Antibiotics: how to prevent the expiry of a great invention? | Uga Dumpis | TEDxRiga

Antibiotics: how to prevent the expiry of a great invention? | Uga Dumpis | TEDxRiga


Translator: Ilze Garda
Reviewer: Denise RQ I want to talk about antibiotics
and the way we are losing them. Antibiotics is one
of the greatest discoveries of science. I have been prescribing
these drugs for 15 years, working in the university hospital, and I want to continue
prescribing these drugs because they save lives. Recently, I’m becoming jealous
of other specialities, rheumotology, oncology, cardiology, because they have
new, more effective drugs that really improve patient outcomes. [On the] contrary,
I’m running out of drugs. Today, I prescribe Colistin
to patients in the intensive care unit, a drug that was introduced in 1955 and soon discarded
because of toxic side effects. Now this drug is back because it’s the only drug
that we can use for treatment of patients infected
with a particularly resistant pathogen. Antibiotics is one of the greatest
discoveries of science. Antibiotics are poisons that act on the cell wall of bacteria
destroying them. We have hundreds of poisons available; some of them, we are able
to use in medicine. Thanks to antibiotics,
billions of lives have been saved. We are able to treat
deadly infectious diseases we were never able to treat before. More than medicine
is based on antibiotics: not only treatment of infectious diseases, but also prosthetic surgery,
transplantation, cancer chemotherapy is dependent on antibiotics
because patients receive prophylaxis. So where did the resistance come from? Some patients tell that they are becoming
resistant to antiobiotics, “Please, prescribe me a more potent one.” It’s not true. Patients are not resistant
to antibiotics, bacteria are. The problem with bacteria
is that there are so many [of them], and they are multiplying
at a tremendous speed. During this multiplication,
genetic mutations occur that make some of them
resistant to antibiotics. If we apply antibiotics
to these colonies of billions of bacteria, then some of them survive,
the resistant ones, and that makes a difference
for the patient. [When] patients
get admitted to a hospital, they receive first line
guideline-based treatment with so-called narrow spectrum antibiotic, but in this case, if a patient
is infected with resistant bacteria, they don’t get better, they get worse. It takes two to three days to understand
that your treatment is not effective. So you have to prescribe
another antibiotic, so-called wide-spectrum antibiotic. Next time, the physician is scared and starts treatment with so-called
wide-spectrum antibiotic, but this antibiotic creates
more selection pressure, and we end up with more
resistant bacteria populations. So it is a problem.
It is the big innovation on reverse. It is as if your mobile phones
would be switched off, or the Internet, or even electricity. This is what it is
for the medical community. So what are the solutions? Some may say, “Science will save us.” OK, that’s correct. There are several reports every month showing us the success of science
in finding new anti-microbial agents. Nevertheless, only some of them
make to the markets. The new drug pipeline is very short, there are not that many drugs
appearing on the market. It is because the pharmaceutical industry needs to invest huge amounts of money
to run clinical trials, and why should they invest in drugs
that will be used for 3 to 5-day-courses and eventually will expire
due to resistance? They would rather invest
in chronic diseases, lifestyle, and aging. So we cannot expect many drugs soon. Another approach is to use vaccines. Vaccines are very important
because they are better than antibiotics. But production of vaccines is even slower,
and more difficult, and more expensive. We can’t expect many vaccines.
We are facing many bacteria. What we do in hospitals is that we try to isolate patients
with resistant bacteria, we employ stringent
infection control measures [to] prevent spread
from one patient to another. That works on a small scale. It can’t be done
in an outpatient setting. We have new equipment
that makes us more capable of detecting pathogens within few hours,
even the resistance genes. Anyway, that is expensive. If you are in an outpatient setting, you still have to bring
a sample to the laboratory. So what can we do? Science will definitely save us
on the long run, I’m pretty sure about that, but what can we do now,
within the next 5 to 10 years? We know that countries
that use less antibiotics have lower resistance rates. It is interesting
that in the European Union, consumption of antibiotics per capita
is quite different; you can see [a lot of] differences
between different countries. What is the explanation?
Nobody knows. It clearly has something to do
with human behavior. Why should Belgium’s
and the Netherlands’ consumption [differ by a factor of two]? Why should the north do
much better than the south? Apparently, some physicians
in low-use countries are more [than] happy
not to prescribe an antibiotic, and patients in some countries
are happy not to take an antibiotic. This is very interesting to understand, the behavioral difference
between countries, between cultures, because we have to reduce
the use of antiobiotics dramatically. This is the only thing
we can do in the next 5 to 10 years. We decided to study the behavior
of the Latvian family physicians. We recorded [the prescriptions
of antibiotics during one week] [by] a large number of family physicians. The results were quite surprising. Most of the antibiotics were prescribed
to children younger than 10 years, followed by teenagers. Altogether, children contributed
to 65% of outpatient antibiotic use. Conditions treated were mainly
bronchitis and sore throat. Those are clearly not infections
caused by bacteria; maybe 1 in 10 can be
a bacterial infection, particularly in children, and that can be easily detected by a good clinical judgement
and simple tests. So, what is the problem? Why family physicians prescribe
so many antibiotics to Latvian children? Latvia, as you saw in the previous slide,
is a low-antibiotic-use country, so it looks [that our problem
is treating children]. It’s a behavior. It’s clear that we need
behavioral research to understand this. Nobody wants to harm children, but this culture
of being on the safe side, “Just in case something happens”, “Take it, antibiotics
won’t harm you anyway”, “Take it for three,
five days, that’s fine,” that is a culture
we all are familiar with here. The same with surgeons in our hospitals: they tend to prolong
surgical prophylaxis with antibiotics for two, three days longer
than it’s required. There is no scientific evidence
for [doing] that. When I tell them that, they look at me like I want them
to drive on the opposite side of the road, because it’s their culture,
it’s their behavior and habit, they have been doing this for decades,
their teachers were doing this. So it is very difficult
to change behavior. I’m not good at changing behaviors,
I’m just an infectious disease doctor. Probably, we should look
for PR and marketing specialists that are able to sell people
things they never need. We really have to look [at this problem
from a wider perspective]. Some examples. This is a report, “British superbug outbreak
could kill 80,000 people.” Terrible news. Full-scale alarm, isn’t it? What can we do? I, as an infectious disease specialist,
say, “Let’s use less antibiotics.” Is it a good answer that answers
these fears [about] the safety of people? No. Another approach is public campaigns
that are focusing on the issue that you shouldn’t treat
viral infections with antibiotics. It’s a negative message, [and] people ask,
“What if it is a bacterial infection? OK, this is clear to me.
But how can you tell it’s not bacterial?” We have a problem here as well. We have to tell people something positive: that we can detect a bacterial infection
with simple tests and clinical judgements. Bacterial infections are extremely rare, and usually, many patients
get directly to hospital because they are obviously sick. So we have an urgent need
for intervention, we have scientific evidence
to do something. We have to flip the switch from “Just in case something happens”, “Let’s give you a drug”,
“It won’t harm you,” to something like, “You should be using
an antibiotic just in some cases.” If we would flip this switch,
I would probably be able to use more antibiotics
in our intensive care unit than this old-fashioned, toxic drug
that can really harm the patient. Thank you. (Applause)

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