Finnegan's Take

Antimicrobial resistance is a growing source of misery but there is no incentive to develop new antibiotics.

It all began with a stumble. My grandmother was in her eighties when she fell at home and broke her ribs. A brush with MRSA and a torrid battle with C. difficile would follow before she finally suffered her last stroke. The death certificate doesn’t say anything about MRSA, C.Diff or superbugs – even though these infections subjected her to several bouts of misery in the year or so before she died. In the way that family illnesses do, the whole saga engulfed several households for months.

Backs and forth to hospitals, meetings with consultants and social workers; it’s a familiar story. We met cousins, aunts and uncles on Christmas morning in the family room of the eerily quiet corridors of a Dublin hospital. The consultant, a skeleton nursing staff, and a few other ashenfaced visitors were the only souls to be found on the ward. Festive cheer was in short supply.

At the height of the C.Diff infection – with a strain the doctors said had killed other patients in the hospital – my grandmother was put in isolation. Visitors had to be masked and gowned.

Remarkably, she battled on, surviving another fall and being moved to a stepdown facility before an appropriate nursing home place was found. There she regained some wit and some weight before a stroke sent her back to hospital for the last time. There, after the bones of five days on a trolley in a relatively secluded corner just off the emergency department, she went.

Subtract the so-called healthcareassociated infections and it would have been the story of an uncomfortable fall, a return to health, and the relatively straightforward passing of the most mischievous old lady you’ve never met. But the superbugs were a source of pure misery and cruelty, turning strength into weakness and stealing independence. They didn’t cause my grandmother’s death but they did undermine her quality of life.

I’m telling you this because when we read figures about hospital infections, we know it’s only the tip of the iceberg. And when reports come in about relatively newer varieties of resistance bugs like CRE or KPC, both of which have hit Irish patients in recent weeks, it is particularly worrying.

Action at EU level

World Health Day was marked this month with a special push at EU level to raise awareness of antimicrobial resistance. In Europe, drug resistant infections directly cause an estimated 25,000 deaths and run up about €1.5 billion in healthcare costs every year. The cause of the problem is familiar: Misuse of antibiotics. Misuse by patients who don’t bother completing a course, and misuse by doctors who overprescribe.

Doctors needlessly dolling out antibiotics to the patient sitting in front of them – at the expense of an anonymous future victim – are like the helpful-looking neighbour who offers to get rid of your old fridge, but proceeds to dump it in the local river. You thank him for doing you a favour, even though he has created an even more serious problem for the entire community.

One of the things the EU plans to do to turn the spotlight on the misuse of antibiotics is raise awareness of the problem and its causes. This will be targeted at the public in the hope that they will put less pressure on doctors to prescribe. They will also target health professionals but the truth is that doctors already know which prescriptions are justifiable and which ones are speculative – or written to appease a time-consuming patient with a viral infection.

One of the big problems with taming drug-resistant infections is that there is no incentive to develop new antibiotics. With so many people affected you might think there is a golden opportunity for an entrepreneurial research team to find a new treatment. But the reality is that no company is willing to invest because the moment they strike gold and find a new broad spectrum antibiotic, it will be immediately quarantined. Microbiologists will rejoice at this new addition to their arsenal but it will be strictly held in reserve as a new last line of defence.

This is, of course, the rational thing to do. If we were to use the new product liberally, our microscopic foes would take the opportunity to acquire resistance. But medicine makers are equally rational in not wanting to develop something – at a cost close to €1 billion – which will be used only scarcely.

So, we’ve misused the antibiotics we had and there are few, if any, coming down the R&D pipeline. This is an area where public money may be needed to entice – or even replace – private investment. Either health research budgets (perhaps from the European pot) are used to find new antibiotics or other incentives are used to encourage investment.

Some have suggested that companies could be given patent extensions on their other medicines in return for bringing a new antibiotic to market but policymakers are still struggling to agree practical solutions. Some answer may come later this year.

In November, the European Commission will publish a new strategy to deal with antimicrobial resistance. For some patients, it can’t come too soon. For others, it’s too late.

Gary Finnegan is a former Editor of IMN and the Irish winner of the EU Health Prize for Journalists 2009 and 2010. He is currently based in Brussels.

[This article first appeared in Irish Medical News]

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