Antibiotic Resistance

Julian Sturdy Excerpts

Wednesday 15th October 2014 Westminster Hall

[Julian Sturdy (York Outer) (Con)]

I am delighted to have been given the opportunity to host a vital debate on antibiotic resistance. As ever, Mr Chope, it is a pleasure to serve under your chairmanship.

Many people will be aware that the 20th century discovery of antimicrobial drugs, a class of medicine that includes antivirals, antimalarials and antibiotics, such as penicillin, is among the greatest medical breakthroughs of our time. However, we have failed to heed the warnings of such people as Alexander Fleming, who, when collecting his part of the Nobel peace prize in 1945, warned:

“there is the danger that the ignorant man may easily underdose himself and by exposing his microbes to non-lethal quantities of the drug make them resistant”.

There has never been any doubt about the link between the misuse of antibiotics and resistance to them, but despite this antibiotics have been misused and, as a consequence, we now face the prospect of losing modern medicine as we know it. If people take a moment to think about the consequences, they will find them frankly horrifying.

In 2013, the chief medical officer, Professor Dame Sally Davies, told Parliament of an horrific scenario, where people going for simple operations in 20 years’ time could die of routine infections because

“we have run out of antibiotics”.

To some, this scenario may still seem too far in the future to warrant any immediate action, but for me the clock started ticking on this issue a long time ago. Yet we are no further forward.

In 20 years’ time, my children will be in their late 20s. Parents and families around the country will all want their children, and the next generation after that, to have the medical guarantees that we have the luxury of being afforded today, so inaction is simply not an option.

Antibiotic resistance is already changing clinical practices in this country, For example, in recent years complication rates for prostate biopsy, which carries a risk of septicaemia, have increased from less than 1% in 1996 to nearly 4% in 2005. Due to this, doctors are now carrying out the biopsy in a different way, changing clinical practice.

The rise of antibiotic resistance is widely seen by organisations such as the European Food Safety Authority and the World Health Organisation as a consequence of the use and overuse of antibiotics in both veterinary and human medicine. However, in this debate I will focus on the continuing overuse of antibiotics in human medicine, where considerable improvements could still be made in many countries.

[Mr David Davis (Haltemprice and Howden) (Con)]

I congratulate my hon. Friend on securing a debate about one of the great threats to modern civilization: the prospective failure of antibiotics. Since he is not going to focus on agriculture, might I ask whether he agrees that, because some 50% of antibiotics are used in agriculture in this country, and 80% in the United States, if we are to take an international lead, as the Prime Minister would wish us to, we have to clean up our own act at home, in the way that the Dutch have in agriculture?

--- Later in debate ---

[Julian Sturdy]

I agree. Although I was only going to touch on that matter briefly, that does not mean that I do not recognise the impact on resistance from use of antibiotics in veterinary medicine. My right hon. Friend is right to mention the problems relating to resistance in the US, especially because the way that veterinary antibiotics are used there is quite frightening. In the UK and Europe, we use antibiotics differently. The Dutch are the example in that regard, and we have to learn from that. If we continue to misuse antibiotics, whether in human medicine or in the veterinary industry, resistance is bound to happen and that is bound to cause a problem, so we have to tackle it on both sides, although I want to focus on the human medicine side.

[Jeremy Lefroy (Stafford) (Con)]

My hon. Friend mentioned malaria and the treatments against it that have been discovered. He may know that, through misuse of the latest generation of artemisinin-based antimalarials, resistance to those is already coming up through Thailand and Burma and will possibly, eventually, get to sub-Saharan Africa, with devastating consequences, as was the case with previous antimalarials.

[Julian Sturdy]

My hon. Friend is right. I was going to touch on that. Multi-resistance is widespread around the world. He mentions antimalarials, but resistance is also apparent in relation to tuberculosis and there is emerging resistance to the antibiotics of last resort—the so called super antibiotics—the carbapenems, which are not licensed for use in farm animals on the veterinary side. That resistance is causing real concern.

