Facilitator: Now I want to start by talking
about antibiotics and I think it’s really important to make the point that these drugs
have really revolutionised, I think, how we live our lives. They really are important
in keeping us healthy. They’re used in multiple areas in our society and I think that these
really underpin a lot of what we do in medicine. Given that antibiotic resistance is on the
rise there’s a real concern that our quality of life will be affected.
What I want to talk to you about tonight is what antibiotic resistance is, how it’s arisen
and what are the things that we can do to at least improve or stop the problem. The
final part of my presentation will focus on one of the new areas that I’m working on which
is looking at policy approaches on how to tackle antibiotic resistance.
I’m going to start from the beginning. I’m going to talk to you first about what microbes
are. I think that’s important. What I want to show you here is a scale so you get an
idea of actually how small these guys are. We’ve got that scale here on my right hand
side, your left, 100 micrometres being about one-tenth of a millimetre so we’re talking
about really tiny things here. At the bottom of that scale we have the atoms
which is what all matter in the universe is made of. The smallest biological agent that
is part of the microbial world are viruses, an example being the AIDS virus, HIV, we’ve
got the polio virus and we’ve also got here a micrograph of the virus that was responsible
for the SARS outbreak. Now as we go up we’ve got the bacteria which
is one micrometre in length or diameter. That’s about one one-thousandth of a millimetre so
very tiny again and this is what I’m really going to focus on here. This is what antibiotics
target. They target the bacteria and this is an important point and I’ll come back to
this later. Beyond that we’ve got what we call the eukaryotic
cells. I don’t want to use technical jargon today but these are the cells that our bodies
are made out of. These are bigger, about 10 microns. That’s about one one-hundredth of
a millimetre, again very small and we do have microbes in that range, biological agents
that can also cause disease. For example this critter at the top here, the protozoa giardia
is responsible for the diarrhoeal disease giardia. That’s a eukaryotic cell.
As I said we’re going to be talking about bacteria tonight. For example here golden
staph which I’m sure you’ve heard of, a really important problem in hospitals.
Now I think microbes get a really bad rap in the media. We always here about how they’re
causing death, disease, morbidity, big outbreaks, et cetera. I don’t want to lie and say that’s
not the case. Of course microbes do cause disease and morbidity and outbreaks and all
of that but I think it’s really important to remember that in fact a lot of the things
that microbes do are good things. On the left here we’ve got the disease causing
bacteria and I think clearly all the good things that microbes do are really making
the scales go in the positive which is that they’re good things. Really important roles
in the environment, they’re really important for cleaning up pollutants, for cycling nutrients,
all these things. Important in food production, who hasn’t used yeast to make bread or pizza?
We use microbes for cheese production and even alcohol. Who doesn’t enjoy a good drink
after work? Then we’ve got bacteria that is inside our
gut, on our skin. Really important for digestion, helping modulate our immune system and also
protecting us from the bad bacteria so they do have an important role.
Finally I just want to talk about insulin production because we as researchers have
manipulated these microbes to do things that are actually quite beneficial and we have
manipulated bacteria to produce insulin, a really important drug for people that suffer
from diabetes. Again just to emphasise, the good most definitely
outweighs the bad. The other thing that I want to get across
is that microbes are everywhere. These guys are great adapters. There’s no place on earth
where you’re not going to find these guys. Here on the left we’ve got some soil. In one
gram of soil there’s about 10 billion different microbial cells, really lots and very rich
in diversity. You’ll also find microbes in the ocean, in fresh water environments, associated
with all these kinds of animals including the animals that we use for food. We find
them in our gut and on our skin. Again really important roles, there are 10 times more cells
in your gut, bacterial cells in your gut than you have cells in your body. Some of us actually
think of people as vessels for bacteria rather than actually being human.
That gives you an idea of all the niches that are out there and the fact that all these
microbes can be found in all these wonderful and fabulous environments.
Now that I’ve given you a bit of a context about microbes are, where they inhabit, I
want to start talking about anti-microbials. There are just anything, chemical solutions
that we use to control the growth of microbes. Many of these you’re very familiar with, you’ve
used them in your home, things like bleach or Dettol, Pine O Cleen, iodine, alcoholic
rubs. We use these anti-microbials to control the growth of microbes. We often use these
anti-microbials in the kitchen or in the bathroom, places where we want to keep clean if we’re
preparing food, we don’t want to risk ourselves with getting an infection.
These anti-microbials are rather blunt instruments. Not only are they bad for the microbes, they
can also hurt us. We can’t necessarily drink bleach. It would be a poison and I’m not advising
that so please do not go home and think hey I can use bleach.
Obviously if you’re suffering from some kind of bacterial infection then you need something
else. We use antibiotics for that. Now again these drugs work specifically against bacteria.
