It is repeatedly stated that we face a global challenge of antimicrobial resistance and catastrophic health and economic impacts, and that this is the product of misuse, abuse, and essentially over-use of antibiotics. It is hard to argue, and I would not wish to, that this is at least partly the case, but it is both dangerous and misleading to present this as the whole of the explanation. What we are seeing is an inevitable consequence of many pressures and their inevitable evolutionary outcomes. That mis-use, over-use, and various pressures other than human health have contributed to the current situation, but there are plenty of other contributory factors – and we cannot genuinely address the problem without naming and facing them.We are concerned about AMR because it challenges human health, and some human’s personal survival. But it should be realized that significant drivers for the AMR challenge we now face had nothing to do with human health. You can’t blame a company for wanting to sell its products, or for rolling out new ones as soon as they are available. By keeping up with the arms race against the bugs rather than seeking to restrict and change practice to focus and minimize the development of new resistances.
I remember when we used to have what is now regarded as a new policy of zero tolerance towards hospital infections with MRSA, and then it was stopped, intentionally! A case of MRSA in hospital triggered a response of containment, isolation, and effective infection control precautions. Possibly infected contacts were screened, contained, and if necessary treated. Then, with excuses such as practice in Australia (where such infections were not contained and were subsequently completely out of control) were cited to show that it wasn’t necessary; while a lack of funding for microbiology and infection control staff to maintain recommended ratios to patients meant that it was practically hard work to deliver. So, what is now our new policy of ‘zero tolerance’ was abandoned in the 1990s.
As COVID-19 should have illustrated for everyone, pathogens are without borders. Our Brazilian AIDS patients had histoplasma lung infections, not the local versions; and our patients who had been to Spain had Spanish AMR infections – 20 years ago. Many countries allow you to buy antibiotics over-the-counter (and STILL do), and this is associated with societies with far greater emergence of AMR than those with more restrictive practices. That reducing the use of antibiotics for viral sore throats by UK GPs has positive effects isn’t up for debate, and the campaign for ‘Antibiotic Stewardship’ is good and wise. But, the types of antibiotics that were over-used in these settings aren’t the ones that the really challenging ones being lost in the battle with AMR, and unless you not only stop other places continuing with much poorer practice (and stop our population going on holiday and collecting them from such places) it isn’t going to make a big difference in the end.
So, two points could be usefully made with respect to the use of antibiotics in human care: First: AMR isn’t caused misuse, at the most it is accelerated by local use and practices. The emergence of AMR is an inevitable consequence of the use of a selective pressure on an evolutionary process. How many tons are used per year in human and other contexts will affect how fast, but not if it will happen. The scale and impact of AMR within hospitals – that’s a separately identifiable issue, but the doctors were put in an impossible position, and the resources and recognition now associated with the new ‘zero tolerance’ policy didn’t exist when it was originally practiced. Second: nobody should blame GPs and other UK-based doctors for a situation which was being more effectively created and imported from elsewhere. And, where the antibiotics that were being marginally over-used locally are not the ones where resistance presents the real challenges we face.
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