Returning to the livestock sector for a minute, there is a tendency among some sections of the intensive livestock industry, and even some Governments, to dismiss almost entirely the contribution to resistance by veterinary use of antibiotics. This is a dangerous path to take, because although antibiotic use in farm animals may not be the main driver of resistance in humans, it is a still an important contributor, and we must recognise that.

[Glyn Davies (Montgomeryshire) (Con)]

Before my hon. Friend moves away from the agricultural sector, let me say that, in a long previous life as a livestock farmer, one of my earliest experiences was of the most amazingly casual approach to the use of antibiotics. If we are going to change the mindset in the agricultural industry, we have to bring on board the unions that advise farmers and get the people running agriculture onside in recognising the danger of this, because an awful lot of individual operators just do not accept the dangers and risks.

[Julian Sturdy]

I agree entirely with my hon. Friend. I said earlier that we must tackle misuse in the livestock sector, as well as misuse in human medicine; we must tackle misuse across the world. Regarding food security and imported food, antibiotics are misused throughout the world in the livestock sector.

It is worth putting on the record that in the UK we have some of the best animal welfare standards in the world, but we do not misuse antibiotics to any extent in the food chain, as is seen in the US. Such misuse has to be stopped and action has to be taken on that.

For far too long antibiotics have been used as if they were a bottomless pit of cure-all miracle treatments. Some 30 years ago, the battle against infectious diseases appeared to have been won, at least in the developed world. The old drugs could handle whatever bugs came along, which meant there was no market for new ones. That is why, since the year 2000, just five new classes of antibiotics have been discovered, and most of these are ineffective against the increasingly significant problem posed by gram-negative bacteria, which are also difficult to detect. The fact is that misuse, over-prescription and poor diagnostics have driven an environment that favours the proliferation of resistant strains of bacteria, rendering once vital medicines obsolete.

[Mr Iain McKenzie (Inverclyde) (Lab)]

I congratulate the hon. Gentleman on securing this important debate. What does he think about the growing pressures on GPs from their patients to prescribe antibiotics, which causes over-prescription?

[Julian Sturdy]

The hon. Gentleman makes a valid point. I hope that, through this debate and beyond, we can get the message out there that the misuse of antibiotics is potentially the greatest threat to mankind that we have seen, and in doing so, I hope that the pressures on GPs will start to subside. He is absolutely right. GPs in my constituency tell me that as soon as some people get a common cold or a sore throat they are breaking down the door, asking for antibiotics. Sometimes it is difficult for GPs to resist those calls. If we are going to secure our long-term future in the medical industry, those calls have to be resisted and that is where it has to start.

If we look at deaths related to MRSA, which is a bacterial infection resistant to a number of popular antibiotics, mortality rates rose steadily in the UK from 1993 onwards to peak at more than 2,000 in 2007. Bacteria and parasites are already developing resistance to front-line antimicrobials, which are over-prescribed and under-regulated, leading to 25,000 people dying each year in Europe from infections that doctors were unable to treat with the drugs available to them. Those statistics, however, are just from the developed world; the misuse of antibiotics is a much more serious problem in lesser developed countries, as my hon. Friend the Member for Stafford (Jeremy Lefroy) said. Hotspots of antimalarial-resistant parasites are springing up in south-east Asia, as are cases of extreme drug-resistant tuberculosis in South Africa and other parts of the African continent. Those are among the many examples that illustrate the urgent nature of this health problem.

In an increasingly interconnected world, an infection that emerges in Delhi today will have an impact in London tomorrow. More needs to be done on a scientific level to develop new antibiotics and to improve diagnostics, but science alone will not solve the problem. Pharmas, which is the collective term for pharmaceutical companies —I put on record that I was a farmer, not a pharma—need to be incentivised to develop new antimicrobials. As with other resources, antibiotic effectiveness can be used up. The eventual loss of current antibiotics is sadly inevitable, but, depending on the actions taken now, it can happen at a much slower pace.