They don’t work against viruses and they don’t work against those eukaryotic larger cells.
The good thing about antibiotics is that you can take them orally or they can be injected
and they have none or very little effect on you but they do target the bacteria and they
get rid of your infection. They’re great fantastic drugs. Antibiotics aren’t necessarily so specific
that they can only target the pathogen. They can affect the normal bacteria that you normally
find in your gut and skin which is why sometimes if you’ve had a course of antibiotics you
might get a sick tummy or you might feel a little bit unwell. That’s because it’s disrupted
the microbiome within your body. Great drugs and the fact that we’re seeing
a rise in antibiotic resistance has really caught the attention unsurprisingly of these
respected medical health bodies such as the Centre for Disease Control and the World Health
Organisation. We’ve also seen responses from our own Australian Government about how we’re
going to meet this threat. You would have seen these kinds of headlines in the popular
media which just reflect I think the concern that our governments have with regard to the
rising threat of antibiotic resistance. The one thing that I think is often overlooked
is that antibiotics aren’t just used to treat infections. Sure if there’s an outbreak of
a specific disease or you’re suffering from tonsillitis, a wound infection of course you
need to take antibiotics but what’s often not known is that antibiotics I think underpin
a lot of the other medical treatments that exist within hospital environments or in the
medial world. Things like surgery, cancer or organ transplants,
antibiotics are provided to prevent infection because many of these treatments come with
high risk of getting an infection. If you have a surgical procedure your body’s been
opened up to the environment and you don’t want any kind of microbe getting in there
causing a nasty infection. After a surgical procedure antibiotics are given to prevent
infection. The fact that we’re getting this rise in antibiotic
resistance means that not only would certain infections be difficult to treat or untreatable,
many of these other treatments would also be threatened and could not be done without
high risk of infection. How did it happen? How is it that we went
from having all these great drugs that we could use to treat the nasties to now having
a situation where we only have a few drugs to treat the nasties?
I want to start with this figure on your left which shows you the mortality rate per 100,000
and the time on the bottom. You’ll see at the beginning of the 20th Century we had a
very high mortality rate from infectious disease, about 500 per 100,000.
Now over time we’ve managed to reduce that quite significantly and there are a number
of reasons for that including vaccination programs, better sanitation and good hygiene
practices. Around the mid-1920s to the early 1930s the first antibacterial drugs were introduced
and we began to see even more or more significant drop in the amount of deaths from infectious
disease so quite a significant drop. Those drugs have now been responsible for
keeping the rate low for quite a long period of time.
Now since about the 1980s – that inlet there with the blue line is showing you a zoom in
on the line in red from the 1980s. We’ve seen a slow increase in infectious disease. Part
of that is due to new emerging infections like HIV but part of it’s also been the rise
of these so-called superbugs where previously these infections were treatable and now they’re
not treatable anymore. We’ve seen that a lot within hospital environments.
Now the reason why it’s escalated to the point it is now is that when the first drugs were
developed in the 1940s we really had a whole bunch of new drugs coming through so we’ve
been in a bit of a race with the bacteria. As they’ve become resistant we’ve developed
a new drug and replaced the old one with a new one. We’ve just been going back and forth
in this kind of race between the microbial world.
You can see that in this bottom image where the purple dots indicate introduction of new
drugs. From about the late 1980s there’s been what we call this discovery void. We don’t
have any new drugs in the pipeline that can replace the current drugs once they become
ineffective. There are a lot of reasons for that and I don’t really have time to talk
about them but one of the reasons is that big pharma has gotten out of making these
kinds of drugs or discovering these kinds of drugs simply because it’s not profitable.
We’re left with a situation where bacteria are kind of beginning to win the race. We
don’t have anything left to combat them. Now therefore we’re relying on the current
drugs that we have and they’re a resource because the more we use them the less effective
they’ve become and we’ve seen some advertising campaigns by the National Prescribing Service
talking about how – don’t waste your antibiotics. That’s simply because antibiotic use leads
to antibiotic resistance. The more you use them the more resistance you get
This image here shows you all the countries and we’ve plotted the amount of resistance
over the amount of antibiotics they use. Those countries that use lots of antibiotics have
higher levels of antibiotic resistance. That’s a nice correlation there shown by the yellow
lines. Now Australia is down there at the bottom
and I think the reason why it doesn’t quite fit that line is I think Australia’s had really
good regulation with regard to use of antibiotics in agriculture. I think that’s protected us
to some extent but you can still see that compared to countries like The Netherlands
or Germany we use a lot of drugs, a lot of antibiotics in medical health.
