“Human resistance to antibiotics could bring ‘the end of modern medicine as we know it’,” according to The Daily Telegraph. The newspaper says that we are facing an antibiotic crisis that could make routine operations impossible and a scratched knee potentially fatal. Similarly, the Daily Mail’s headline stated that a sore throat could soon become fatal.
The alarming headlines follow a new report by the World Health Organization (WHO , which set out ways to fight the growing problem of antimicrobial resistance (AMR . AMR occurs when infectious organisms, such as bacteria and viruses, adapt to treatments and become resistant to them. The publication specifically addressed the long-known problem of antibiotic resistance, where increasing use of antibiotics can lead to the formation of “superbugs” that resist many of the antibiotic types we currently have. It outlined a variety of measures that are vital for ensuring we can still fight infections in the future and described how other major infectious diseases, such as tuberculosis, HIV, malaria and influenza, could one day become resistant to today’s treatment options.
However, despite the future danger posed by antimicrobial resistance, the situation is not irretrievable. As Dr Margaret Chan, director general of WHO, said: “much can be done. This includes prescribing antibiotics appropriately and only when needed, following treatment correctly, restricting the use of antibiotics in food production to therapeutic purposes and tackling the problem of substandard and counterfeit medicines.” The report also highlighted successful cases where antimicrobial resistance has been tackled, demonstrating that we can safeguard the effectiveness of important antimicrobial medicines with dedicated, rational efforts.
Where has the news come from?
WHO has just published a new report (“The evolving threat of antimicrobial resistance - Options for action” that sets out a global strategy for fighting antibiotic resistance. It explores how over past decades, bacteria that cause common infections have gradually developed resistance to each new antibiotic developed, and how AMR has evolved to become a worldwide health threat. In particular, the report highlights that there is currently a lack of new antibiotics in development and outlines some of the measures needed to prevent a potential global crisis in healthcare.
This is not the first time WHO has set out such a strategy. In the 2001, WHO published its “Global strategy for containment of antimicrobial resistance”, which laid out a comprehensive list of recommendations for combating AMR. The current report looks at the experiences over the past decade of implementing some of these recommendations, the progress made, and what else should be done to tackle AMR.
What is antimicrobial resistance?
Antimicrobial resistance (AMR occurs when microorganisms, such as bacteria, viruses, fungi or other microbes, develop resistance to the drug that is being used to treat them. This means that the treatment no longer effectively kills or inactivates the microorganism. The term “antimicrobial” is used to describe all drugs that treat infections caused by microorganisms. Antibiotics are effective against bacteria only, antivirals against viruses only, and antifungals against fungi.
The case of penicillin illustrates the AMR phenomenon well. When penicillin was first introduced in the 1940s, it revolutionised medicine and was effective against a wide range of staphylococcal and streptococcal bacteria. It was also able to treat infections that had previously been fatal for many people, including throat infections, pneumonia and wound infections. However, with increasing use of antibiotics over the decades, bacteria began to adapt and develop changes in their DNA that meant they were resistant to the actions of the once-powerful antibiotic. These bacteria would survive and proliferate, which meant their protective genes would then be passed on to other strains of bacteria. As a result, new and stronger antibiotics had to be created to combat the resistant bacteria.
AMR is driven by many factors, including overuse of antimicrobials for human and animal health and in food production, which can allow microbes to adapt to antimicrobials they are exposed to. Poor infection-control measures, which fail to prevent the spread of infections, also contribute. In particular, the WHO publication reports what it describes as the five most important areas for the control of AMR, as recognised in its 2001 strategy:
- surveillance of antimicrobial use
- rational use in humans
- rational use in animals
- infection prevention and control
- innovations in practice and new antimicrobials
How big is the problem?
As the report describes, AMR makes it difficult and more expensive to treat many common infections, causing delays in effective treatment or, in the worst cases, an inability to provide effective treatment at all. Many patients around the world suffer harm because infections from bacteria, viruses, fungi or other organisms can no longer be treated with the common medicines that would once have treated them effectively.