While there are many examples of misuse in lesser developed countries, I want to look specifically at the case of India, as the challenges associated with controlling antibiotic resistance there are many and multifaceted. India has a problem with the overuse and underuse of antibiotics. The underuse is mainly due to the lack of prescriptions. For example, prescriptions were not presented for one fifth of the antibiotics purchased recently in Delhi. However, in 2005-06, a large proportion of infant and childhood deaths from pneumonia would not have occurred if the children had been properly treated with antibiotics. On the overuse, patients with coughs and colds are often prescribed antibiotics, which wastes their effectiveness. As I said, many continue to purchase antibiotics without a prescription.

India has emerged as the world’s largest consumer of antibiotics, with a 62% increase over the past decade. They consume an average of 11 antibiotic tablets a person a year—that is five days of antibiotics for every person in the country. Additionally, the use of last resort drugs such as carbapenems has gone up significantly. That is due to the enzyme known as NDM-1, which makes bacteria resistant to a broad range of antibiotics, including the antibiotics of the carbapenem family. Bacteria that produce carbapenemases are often referred to in the media as superbugs, because the infections they cause are difficult to treat. In India, 50% of all superbugs are resistant to all known antibiotics. The only exception to that is colistin, but that is because the antibiotic, which was introduced in 1959, is considered toxic.

In India, it is commonplace for someone with a sore throat to go to the chemist and choose the antibiotic they want to use. From there, many people will go to a clinic and are given their chosen antibiotics intravenously to treat the sore throat. Usually, the full dose is not administered. That is a horrendous example of the misuse of antibiotics and simply cannot be allowed to continue. Over-the-counter regulation needs to be tightened in lesser developed countries and people need to be better educated on the problems associated with misuse.

On funding and bringing new drugs to the marketplace, when pharmaceutical companies are deciding where to direct their research and development money, they naturally assess the market for a drug candidate. They have an incentive to target diseases that affect developed countries, because they can afford to pay. The pharmas also have an incentive to make drugs that many people take, and take regularly for a long time, such as statins and antidepressants, which leads to enormous under-investment in certain kinds of diseases and certain categories of drugs. Diseases that mostly affect poor people in poor countries are not a research priority, because it is unlikely that those markets will ever provide a decent return. That problem can still be seen with antimicrobials. Again, the trouble is the business model. If a drug company invented a powerful new antibiotic, Governments would not want it to be widely prescribed, because the goal would be to delay resistance. Public health officials would, appropriately, try to limit sales of the drug as much as possible. That makes for good public health policy, but a bad investment prospect.

As we all know, pharmaceutical companies form a major part of how the problem can be addressed, but we have to keep regulation in mind. By that, I mean the ability to identify infected patients quickly and cost-effectively and, indeed, to identify whether antimicrobials are needed at all. Failure on that is a root cause of the blanket drug usage we are seeing around the world. Surveys in the UK have shown that many doctors, as the hon. Member for Inverclyde (Mr McKenzie) said, still prescribe antibiotics far more often than necessary, and they are often under intense pressure to do so. A significant number of patients fail to complete a full course of antibiotics, and I hold my hands up and say that I have done that, as I am sure have many other Members. As resistance becomes more commonplace, it increases the chances that the initial antibiotic prescribed will be ineffective. As a result, resistance to antibiotics, such as carbapenems, has grown from five patients in 2006 to 600 in 2013.

While improved diagnostics would increase the effectiveness of the antimicrobials already available, the need to develop more sophisticated drugs that can keep pace with resistance is critical. The development of new drugs, however, will only come when pharmaceutical companies invest once again in antibiotics. That will occur only when those companies know they can recoup their investment costs. Of the 18 to 20 pharmaceutical companies that were the main suppliers of new antibiotics 20 years ago, just four persist in the field. Ultimately, given the choice between making an antibiotic that a person might take for two weeks once in a lifetime or developing an antidepressant that a person would take every day for the rest of their life, pharmas will naturally opt for the latter. It is thought that we need some 200 new antibiotics to cope with the growing problem. However, pharmas are clearly wary of funding this type of investment if the scope for use afterwards is limited.