How do these bacteria become resistant? What is it that they’re doing? I really want to
give you an idea of how this process occurs and you can see here in panel number one we’ve
got a mixture of different bacteria. We’ve got some that are blue. These are the bacteria
that are sensitive to the given antibiotic and then we’ve got some in pink which are
the ones that are resistant. Panel two shows that we’ve used some antibiotic
and those blue bacteria have been killed so we’re left with only the pink ones. Mind you
these pinks ones have just naturally mutated, they’ve adapted, that’s what bacteria do and
they’ve evolved resistance to the antibiotic. In the third panel we can see that the pink
ones have grown because they’re the only ones that can survive and grow. Now they outnumber
the blue ones and that’s the issue we’re seeing now. The more antibiotics we use, we are selecting
– and we call this selection pressure – we are selecting for those bacteria that are
resistant. Therefore the chances of us picking up a resistant infection of course increases.
Beyond that and in panel four you’ll see that pink bacteria is passing a gene across to
blue bacteria. Bacteria can actually share their DNA. If one bacterium evolves resistance
it can pass that gene on to another bacterium and it now becomes resistant.
Now this image here at the bottom, which is rather complicated and I really don’t want
to frighten you with it but the point is it’s just a bit of DNA. On that bit of DNA you’ve
got multiple resistance genes, five or six. That bit of DNA can be passed from one bacterium
to another and that bacterium that is sensitive now is resistant to five or six antibiotics
and that’s the situation that we currently have, particularly in hospital environments.
It is more complicated. Bacteria adapt. That’s what they do. It’s normal for them to mutate
and evolve resistance. It’s normal for them to pass their genes on.
What I think though what we’ve done is we’ve helped the process. We’ve exacerbated it by
some of the things that we do. I want to talk you through that. Now remember how I said
that bacteria are everywhere? Firstly we’ve got this image here of the antibiotics
and we use antibiotics in agriculture. What have we done? We’ve selected for those bacteria
that are resistant in the guts of those animals. Okay? It’s selection pressure.
Number two, we use antibiotics in society. In medical health we use them. Again the bacteria
in our guts that are sensitive to those antibiotics die but we’re selecting for the ones that
are resistant so increasing their numbers. The same is true for hospitals and nursing
homes. Where antibiotics are used we find a high level of resistance.
It goes on from that. Now as the bacteria are moved around by various processes particularly
with regard to food production if there are bacteria that are resistant from agriculture
we consume the meat and those bacteria come into us and the genes that they have can be
passed to our own natural bacteria in our guts so we pick up resistance genes. I guarantee
that all of you would have had at least one resistance gene in the bacteria colonised
in your gut. The same is true for vegetables. We use the
manure from these animals to grow vegetables so the bacteria on the vegetables can also
have resistance. You consume that you can pick up some of the genes in your gut.
Beyond that it’s also the way we treat our waste. About 50 per cent of the antibiotics
we take comes through our waste then that goes back into the environment through waste
water systems and we are priming the bacteria in the environment to become resistant because
we’re pushing all those antibiotics out there. Of course then those bacteria that become
resistant can find their way back into the food stream through our vegetables and back
into us. What we’ve done, we’ve overused antibiotics
in different environments so we’ve really encouraged this process of evolution or selection
pressure. We can’t do anything, I don’t think, about
how bacteria adapt. That’s what they do. They’ve been here for four billion years, three-and-a-half
billion years I should say, they’re good at it. I think what we can change is the rate
at which they become resistant. I think we can slow it down by moderating the use of
antibiotics. Given that we only have a certain amount left that we can use in treatment we
want to slow that process down to buy ourselves more time so we can find alternative treatments
for these kinds of infections. That’s what I’m advocating today. Now given
the fact that we’ve used antibiotics in different environments whether it be in agriculture,
in medical health and we also are pumping these guys out into the environment, it’s
becoming apparent that we need to use this one health approach. That is, whatever we
do to solve the problem it has to involve thinking about antibiotic use within human
society, within the environment and also within agriculture because any inroads that we make,
for example improving antibiotic use in medical health, can be outdone by using too much in
agriculture. We have to take this one health approach and
I think all the medical health institutions internationally and governments are beginning
to see that we have to look at this problem holistically and not just focus on one thing.
I think some of the research that we’re doing at UTS can assist this process, can assist
one health and that’s by reframing antibiotic resistance as a natural disaster.
We all know what disasters are, things like bushfires, earthquakes, tsunami, et cetera.
We’re arguing that we should reframe antibiotic resistance in the same way because a disaster
is defined as a serious disruption of the functioning of a community or a society. I
won’t read the whole thing but just say which exceeds the ability of the affected community
or society to cope using its own resources. When a community is overwhelmed by some event
and it’s unable to cope we call that a disaster and that’s when additional resources are made
available to help that community. We would look at this in the same way because antibiotics
are a resource that we’re using to hold back I suppose infectious disease but as resistance
rises our capacity to cope is more difficult or is washing away.
In many ways we can say we’re therefore approaching a disaster situation.
