Legionnaires’ disease is associated with poorly maintained air conditioning, cooling towers and portable water systems. Cooling towers in Milwaukee may be linked to the outbreak.
A late start to summer weather in the Upper Midwest may be linked to an outbreak of 27 cases of Legionnaires’ disease in Milwaukee County since June 1 of this year, a health official said on Thursday.
The outbreak includes 19 cases of the illness, a severe form of pneumonia, among Milwaukee residents, according to the city’s health department. Two other county cases are suspected.
We need to heed the chief medical officer’s warning about drug-resistant bacteria, says Michael Hanlon
Imagine a world where a scratch would strike terror into your soul. A place where giving birth is a life-and-death experience, where every sore throat and stomach upset is potentially lethal. A world where almost no surgeon will operate unless the only alternative is certain death, and where chemotherapy is too deadly to contemplate. This could be our awful future, according to Professor Dame Sally Davies, the Government’s chief medical officer. She has warned that the world faces an antibiotic apocalypse, a “ticking time bomb”, and a “catastrophic threat to the population” as medicine faces the prospect of losing probably the most powerful weapon in its armoury – the effective antibiotic.
The tragedy is that this is a disaster of our own making. Thanks to a combination of profligacy, wilful stupidity, the laziness of thousands of doctors, and the selfish persistence of millions of patients in demanding instant cures for minor illnesses that would go away on their own, simple bacterial infections could once again become the scourge of humanity.
When antibiotics were developed in the 1930s and 1940s, doctors found themselves equipped with cheap, safe and effective miracle drugs that transformed the prognoses of millions of patients. The first penicillin antibiotics were incredibly effective against a host of diseases, such as tuberculosis, and in fighting off myriad infections caught through bacterial transmission or as a result of accidental or surgical wounds.
In the Forties, Fifties and Sixties, it seemed that the germs had no answers to penicillin and other wonder drugs, which along with sanitation and vaccination, were responsible for adding years, and then decades, to life expectancies across the planet. When one bacterial species proved to be resistant to the antibiotic armageddon being rained down upon it, new drugs would emerge from the pharmaceutical laboratories, synthesised and semi-synthetic versions of natural compounds produced by species of fungus (such as Penicillium itself and Acremonium).
The hardiest bacteria, such as E. coli, held their ground until a new class of antibiotics, the carbapenems, was developed in the 1980s. These were the hydrogen bombs of the antibiotic world, able to outwit the cleverest evolutionary and molecular tricks of our bacterial foes.
But in the last two decades, we’ve had a problem. No antibiotic, however potent, is ever completely effective. Like that disinfectant which “kills 99 per cent of germs”, it is the one per cent that survive which you have to worry about.
Bacteria reproduce, by dividing, at an alarming, exponential rate. One becomes two becomes millions in days. Amid this frenzied asexual promiscuity, the bacterial genome gets the chance to be endlessly tweaked and modified. As with most mutations, these alterations will usually be either fatal or unremarkable. But a few will, by chance, confer upon the microbe the ability to see off the best the medicine can do – including the carbapenems that may have turned out to be our weapon of last resort.
In the late 1990s, Methicillin-resistant Staphylococcus aureus, a germ resistant to both the penicillin-based and cephalosporin antibiotics, emerged. It rapidly became the scourge of our hospitals. Most strains of MRSA are almost impossible to treat and the only line of defence (as our hospital managers have belatedly realised) is better hygiene.
Then, in the late Noughties, a new “indestructible” germ emerged from India, an E. coli gut bacterium modified by a gene called NDM-1 (New Delhi Metallo-beta-lactamase-1). Worryingly, the DNA responsible for the mutation has been found to be capable of being transmitted easily to other species of bacteria.
This sad story is a version of the “tragedy of the commons” – a disaster that occurs when an action beneficial to an individual causes great harm to the community. The main cause of the antibiotic apocalypse has been overprescribing, which increases the exposure of bacteria in the population as a whole to the drug in question, and gives these microbes more opportunity to evolve resistance.
