Lancet commission calls for major changes in antibiotic use

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The week of Nov. 18-24, was Antibiotic Awareness Week in the United States, Hong Kong, Canada and Australia. In keeping with the theme that week, the medical journal The Lancet published an editorial calling for a coordinated, global effort to combat antibiotic resistance.

To address the issue, The Lancet appointed an international expert commission, which operates under the theme of “Antibiotic resistance — the need for global solutions.” The goal of the commission is to explore “why antibiotic resistance has become such a problem worldwide, and, most importantly, propose solutions to avert the impending crisis.” The Lancet recruited experts in the various topics and asked them to write pieces focusing on how we got to this point and potential solutions to the problem.

The individual contributions were peer-reviewed, revised and assembled into a single document.

Antibiotics paved the way for unprecedented medical and societal developments, and are today indispensible in all health systems, the commission notes. “Achievements in modern medicine, such as major surgery, organ transplantation, treatment of preterm babies and cancer chemotherapy, which we today take for granted, would not be possible without access to effective treatment for bacterial infections. Within just a few years, we might be faced with dire setbacks — medically, socially and economically — unless real and unprecedented global coordinated actions are immediately taken.”

The group says bacterial resistance has resulted from use of antibiotics “prescribed pointlessly for viral infections, added to animal feed to boost growth of livestock and handed out like cough sweets in the community.”

The report notes that nonprescription antibiotic use is common in many countries, accounting for 19 to 100 percent of antibiotic use outside northern Europe and North America. It also notes that when prescriptions are needed to obtain antibiotics, physicians might not adequately screen for appropriate use.

The authors also say antibiotic use in veterinary medicine and for growth promotion and disease prevention in agriculture, aquaculture and horticulture is also a major contributing factor. “Although precise estimates are scarce, of the crudely estimated 100,000-200,000 tons of antibiotics manufactured every year, most go to the agricultural, horticultural and veterinary sectors. Although the transfer of antibiotic-resistance plasmids from treated animals to human beings has been long suspected, findings from recent studies using whole-genome sequencing have confirmed animal-to-human transfers of resistance genes.” In its call to action, the commission identifies specific points for which urgent responses are needed as well as longer-term goals. These include hospital stewardship, responsible use in agriculture (including a global phase-out of use of antibiotics for growth promotion), access in countries with weak health systems, community education and environmental management.

The authors note we have seemingly exhausted the potential of the antibiotic classes in use so far, and new drugs — either antibiotics or from other approaches — are needed. “But academia and pharmaceutical companies have not focused on this problem for so long that antibacterial drug-development programs have withered. To stimulate drug discovery, novel incentives for industry and new approaches to funding, licensing and patenting may be needed.”

Notably, the authors say it is “time to move on from blame and shame.” They acknowledge the use of antibiotics in food animals remains controversial, with knowledge gaps in the understanding of the resistance dynamics, conflicting results in various studies and, in particular, the difficulty quantifying the potential effect on public health. “Implementation of prudent use relies on the daily work of farmers and veterinarians. Legitimate conflicting interests can surround this implementation, e.g., production economy and the ethical obligation to care for diseased animals. In view of the polarized debate, veterinarians and farmers might feel that they are blamed for a problem they perceive is essentially generated by medical doctors. This situation might lead to a defensive attitude and does not cater for productive solutions. A way forward would be to acknowledge that human health, animal health and the environment are all interlinked, and that the responsibility for dealing with the problems of resistance is shared by all stakeholders,” the authors write. “Strong local and global partnerships are needed in which policy makers, academia and professionals from all sectors work together to improve present systems. The common goal should be to preserve the effect of  antimicrobials for future generations of human beings but also for animals.”


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