Beyond that when we prepare our communities for disasters it’s about empowering them and
helping them prepare themselves and letting the community become empowered and own the
problem. When we talk about bushfires or earthquakes, et cetera, and we go in to help these people
we’re empowering them. The same thing we can do with antibiotic resistance.
I think this is our problem. It’s not just a problem for medical health. We all use antibiotics.
We all enjoy the health that comes from that and I think we all need to take responsibility
and own the problem. We’ve talked about this in an article that was published in The Sydney
Morning Herald last year, exactly talking about reframing antibiotic resistance as a
natural disaster. Now I’ll talk a little bit more about that.
What’s currently being done and I think this is great stuff that’s being done is that medical
health organisations have been using what we call top down policy approaches. That’s
largely with regard to restricting use of antibiotics.
Anti-microbial stewardship programs are about educating doctors about when to prescribe.
We restrict use in agriculture and we place – largely the responsibility’s placed on the
government to regulate. We call this top down. These approaches do work but I think what
we’re arguing is that the policy approaches using disaster management beautifully complement
this other approach of top down. We call that bottom up.
As I said to you, when we talk about disasters and preparing communities it’s about engaging
with the community and empowering them with information and also talking to them about
solutions. That’s what this bottom up policy approach is about, education, consultation
and we all take responsibility for the problem. For example, there’s no point restricting
antibiotics in agriculture if the farmer is going to lose out. They’ve got bills to pay
so we need to engage with these people and find out what are some solutions that we can
come up with that are palatable to everyone? Nobody likes being told what to do especially
if they haven’t had an opportunity to engage in the process, right? That’s the approach
that we want to take by reframing antibiotic resistance as a disaster.
Our first step is looking at what you guys know and think about the problem. We launched
a survey a couple of months ago on antibiotic resistance using Facebook and various other
online sites. We’ve had approximately 600 responses and you can see here on my right
hand side the greater Sydney metropolitan area and the green dots indicate where the
responses have come from. You can see that we’ve managed to get a really good spectrum
of responses from all over Sydney including the advantaged areas which are shown in blue
and disadvantaged areas which are shown in red and yellow.
Now we can begin to look and see what people in Sydney know or think about the problem.
Then that gives us an opportunity to go in more focused and ask more specific questions
and begin that consultation process. I don’t have time to talk about all the survey
but I’ve just got a few things that I want to talk about. Firstly one of the questions
we asked was have you ever taken antibiotics when you had a cold or a ‘flu and great, 60
per cent said no. Remember viruses aren’t affected by antibiotics
so there’s no point taking them. I still think there’s a significant proportion of people,
30 per cent or maybe even 40 per cent, that are so there some room for improvement there.
Secondly, we asked the question – I’m sorry it’s not very clear here but we asked what
do you think the following could be a risk to your life at some point in the future?
Unsurprisingly cancer was a very high one but antibiotic resistance actually ranked
as high as cancer as well as some other medical health problems.
Surprisingly terrorism was actually down the bottom of the list and we know how much resources
are placed into terrorism so maybe we need to talk to our MPs and say come on, start
putting some resources into some of the things we find as being important.
These are responses from you guys. You think antibiotic resistance is important so we should
get more resources into that. The last one is who do you trust for sources
of information about the medicine? You don’t need a survey to find out that politicians
rank at the bottom, right? There they are. We don’t trust them so we definitely would
not engage with politicians to communicate this message because you’re just not going
to believe them, right? What we did find is that you do trust doctors,
medical health practitioners, nurses, which is great. These are the people that – I’m
sorry? And pharmacists, yes. All the medical health practitioners, which is great so what
we want to do is get these guys to be on the frontline communicating the message to you
guys because these are the people you trust and that’s great.
I’ll finish off with just a few bullet points on what you can do to help fight against antibiotic
resistance. Firstly, use antibiotics only when you need them. This is by no means me
saying to you that you shouldn’t use them. If you have a bacterial infection of course
take antibiotics. It’s about being healthy but if you don’t need them don’t use them.
Use antibiotics as directed. If your doctor says to take the full course please take the
full course. If you don’t then you can be exacerbating the problem.
Spread the word. Thank you all for coming tonight. This is great. It’s a good turnout.
Now go home and talk to your friends and family. Tell them about antibiotic resistance. Tell
them what you’ve learned tonight because you really want to get that message out and we
want to raise the profile of this problem. Raise the profile of this issue with your
federal MP. We need more resources to help us fight this problem because it will only
get worse. If we do all those things hopefully we cannot
go back to the 1930s where it wasn’t too long ago I think where it wasn’t uncommon to lose
a family member from a horrible bacterial infection. It was a really horrible time.
It was very frightening to know that perhaps your child or one of your family members could
die from a bacterial infection. I thank you very much for your attention.
I’ll take any questions later. Thank you.