The report presents some startling facts on major infectious diseases worldwide:
- Malaria: malaria is caused by parasites that are transmitted into the blood stream by a bite from an infected mosquito. Resistance to antimalarial medicines has been documented for all classes of the drug, which presents a major threat to malaria control. The report describes that a change in national antimalarial treatment policy is recommended when the overall treatment failure rate exceeds 10%. Changes in policy have been necessary in many countries due to the emergence of chloroquine resistance. This means that alternative forms of combination therapy have to be used as first-line treatment.
- Tuberculosis: in 2010, an estimated 290,000 new multidrug-resistant tuberculosis (TB cases were detected among the TB cases notified worldwide, and about one-third of these patients may die annually. Inaccuracies in diagnosis also impede appropriate treatment.
- HIV: resistance rates to anti-HIV drug regimens ranging from 10% to 20% have been reported in Europe and the USA. Second-line treatments are generally effective in patients when the first-line therapy has failed, but can only be started promptly if viral monitoring is routinely available.
- Common bacterial infections: various bacteria can cause infections within the chest, skin and urinary tract bloodstream, for example, and the inability to fight these infections appears to a growing problem in healthcare. Estimates from Europe are that there are 25,000 excess deaths each year due to resistant bacterial hospital infections, and approximately 2.5 million avoidable days in hospital caused by AMR. In addition, the economic burden from additional patient illness and death is estimated to be at least ˆ1.5 billion each year in healthcare costs and productivity losses.
What can be done about AMR?
The five key areas that the report highlights could tackle the problem of AMR are as follows:
Surveillance of antimicrobial use
Tracking antimicrobial use (in particular antibiotic use and looking at the emergence and spread of resistant strains of bacteria is a key tactic in the fight against AMR. This can provide information, insights and tools needed to guide policy and measure how successful changes in prescribing may be. This can happen both locally and globally.
AMR is a global problem but, at present, there appears to be wide variation in the way regions and countries approach AMR surveillance. This means there is a long way to go before it can be carried out worldwide.
Rational use in humans
Antimicrobials can obviously be important or even lifesaving in appropriate situations, but it is just as important to prevent unnecessary use of antimicrobials, which can lead to resistance. Putting this into practice worldwide is said to be difficult, but rationalising antimicrobial use has had a demonstrable impact on AMR in some cases.
Rational use in animals
Antibiotics are said to be used in greater quantities in food production than in the treatment of disease in human patients. Also, some of the same antibiotics or classes are used in animals and in human medicine. This carries the risk of the emergence and spread of resistant bacteria, including those capable of causing infections in both animals and people.
The problems associated with the use of antibiotics in animal husbandry, including in livestock, poultry and fish farming, are reportedly growing worldwide without clear evidence of the need for or benefit from it. There are said to be major differences in the amounts of antimicrobials used per kilogram of meat produced in high-income countries, and actions need to be taken by national and international authorities to control this.
Infection prevention and control in healthcare facilities
The hospital environment favours the emergence and spread of resistant bacteria. The report highlights the importance of infection-control measures to prevent the spread of microbes in general, regardless of whether they are resistant to antimicrobials. Many facilities and countries are reported to have progressed well since 2001, implementing many recommendations on infection control and prevention, although gaps and challenges still remain.
Innovations
Lastly, the report describes how innovative strategies and technologies are needed to address the lack of new antimicrobials being produced. As the report says, while antimicrobials are the mainstay of treatment for infections, diagnostics and vaccines play important complementary roles by promoting rational use of such medicines and preventing infections that would require antimicrobial treatment. So far, new products coming on to the market have not kept pace with the increasing needs for improvements in antimicrobial treatment. However, current challenges to new research developments can be both scientific and financial.
Can these strategies really stop AMR?
