On the heels of the director of the U.S. Centers for Disease Control declaring emerging antibiotic resistance a “nightmare,” the U.K.’s Chief Medical Officer released a report today in which she calls resistance a “catastrophic threat” which poses a national security risk as serious as terrorism. In an interview published overnight, she warns that unless resistance is curbed, “We will find ourselves in a health system not dissimilar to the early 19th century” in which organ transplants, cancer chemotherapy, joint replacements and even minor surgeries become life-threatening.
The lengthy report (152 pages) constitutes the second half of the Chief Medical Officer’s annual report to the country; apparently the first volume is a report on existing conditions, and in the second, the official occupying the post chooses one major health threat to focus on. This year, Professor Dame Sally Davies chose “Infections and the rise of antimicrobial resistance” — and as with CDC Director Frieden last week, is unusually direct in her statement of the threat.
The report is co-written by U.K. researchers and representatives of the U.K.’s Health Protection Agency, and provides a sobering view of the advance of resistance in Britain. (Recall that the HPA was the first national health agency to sound the alarm about NDM-1, the “Indian supergene” which confers resistance to almost all antibiotics.) The key point — TL;DR here — is that it enumerates 17 specific actions that Davies wants the U.K. government and private sector to take to counteract the threat. No. 1 on the list: “Put antimicrobial resistance on the … National Security Risk Assessment,” enshrining it alongside terrorism and pandemic flu as a border-crossing threat which demands immediate action.
This report is supposed to be followed up shortly by a new “Five Year Antimicrobial Resistance Strategy and Action Plan,” which will set out national guidelines and targets. The Plan is previewed in an editorial in the BMJ today that is blunt about the difficulties that serious attempts to control resistance will face. The authors say the new rules will enforce screening any patients who have received any healthcare in other countries — probably by rectal swab since the most serious resistant organisms are gut-dwelling — and enacting national standards for prescribing existing drugs, in order to preserve them as long as possible. It adds that those prescribing standards will be made for specific “bug-drug” combinations, making the U.K. the first country to do that.
What the U.K. is doing here appears to be more urgent, and also more top-down, that what any health agency in the U.S. has managed. (This is one of the effects of having a government-funded health system.) An analysis that is also published in the BMJ today says these steps will barely be in time if we are to avoid having antibiotic resistance bankrupt healthcare and undermine societies. Here’s just one example:
…The costs of resistance could be much higher than (existing) estimates (of $55 billion per year in the US) suggest. As an example we estimated the consequences of having no antibiotics for patients having a total hip replacement. Because antibiotics have been used as prophylaxis and treatment for hospital-acquired infection since hip replacements were first performed, we looked at information relating to limb amputation, as a proxy for what infection rates might have been with and without antimicrobials.
…Currently, prophylaxis is standard practice, and infection rates are about 0.5-2%, so most patients recover without infection, and those who get an infection have it successfully treated. We estimate that without antimicrobials, the rate of postoperative infection is 40-50% and about 30% of those with an infection will die. Thus, removal of antibiotics would increase postoperative infection by 1-50% and deaths by 0-30%.
It’s worth saying that again: If antibiotic resistance continues to rise unchecked, one-sixth of people who undergo hip replacements — now a major, but routine, surgery — might die. There are 800,000 hip replacement per year in the US; 43 million Americans have arthritis and another 23 million have other chronic joint problems, the conditions for which hip replacements are performed. If antibiotic resistance continues unchecked, then just one of its effects would likely be a sharp drop in medicine’s willingness to perform major joint replacements, just as the largest and most athletic generation in history reaches the age when those operations are needed. And that could lead to more pain, less mobility, and a potential society-wide conversion from what we now think of as fun-filled retirement to the kind of old age we used to dread.
Changes like that are what lie behind the alarm that the CDC raised last week and the HPA today. Just as with last week’s news, we have to hope that people are listening, and that the alarm has been sounded in time.