I originally believed that the best way to tackle the problem would be for the Government to agree a decent unit price for antibiotics. However, it is likely that pharmas would not trust the Government—of whatever colour or combination—to deliver on that promise, so the best option could be to let the market handle the unit price, meaning that Government would stop restraining the price of antibiotics and allow them to increase to entice pharmas to invest. The more I have researched the topic, however, the more convinced I have become that that idea would not succeed. Introducing a targeted antimicrobial and selling it for the price of a cancer drug is likely to be impossible, because this is a market where people are used to getting antibiotics for next to nothing. Why would they suddenly start paying such high prices? As a result, the best solution may be incentives. The key would be to reward companies for creating substantial public health benefits, and the simplest way to do that would be to offer cash prizes for new drugs. For example, the Government would make a payment to the company, and the company would in exchange give up the right to sell the product. That would ensure the pharmaceutical company would be paid, and it would avoid all the expenses of trying to push a new product, as touched on in a report by the Select Committee on Science and Technology.

Additionally, Governments could use the approach that worked with vaccines and new pre-purchase antimicrobial drugs for a set number of years. Such pre-purchasing agreements would mean that the health care system becomes responsible for the proper usage and surveillance of antimicrobials. Currently, no Government grants are aimed at antibiotic discovery, but I welcome the independent review into antimicrobial resistance that the Prime Minister announced in July. I also welcome the brilliant news that the public recently voted to focus the new Longitude prize on antibiotics. The money will go to whoever can develop a rapid bacterial infection diagnosis test within five years. Announcements such as that ensure that antimicrobial resistance is kept in the news and on people’s minds.

Another way to ensure progress is to set up a global organisation that focuses solely on antimicrobial resistance. The World Health Organisation is now devoting considerable time to the problem, but it only produced its first global report in April this year. We are entering a perfect storm with no global organisation or global pharmas tackling the issue head on. Ultimately, a global network needs to be created to fund global antibiotic discovery. In addition, we need to ensure that people are aware of the problem and how it can be solved. Only with the public’s interest can we rally enough support to ensure antimicrobial resistance stays at the top of the political agenda, which will ensure that action is finally taken.

Overall, the purpose of today’s debate is to raise the profile of the devastating threat of antimicrobial resistance and hopefully to strike a chord across the House. Solving the problem will not be easy and will take considerable time. However, if we do not act now, things will only get worse. Many people in positions of authority in the medical profession consider antimicrobial resistance to be one of the biggest threats to mankind and I agree with that assessment. Therefore, I would like to outline a three-step plan to the Minister, which is essential to tackle the problem head on.

First, I have always believed that an in-depth report is needed into antimicrobial resistance. As such, I am extremely pleased by the Prime Minister’s announcement in July that a report will be carried out by the renowned economist Jim O’Neill. The report will look at the increase in drug-related strains of bacteria; market failure, which is crucial; and the overuse of antibiotics globally. Secondly, a global network needs to be created to fund global antibiotic discovery. Finally, the Government must step up and support small companies that invest in antibiotic discovery. As the Prime Minister said in July, the UK should be proud to lead the way in tackling antibiotic resistance, but we must ensure that the rest of world keeps pace. All Governments have a responsibility to tackle the problem and only with full co-operation across the world can we make a real impact.

We live in a globalised world, and 70% of the bacteria in it have developed resistance to antibiotics. We have been through a golden age of discovery and have sadly become complacent. We cannot become the generation that squanders that golden legacy. As the director of the Wellcome Trust, Jeremy Farrar, said:

“We are sleepwalking back into a time where something as simple as a grazed knee will start to claim lives.”

The golden age of medicine could well be behind us. It is time to step up to the plate as politicians and take decisions which might not bear fruit in the short term and might not secure votes in forthcoming elections, but can help to secure the golden age of medical discovery that we in this room have had the fortune to benefit from. We must ensure that it is not squandered for future generations.