While AMR poses a significant threat to health in the future, the situation does not appear to be irretrievable. The WHO report and an accompanying press release highlight some examples of success stories over the past years:
- In Thailand, the "Antibiotic Smart Use" programme is reported to have reduced both the prescribing of antibiotics by prescribers and the demand for them by patients. It demonstrated an 18–46% decrease in antibiotic use, while 97% of targeted patients were reported to have recovered or improved regardless of whether they had taken antibiotics.
- A pharmacy programme in Vietnam reportedly consisted of inspection of prescription-only drugs, education on pharmacy treatment guidelines and group meetings of pharmacy staff. These measures were reported to give significant reduction in antibiotic dispensing for acute respiratory infections.
- In Norway, the introduction of effective vaccines in farmed salmon and trout, together with improved fish health management, was reported to have reduced the annual use of antimicrobials in farmed fish by 98% between 1987 and 2004.
- In 2010, the University of Zambia School of Medicine was reported to have revised its undergraduate medical curriculum. AMR and rational use of medicines were made key new topics to ensure that graduates who enter clinical practice have the right skills and attitudes to be both effective practitioners and take a role in fighting AMR.
How can I do my part?
There are times when antibiotics are necessary or even vital. However, as patients and consumers, it is important to remember that antibiotics or other antimicrobials are not always needed to treat our illnesses, and we should not expect them in every situation.
For example, the common cold is caused by a virus, which means it does not respond to antibiotics. However, people may expect to be given antibiotics by their doctor when they are affected, even though they offer no direct benefit and could raise the risk of bacteria becoming resistant. Furthermore many common viral and bacterial infections such as coughs, throat and ear infections and stomach upsets, are “self-limiting” in healthy people, which means they will generally get better with no treatment at all.
If, on the other hand, you are prescribed an antimicrobial, it is important to take the full course as directed. Taking only a partial course of an antimicrobial may not kill the organism but may expose it to a low dose of a drug which can then contribute to resistance.
Links To The Headlines
Health chief warns: age of safe medicine is ending. The Independent, March 16 2012
Human resistance to antibiotics could bring "the end of modern medicine as we know it", WHO claim. The Daily Telegraph, March 16 2012
Why a sore throat could soon be fatal: Bugs are becoming more resistant to antibiotics, warn health chiefs. Daily Mail, March 16 2012
Links To Science
WHO: The evolving threat of antimicrobial resistance - Options for action. March 16 2012
The news was reported by Lynne Terry of The Oregonian. She wrote that Del Monte Fresh Produce notified the state earlier this month that it would not go forward with legal action against William Keene and his department.
Del Monte Fresh Produce had announced its threat in a news release in August, claiming that "misleading allegations" had been made in naming the Guatemalan cantaloupes as the likely source of Salmonella infection that sickened at least 20 people, and sent three to the hospital. The case patients were from Arizona, California, Colorado, Maryland, Montana, Nebraska, Oregon, Pennsylvania, Utah and Washington.
Twelve of 16 ill people had reported eating cantaloupe in the week before they became ill, according to a Centers for Disease Control and Prevention report on the outbreak investigation. Eleven of those 12 people had purchased cantaloupes from eight different Costco stores and traceback information indicated the melons were from a single farm -- Asuncion Mita in Guatemala.
Del Monte Fresh Produce voluntarily recalled the Guatemalan cantaloupes on March 22, 2011 after it was notified of the epidemiological link between the melons the outbreak of Salmonella Panama infection.
But when the Food and Drug Administration banned further cantaloupe imports from the company's Guatemalan farm, Del Monte Fresh Produce sued the FDA and got it to back down on the import alert. It also claimed it was wrongly blamed for the outbreak.
Food safety experts and consumer activists predicted the case targeting Oregon Public Health -- recognized for its food safety leadership -- would not go far, but said they saw the complaint filed by Del Monte Fresh Produce as an attempt to intimidate public health programs across the country.
