'It's time to take this seriously. The bugs are smarter than us'
We live in a post-antibiotic era, where superbugs and other bacterial infections are less responsive to our most powerful drugs. And antibiotic resistance is not just an issue for hospitals - it's also a critical issue for farmers and vets. Ahead of Antibiotic Awareness Day, our reporter talks to the experts calling on the Government to invest in new drugs, and implement legislation to combat antibiotic resistance
As winter season approaches, many of us will flock to GPs demanding an antibiotic prescription to 'fix' the problem. And many GPs, against their better judgement, will prescribe powerful antibiotics that are useless to fight viral coughs and colds while reducing our ability to fight serious bacterial infections.
For years, a red flag was raised on how deadly 'superbugs' are less responsive to antibiotic drugs. But we have now reached that critical point where powerful drugs relied on for decades are just not working.
"We are actually in a post-antibiotic era because we have bacterial infections that are not treatable using any antibiotic available to us today," says Professor Ramanan Laxminarayan, director and senior fellow at the Centre for Disease Dynamics, Economics & Policy in Washington DC.
Ahead of European Antibiotic Awareness Day on November 18, experts like Professor Laxminarayan insist that governments must mobilise public campaigns on a similar scale to the battle against smoking in the 60s.
"We have a limited window now - we don't want to regress to the world we had before antibiotics. We always knew this was coming but resistance has grown in the past 10 to 15 years to the point where it is now a serious threat to public health," he says.
Pharmaceutical companies are not investing in new drugs on grounds of high investment costs, and no new antibiotics have been developed since the 1980s.
The burden of infections and global resistance means that a healthy person can unexpectedly succumb to deadly superbugs, although patients receiving cancer treatment and post-surgery, women following childbirth, newborns and the elderly, are at specific risk.
All the experts agree on the need for a major step up in state efforts to reduce antibiotics, not only in hospitals, GP and veterinary surgeries, but also in meat products for supermarket shelves and in waste water supplies. But changing practices is another matter.
Four million patients across the EU are struck down with a healthcare-related infection each year. About 25,000 human deaths yearly are linked to drug-resistant bacteria, according to the European Centre for Disease Prevention and Control (ECDC). Related health care costs run to ¤1.5 billion per annum.
"Ireland is in the top third of antibiotic consumption in the EU - and levels of antibiotic resistance and use are closely linked," explains Dr Nuala O'Connor, who is the Irish College of General Practitioners' lead advisor on antibiotic resistance.
Ireland is about mid-way among EU countries in resistance levels; Greece and Italy show high resistance and Sweden is at the lower end.
A major concern is resistance to powerful drugs, for example, carbapenems which are a last line therapy in patients with serious hospital-acquired infections. In the 'hot spots' of China, India and Thailand, resistance to the drug increased from 1pc in 1999 to 40pc in 2010.
"The bug that's really worrying right now is CRE (carbapenem-resistant enterobacteriaceae) which is reported in countries including Ireland, and is highly resistant with a high mortality rate. While the numbers are small, there's evidence it's starting to circulate in the community," O'Connor says.
Ireland has the highest rates in Europe of the bowel bug VRE (vancomycin-resistant enterococcus), she adds.
GPs in Ireland prescribe too many broad-spectrum antibiotics - far more than countries who are achieving low levels of antibiotic resistance and are using more targeted, narrow spectrum antibiotics. "It's like using bleach-type products for everything instead of washing-up liquid for most jobs," O'Connor explains.
Residents of Irish nursing homes are more than twice as likely to be on an antibiotic than in any other European country. Almost 40pc of antibiotics used in nursing homes and long-stay facilities in 2013 were prescribed on a purely preventative basis.
"We are reducing the number of antibiotic prescriptions especially for those under the age of 16 and we are also reducing broad-spectrum antibiotics. But we have a long way to go. Currently Irish patients use twice as many antibiotics as Scottish patients," says O'Connor.
MRSA has decreased somewhat because, as a skin-borne bug, it is easier to manage through hand washing.
"But there are other serious bugs in the bowel on the rise and when you get ill, those bugs can take over. Every single antibiotic used when it's not necessary is a problem. Doctors need to do better and it's important that people listen to medical professionals when they tell them they don't need antibiotics and they're ineffective for the vast majority of colds which are viral."
There is frustration in the Irish medical and science community which says the Government is not moving with the urgency, purpose or resources needed to tackle the problem. The first national strategy to combat the problem of antibiotic resistance, SARI, was launched in 2001 and has still not been fully implemented, according to O'Connor.
"We urgently need a comprehensive national action plan for antibiotic resistance supported by a properly resourced implementation programme," she says.
Both the departments of Health and Agriculture, Food and the Marine are working on a national action plan with the human health, animal health and environmental sectors. A Joint National Interdepartmental Antimicrobial Resistance Consultative Committee was established in 2014.
"The committee meets twice yearly and most recently met on April 13 2016; a further meeting is scheduled for November 2016. The plan will be finalised in the early part of 2017."
