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.
19 August 2015
The discovery of antibiotics revolutionised human health and medicine. We now take these drugs for granted and bacteria are fighting back leading to antibiotic resistance.
Education and understanding of the risks is low, patients demanding antibiotics for viral infections or patients failing to complete a full course of antibiotics. These behaviours increase the rate of resistance. Do we need a new approach to tackling the global antibiotic resistance crisis?
Test Tags: antibiotic resistance, microbiology, bacteria, virus, infections, antibiotic, human health, medicine
About the speaker
Dr Maurizio Labbate is a microbiologist with expertise in microbial physiology, lateral gene transfer, vibrio genetics and antibiotic resistance. Dr Labbate is with the School of Life Sciences, ithree institute.
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