Dr. Katrina Hedberg, Oregon state epidemiologist, told The Oregonian that dealing with the tort claim had been time-consuming, so it was a relief when it was withdrawn and they could resume focusing on their job -- protecting the public's health.
The claim was unprecedented, Terry noted:
State epidemiologists investigate dozens of foodborne illness outbreaks every year and name the culprits to prevent more people from getting sick. No other company has ever filed a suit or threatened to sue Oregon over one of those investigations.
"There have been lots of outbreaks," Hedberg said. "Why some companies choose to work with public health and others want to fight it -- I can't answer that."
A Del Monte Fresh Produce spokesman declined to comment, telling Terry the company "does not comment on ongoing or closed investigations."
Lab tests confirmed L. monocytogenes in a sample of the company's Los Corrales Queso Fresco Fresh Cheese and Banana Leaf (code date 03/16/12 , according to a NJDHSS news release Thursday. The pregnant woman's Listeria infection was diagnosed March 2 at a New Brunswick hospital.
El Ranchero del Sur, based in South River, NJ, has agreed to recall its products and close its production plant. While the facility is inspected, all products and ingredients have been embargoed, state public health officials said.
According to the news alert, El Ranchero del Sur cheese products are found primarily in Mexican and Latin American grocery stores, restaurants, and other Hispanic food establishments under the name brands El Ranchero, Los Corrales, and Carnes Don Beto. The plant number 34-0013669 is marked on the label. All products are 14 ounces in weight, except for the Queso Hebra Oaxaca String Cheese ball, which is sold in 10 pound packages.
The state health department's Food and Drug Safety Program is requesting that local health departments check to ensure that El Ranchero del Sur products are removed from retail food establishments in their area.
According to the Centers for Disease Control and Prevention (CDC , Listeria infection can be passed to an unborn baby through the placenta, even if the pregnant woman is not showing signs of illness. Listeriosis can cause premature labor and miscarriage and, if passed along to a newborn, may result in sepsis or meningitis and be fatal.
In 1985, in an outbreak of Listeria infection that sickened 142 people who had eaten commercially produced soft cheese mixed with unpasteurized milk, 93 of the victims were pregnant women or their offspring. Twenty fetuses and 10 newborns died in that outbreak.
The CDC advises pregnant women not to eat soft cheeses such as feta, Brie and Camembert, blue-veined cheeses, or Mexican-style cheeses such as queso blanco, queso fresco, and Penela unless they have labels that clearly state they are made from pasteurized milk.
Sanuwave plans to run additional clinical trials of its dermaPace foot ulcer treatment after the FDA deems its initial submission insufficient.
Regenerative medicine firm
Sanuwave Health (OTC:
SNWV will run another clinical trial of its dermaPace foot ulcer treatment, after the FDA determined that its initial pre-market approval bid failed to meet its primary endpoint.
New trials may take up to 2 years before the company re-submits its device for FDA review, according to a press release.