Antibiotic-resistant bacteria are found in sewage from hospitals and homes that is ending up in the natural environment. The Environmental Protection Agency published research showing that while pre-treatment before discharge can reduce the presence of resistant bacteria, including E coli, it did not eliminate them completely. Many authorities don't treat sewage and the report warned of the dangers of such discharges.
How antibiotic resistance in meat, especially pork, can filter through the food chain and onto consumers' plates is another concern.
Veterinary Ireland estimates that premix antimicrobial drugs account for 32pc of national use, and the pig industry accounts for most of this. A study by Teagasc found that half of all pig farmers believe in-feed medication is the only way to deal with health issues and ensure good welfare.
In March, MEPs voted in the European Parliament to ban the use of preventative antimicrobials on animals; to restrict the collective dosing of animals to specific cases of illness; prohibit the use of antibiotics in animals that are critical to human medicine, and to end online sales of antibiotics and vaccines.
But many elements of the legislation - the EU Animal Health Law (EU Regulation on Transmissible Animal Disease) - won't enter domestic law until 2021. In the meantime, more action is needed to reduce antibiotic use, according to Dr Nola Leonard, veterinary surgeon and senior lecturer in the School of Veterinary Medicine in UCD.
"There is a huge problem with antibiotic-resistant organisms that are present both in the human population and the animal population, particularly intensively farmed animals. We have animals with infections that are very difficult to treat - it's the same story that we have in hospitals. In Ireland, there are too many infeed antibiotics used in the pig industry, less so in the cattle and dairy industry which is not as intensive," she says.
As a first step, Ireland needs to access more sophisticated data on prescribing practices to identify the extent of the problem in animals. "We have only industry sales data. We must have effective surveillance and electronic recording of prescriptions and usage," Leonard says.
The mandatory visits by vets to farms which was reduced to once yearly under legislation introduced in 2007 should be revisited, so that antibiotic use, and especially preventative use on farms can be regularly reviewed.
"In Ireland, many vets supply antibiotics to farmers as well as write the prescriptions. Whereas in countries like Denmark they've separated prescribing from dispensing and vets can only write prescriptions. The farmer must go to the pharmacist to get the drugs."
Should Ireland consider a similar separation? "Reports from different countries suggest it's a very good thing to separate prescribing from dispensing. The Danes, for example are great advocates."
The Dutch did not separate these functions, but still managed to reduce antibiotics by over 50pc in animal production. In response to public concern, parliament legislated for a 50pc reduction which was achieved. The Dutch have since set a new target of 70pc reduction.
McDonalds, the world's biggest restaurant chain, announced it would stop using antibiotics in chicken for its US restaurants by March 2017.
Bord Bia has alerted Irish farmers that some US food companies are switching to 'free from' products, with "antibiotic free" and "hormone free" meat and poultry recording high growth in 2015.
With over 60,000 farms participating in its Quality Assurance schemes, Bord Bia says it promotes the responsible use of antimicrobials and auditors specifically check this during every audit.
Can the Irish meat industry go antibiotic-free? "To a large degree it's possible but it would mean big changes in management and probably price increases," says Leonard. "This is because pig feed is a large cost in Ireland since we're mostly a grass-producing rather than cereal-producing country.
"If you want a pig industry with good welfare and management practices, you must pay for it, and you can't do it at the cheap prices consumers are paying for it currently."
Anti-microbial medication is put in feed for broiler chickens to prevent the coccidia parasite, commonly found in the intensive poultry industry. "We should investigate the cost of vaccinating day-old broiler chickens to see can we come up with a solution that would eliminate the use of anticoccidial drugs," says Pat Kirwan, former president of Veterinary Ireland.
"The breeder stock is deemed worthy of vaccination, but it's not seen as worthwhile to vaccinate broilers on cost grounds. The vaccines are available if that's what consumers want, but they're not as cheap an alternative or as readily available as drugs. All costs to the industry are considered significant."
Kirwan estimates antibiotics are administered in less than 10pc of broiler chickens for the supermarket shelves. A combination of consumer demand, retail standards and the forthcoming EU Directive will drive changes required in the mass market, since organic meats are still too pricey for most consumers.
"Organic chickens are affordable for some consumers but for you, me and the ordinary person, organic doesn't apply. We don't buy a chicken for €15 when there's one for a fiver staring us in the face."
Animal Health Ireland's chairman Mike Magan believes consumers should be reassured that dairy farmers adhere to a "gold standard" and every tank of milk from the farmyard to the processor is checked. If there's a problem, each individual sample is checked. "When the culprit is found he's fined and the entire tank is discarded."
The AHR runs programmes to dissuade farmers from routinely using antibiotics to prevent mastitis in cows, a practice that will be banned under EU legislation when it comes into effect in five years' time.
"We all have a responsibility to educate ourselves to minimise the use of antibiotics, so if we use them, we use them correctly. Because someday, somebody close to us will need an antibiotic and it won't work. The bugs are smarter than we are, they've been around a lot longer than we have."
Health & Living