­ment pipe­line.

Com­pa­nies that do not man­u­fac­ture or sell an­tibi­otics for agri­cul­tural pur­poses, or that refuse to pro­mote the use of an­tibi­otics for dis­eases that do not re­quire such drugs, would gain points as well. Those that en­gaged in the op­po­site be­hav­iours – sell­ing an­tibi­otics as live­stock “growth pro­mot­ers” or ac­tively en­cour­ag­ing physi­cians to pre­scribe

in­ter­na­tional mea­sures – they


far the drugs – would lose points.

At first, vir­tu­ally all drug com­pa­nies would have neg­a­tive scores. But, over time, the rat­ings could be ad­justed, al­ways ac­cord­ing to sci­en­tif­i­cally sound ad­vice from an independent group of ex­perts. The rat­ings could then be used to guide drug-pur­chas­ing de­ci­sions.

For many kinds of rel­e­vant drugs, there are sev­eral op­tions with sim­i­lar ef­fi­cacy and safety, pro­duced by dif­fer­ent com­pa­nies. So clin­i­cians could pre­scribe drugs mostly from highly rated com­pa­nies, and avoid drugs from com­pa­nies with low rat­ings. Pa­tients could en­cour­age such de­ci­sion­mak­ing, and fol­low suit when pur­chas­ing over-the-counter drugs. Over time, an­tibi­otics could be­come more prof­itable again, as en­gaged com­pa­nies sell more of their other drugs and the need for costly in­cen­tives di­min­ishes.

The key to NANBU’s suc­cess will be to en­sure wide­spread un­der­stand­ing of the an­tibi­otic-re­sis­tance threat and what is needed to com­bat it. This would give pa­tients and doc­tors the im­pe­tus to re­gard NANBU rat­ings in mak­ing drug de­ci­sions, as well as to pres­sure their gov­ern­ments to take even stronger ac­tion. The use of a public aware­ness cam­paign to in­ten­sify pres­sure on gov­ern­ments to pur­sue nec­es­sary but dif­fi­cult mea­sures has worked be­fore – for ex­am­ple, in ad­vanc­ing for­est and fish­ery sus­tain­abil­ity.

Public aware­ness was among the pri­or­i­ties high­lighted at the UN meet­ing. To carry out that global ef­fort, how­ever, we need a new global in­sti­tu­tion that re­ally is up to the task. NANBU, as an in­ter­na­tional NGO, would be able to cope with the transna­tional na­ture of most drug com­pa­nies, while be­ing pro­tected from na­tional-level lob­by­ing or po­lit­i­cal pres­sure.

An­tibi­otic-re­sis­tant bac­te­ria rep­re­sent a global threat, and there­fore can­not be ad­dressed with na­tional mea­sures alone. The world must think and act to­gether to pre­serve the huge gains to hu­man health and well­be­ing that an­tibi­otics have en­abled.

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