Diabetes,
Food & Drug Administration (FDA ,
Pre-Market Approval (PMA ,
Regenerative Medicine
Cancer Research, explains that dietary cadmium - a heavy metal long identified as a carcinogen which leaches into crops from fertilizers and when rainfall or sewage sludge deposit it onto farmland - can potentially increase a woman's risk for breast cancer, writes Christine Kearney for
Medical News Today. Associate professor Agneta Akesson, from the
Karolinska Institute in Sweden said in a recent press release: “Because of a high accumulation in agricultural crops, the main sources of dietary cadmium are bread and other cereals, potatoes, root crops and vegetables. In general, these foods are also considered healthy.” The 12-year study found that among 55,987 post-menopausal women, the one-third with the highest cadmium intakes were 21 percent more likely to develop breast cancer than the one-third with the lowest intakes. Among obese women, the study found no increase in breast cancer rates with higher cadmium exposures. The finding comes just three months after the Institute of Medicine (
IOM , a prestigious body of independent biomedical researchers, concluded that a host of other factors — most within a woman’s power to control, such as obesity and hormone-replacement medication — were the most important sources of breast cancer risk. The IOM had called it “biologically plausible” that estrogen-like pollutants promote breast cancers, but noted that evidence that they contribute significantly was inconclusive. By contrast, studies in human populations strongly point to fattening foods, hormone-replacement drugs, alcohol and cigarettes as having roles in boosting a woman’s breast cancer risk. A woman’s lifetime exposure to estrogen powerfully influences her risk. In animals and in laboratory tests, cadmium has been shown to exert estrogen-like effects more powerfully than other environmental pollutants, and so suspicion has fallen on the heavy metal as a possible promoter of breast cancer. “Cadmium is receiving a lot of attention these days because of its estrogenic properties,” Rudolph Rull, a research scientist at the Cancer Prevention Institute of California in Berkeley, told Melissa Healy of the
Los Angeles Times. Both estrogen receptor-positive and negative tumors had the same risk increase at roughly 23 percent. Akesson said that women who consumed higher amounts of whole grain and vegetables had a lower risk of breast cancer compared to women exposed to dietary cadmium through other foods. “It’s possible that this healthy diet to some extent can counteract the negative effect of cadmium, but our findings need to be confirmed with further studies,” said Akesson. “It is, however, important that the exposure to cadmium from all food is low.”
USDA announced on Thursday. According to Michael Hill of the
Associated Press (AP , starting next fall districts will be able to choose to continue receiving 95% lean beef patties that include the filler product, or fattier cuts of ground beef that is free of the ammonia-treated substance. The change in policy cannot go into effect immediately due to existing contracts, an unidentified USDA official told the news organization. "Though the term 'pink slime' has been used pejoratively for at least several years, it wasn't until last week that social media suddenly exploded with worry and an online petition seeking its ouster from schools," Hill wrote. "The petition quickly garnered hundreds of thousands of supporters" "The low-cost ingredient is made from fatty bits of meat left over from other cuts. The bits are heated to about 100 F and spun to remove most of the fat. The lean mix then is compressed into blocks for use in ground meat. The product, made by South Dakota-based
Beef Products Inc., also is exposed to 'a puff of ammonium hydroxide gas' to kill bacteria, such as E. coli and salmonella," he added. The USDA told Hill that the agency, which is responsible for purchasing about 20% of the food used in school lunches across the country, "continues to affirm the safety" of the boneless lean beef trimmings. However, they said that they wanted to be "transparent" and recognized that schools wanted to be able to opt out of receiving the ammonia-treated lean finely textured beef. The controversy involves not just the beef itself, but also the use of ammonium hydroxide to treat the meat. The product itself,
AFP reporter Robert MacPherson says, is "left-over bits of slaughtered cattle… that is mixed in a centrifuge" -- or as chef Jamie Oliver puts it, according to an article by Amy Hubbard of the
Los Angeles Times, "all of the bits that no one wants." Once the beef products are mixed together, they are treated with ammonium hydroxide in a USDA-approved process in order to prevent E. coli and salmonella contamination, Hubbard said.
International Food Information Council Director of Media Relations Steven Cohen told her that the substance had been reviewed and deemed safe by the Food & Drug Administration (
FDA in 1974, and that it is an additive used in other products, including cheese and chocolates. However, the Times reporter adds that it is also used as a "sanitizer in many household and industrial cleaners," which has led
McDonalds and other restaurant chains to discontinue the use of the so-called "pink slime" beef products. Despite the USDA's announcement Thursday, Hill says that Maine Representative
Chellie Pingree has asked
Agriculture Secretary Tom Vilsack to immediately and permanently ban its use in schools. "The beef industry sent my office an email the other day describing pink slime as 'wholesome and nutritious' and said the process for manufacturing it is 'similar to separating milk from cream.' I don't think a highly processed slurry of meat scraps mixed with ammonia is what most families would think of as 'wholesome and nutritious,'" the Congresswoman said in a statement.
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