Penicillin is magic bullet in Strep A battle but its overuse risks defeat in war with superbugs
Experts are calling for a different approach towards antibiotics, with a Covidstyle test part of the answer
Antibiotics are one of the few medicines which can truly be considered “wonder drugs”. Their discovery rid the world of diseases which have been the scourge of humanity for millenia.
They have saved untold lives since penicillin was serendipitously discovered by Sir Alexander Fleming in the 1920s and continue to do so as they are being used to treat the current Strep A outbreak.
Strep A causes tonsillitis, scarlet fever, impetigo and other conditions but the most serious occurs when it becomes “invasive”, called iGAS, when the bacteria reaches deep into the body, such as the bloodstream.
This is what has killed at least 16 children since the start of September and turns the normally mild streptococcus pyogenes bacterium into a lethal disease.
Almost one in ten people who develop iGAS die of it, figures show.
But, fortunately, there is a magic bullet. Penicillin. It kills the bacteria and is exceptionally effective.
Now, amid soaring cases and deepening worry from parents, doctors have been told to have a “low threshold” for prescribing penicillin.
But, in a classic catch-22, by giving out more antibiotics we risk neutering them completely.
Superbugs – or “antimicrobial resistant bacteria” – are on the rise, driven by too many antibiotics being used. They threaten to tame penicillin, the primary weapon of physicians for almost a century. The more we use this precious medicinal resource, the more we fuel superbugs. It is a nigh impossible balance to strike, with doctors tasked with preserving antibiotics while ensuring people who need them can get them.
But concern over Strep A has led to a clamour for antibiotics. Entire year groups, hundreds of children, may be given antibiotics to curb outbreaks. Antibiotic prescription dropped by
‘I’m worried about antimicrobial resistance because I want antibiotics to work when needed’
15 per cent in the past year but now that the bar has been lowered the situation favours superbugs.
Antibiotics may get us out of this Strep A outbreak, but maybe not future ones if we don’t preserve them. Lord Jim O’Neill said that to continue dishing them out “like sweets” in the long term would be “madness”, “insanity” and “ridiculous”.
Lord O’Neill wrote a seminal review in 2016 on the topic after being commissioned by then prime minister David Cameron. Another study has since found 1.27million people a year are dying from superbugs. Lord O’Neill, as well as myriad other experts, is convinced that it is right to give out more antibiotics amid the current situation, but there is concern over the knock-on implications.
Dame Sally Davies, UK special envoy on AMR, ex-Chief Medical Officer, said: “I’m worried about antimicrobial resistance because I want antibiotics to work when they’re needed.
“Strep A infections, particularly when they’re invasive, are one of the reasons I want them to work so we have to always use them carefully.
“My concern about AMR is not to stop people using antibiotics, but to support their effective use and that when they are used, they work.
“In this situation, I can see why doctors appear more generous with antibiotics than normal but, antibiotic use responds to clinical need.
“My push on antimicrobial conservation and stewardship is so that antibiotics work when we need them, so if healthcare workers feel they should use them, they should.”
Craig MacLean, professor of biology at the University of Oxford, said: “All doctors have a duty to their patients, and right now it is completely reasonable to expect doctors to err on the side of prescribing antibiotics. That’s good for their patients, but it’s going to also lead to potentially unnecessary antibiotic use.”
The solution, according to experts, sounds simple. Use less, discover more, and use tests to tell if a person needs them before giving them out.
The first two are hard and slow, but the third is available now, and experts want to use Covid style lateral flows to help curb superbugs. Most sore throats and colds are caused by viruses, not bacteria, and yet it is difficult for a doctor to know the difference.
Tests to help with this exist, but are not being used. A lateral flow Strep A test was trialled by Boots in 2016 and reduced the number of people who got antibiotics significantly. Of more than 2,000 who went to a pharmacist complaining of a sore throat, only 36 needed antibiotics and just 11 had to go to the doctors, with the test service cutting GP appointments for sore throats by around 99 per cent.
“Any way that we can reduce the inappropriate use of antibiotics is needed and what would be better than affordable, quick diagnostic tests,” Lord O’Neill said about the Boots trial of tests which cost just £7 each and work in five minutes but are not widely available on the NHS in England. “Win-wins are pretty rare, but it is a complete win-win.”
Prof MacLean added: “One form of test that would help are rapid diagnostic tests like the Covid lateral flow tests we’ve all taken. We don’t have widespread tests like that. It would be better if we could use antibiotics smarter and use diagnostic techniques to target them.”
Tests are not a panacea, however, and more work is needed to refine them, which requires funding. Lord O’Neill believes this has to come from government.
Professor Alistair Hay, a GP and scientist at the University of Bristol is running a trial, and said that a Covid-like lateral test which tells if a sore throat is viral or bacterial is “the holy grail of research”.
He warned it is still a while away yet.But added that quelling the rise of superbugs and fighting bacterial infections are not mutually exclusive. The key is to ensure that only those who need the drugs take them.
“The two are completely compatible. What we’re trying to do is get antibiotics to the people who need them and avoid prescribing when not necessary.”