For half a century, the mildly ill, the hypochondriacal and the worried well have demanded – and often been given – antibiotics to treat bacterial infections that are so mild they will be dealt with in a few days by the body’s immune system. Worse, many have taken antibiotics for illnesses – such as colds and influenza – that are not caused by bacteria but by viruses, which are immune to antibiotics. Such over-prescription greatly increased the chance of resistance emerging. And while antibiotic overuse has declined in the West, it has exploded in India and China, where the drugs are usually sold prescription-free.
Another major cause is the massive quantity of antibiotics fed to livestock. Cattle, pigs and chickens are not just given the drugs to cure illness, but for their side effects, which include their ability to stimulate growth.
Although banned in the EU, such prophylactic use is common across the world – so common that in the United States, it is hard for farmers to obtain feed that does not contain these drugs. As well as increasing exposure to antibiotics generally, there is the risk that drug-resistant strains may enter the human population through food.
Finally, we have not seen a new class of antibiotics since 1987. It does not make sense for drug companies to spend huge amounts creating a low-profit drug that may only be effective for weeks, until the bacteria evolve a new line of defence. Leaving the development of drugs to market forces is proving to be an ineffective and inefficient way of improving the medical arsenal.
So is the antibiotic apocalypse inevitable, or as big a risk to our society, as Sally Davies warns, as international terrorism?
Not necessarily. New rules are needed to discourage, even penalise, overprescribing. According to Professor Richard James, an expert in bacterial infections at the University of Nottingham, it might be worth exploring “economic measures, such as a tax on antibiotic use, to prevent [this] tragedy of the commons scenario”; the income from such a tax could be channelled into new research.
Global co-operation is also needed. Countries where antibiotics are available over the counter need to change their laws to stop the practice. Antibiotic resistance is exacerbated by international travel, so we need more screening at airports. We need new ways to encourage drug firms to invest in antibiotics. And we need all this fast – otherwise, our children will wonder why our generation and the generation before squandered one of the greatest advances in health and wellbeing ever stumbled upon by humanity.
Warning over rising death toll as antibiotics fail to tackle rising incidence of ‘gram negative’ bacterial diseases
Antibiotic-resistant bacteria with the potential to cause untreatable infections pose “a catastrophic threat” to the population, the chief medical officer warns in a report calling for urgent action worldwide.
If tough measures are not taken to restrict the use of antibiotics and no new ones are discovered, said Dame Sally Davies, “we will find ourselves in a health system not dissimilar to the early 19th century at some point”.
While antibiotics are failing, new bacterial diseases are on the rise. Although the “superbugs” MRSA and C difficile have been reduced to low numbers in hospitals, there has been an alarming increase in other types of bacteria including new strains of E coli and Klebsiella, which causes pneumonia.
These so-called “gram negative” bacteria, which are found in the gut instead of on the skin, are highly dangerous to older and frailer people and few antibiotics remain effective against drug-resistant strains.
As many as 5,000 patients die each year in the UK of gram negative sepsis – where the bacterium gets into the bloodstream – and in half the cases the bacterium is resistant to drugs.
“Antimicrobial resistance poses a catastrophic threat,” said Davies. “If we don’t act now, any one of us could go into hospital in 20 years for minor surgery and die because of an ordinary infection that can’t be treated by antibiotics. And routine operations like hip replacements or organ transplants could be deadly because of the risk of infection.
“That’s why governments and organisations across the world, including the World Health Organisation and G8, need to take this seriously.”
There has been an 85% reduction in MRSA (methicillin-resistantStaphylococcus aureus), which has meant that many large, acute hospitals have no more than two or three cases a year. But there are now 50 to 100 cases of gram-negative bacteria infection for every MRSA case, according to Professor Mike Sharland of St George’s hospital in London, an adviser to the Department of Health on the use of antimicrobials (antibiotics and antivirals) in children.
“This is your own gut bugs turning on you. Between 10% and 20% are resistant to drugs. We do not yet know why they are on the rise, although some hospital procedures, such as the use of catheters, may be implicated. Many are in the very young or older population,” he said.
“There is a lot of work going on through Public Health England and the Department of Health to try to work out why it has suddenly risen.” In the second volume of her annual report, Davies calls for politicians to treat the threat of the new bugs and the failing antibiotics as seriously as they did MRSA. She wants action across government departments – involving the Department for Environment, Food and Rural Affairs in particular – because of the use of antibiotics in farming.
She is asking for the threat to be added to the government’s strategic risk register, which will make it easier to raise as an issue abroad. Drug resistance is a global problem as the resistant strains of bacteria travel the world.
Multi drug-resistant TB and even some cases of extremely drug-resistant TB (only treatable with difficulty and with last-line antibiotics) have come to Britain.
Antibiotics fail because bacteria develop resistance to the drugs over time. In the decades after the invention of penicillin it did not seem to be a problem because drug companies developed new versions. But no new classes of drugs have been discovered since 1987 and the pipeline has now dried up.
Davies wants to find ways to give the pharmaceutical industry incentives to invest in finding new antibiotics. Most companies have given up because the search has become hard and, because resistance always develops, their lifespan is not long, so there is not much profit to be made.
The sort of incentives that could be offered have not yet been decided, but Davies praised the Innovative Medicines Initiative in Europe, a new public/private partnership. Other recommendations in the report include more education for medical students and qualified staff on the use of antibiotics and encouragement for women to be vaccinated where appropriate in pregnancy, for instance to protect their baby against whooping cough.
The Department of Health said it would shortly publish a five-year action plan to tackle the issues of antibiotic resistance raised in the report, which will include measures to ensure the drugs are prescribed only when they are needed.
Experts warmly welcomed the report. But Richard James, former director of the centre for healthcare associated infections at the University of Nottingham, pointed out that the UK could not solve the problem on its own and global action in countries where antibiotics are over-used, wrongly used and can sometimes – even in southern Europe – be bought over the counter, was vital.
“Anyone reading the report will realise that there are no magic bullets,” he said. “The majority of the 17 recommendations relate to actions in the UK alone but there is acknowledgment of the requirement for the UK government to campaign for this issue to be given higher priority internationally.”
He suggested exploring the use of a tax on antibiotic use and also measures to encourage the developments of alternatives by small biotechnology companies and universities, such as vaccines.
Laura Piddock, professor of microbiology and deputy director of the institute of microbiology and infection at the University of Birmingham and director of Antibiotic Action, said she was glad Davies was drawing political attention to the antibiotic discovery void.
“However, there are an increasing number of infections for which there are virtually no therapeutic options, and we desperately need new discovery, research and development; the UK is extremely well-placed to do basic discovery and research for new antibacterial molecules,” she said.
The Association of the British Pharmaceutical Industry (ABPI) said Davies was right to raise concern. “Antimicrobial resistance is a serious and growing problem,” said chief executive Stephen Whitehead, noting the Innovative Medicines Initiative in Europe. “There are, however, pharmaceutical companies actively involved in researching and developing new antimicrobial medicines.
“But more still needs to be done and we believe that for there to be a continual supply of effective antibiotics, a comprehensive review of the R&D [research and development] environment and good stewardship are required urgently.”
- Antibiotics Breed Apocalyptic Diseases (vineoflife.net)
An increased number of hospital patients are suffering from deadly infections caused by antibiotic-resistant bacteria, the Centers for Disease Control (CDC) reports in a March 5 press release. Carbapenem-Resistant Enterobacteriaceae (CRE) infections kill up to half the people infected with the bacteria. The percentage of CRE cases has increased by 400 percent over the past decade. In the nation, the northeastern states have reported the most cases of CRE.“CRE are nightmare bacteria. Our strongest antibiotics don’t work and patients are left with potentially untreatable infections,” — CDC Director Tom Frieden, M.D., M.P.H.
- ‘Nightmare’ bacteria spreading in U.S. hospitals, nursing homes: CDC (vineoflife.net)