New Zealand Science Teacher

An antibiotics uprising

23/09/2014

Antibiotic resistance is a battle in which we are the underdog, writes Year 11 biology student KRISTEN BLABER-HUNT.

This is the student essay referred to by Remco Baars in her piece "Infernal Essays'.

Battleship. A game most people have played or will play in their lifetime. A game where you are clueless as to what your opponent is thinking, what they are doing, and what their plan is. You have absolutely zero sense as to what is going to happen. Will they hit you? Or will they miss? One small wrong move, and you are dead. Gone, sunk to the bottom of the ocean. YOU choose where to put your ships. Yet there is that chance you could die and lose to your opponent. For you did not have a clue as to how the war was going to end. You chose your locations, and you will face the consequences of your decisions.

Luckily, it’s just a game.

But is it? What if there was a real game of Battleship going on, right now. Worldwide. What if we are treading on something so dangerous, it could wipe out our whole population? One small wrong move and a pandemic could arise. What if we as a population are clueless to the consequences we may face if we continue?

Truth is, there is no ‘what if’. This is happening. Right here, right now. We are currently in our very own battle, all 7 billion of us. We are fighting against an uprising of tiny organisms so smart that they can adapt to our weapons, they can mutate and change themselves for survival. Something we were not granted with the ability to achieve. We are the underdogs in this fight; we must become aware of our choices. We must realize what is happening before it is too late.

Bacteria are developing resistance. Antibiotic resistance is the biggest Battleship game we have yet to win. The World Health Organization (WHO) warns us; “It is happening right now in every region of the world and has the potential to affect anyone, of any age, in any country.”

As the rate of resistance grows, fewer antibiotics remain in the battlefield to fight the common diseases. Although this situation is growing worldwide and happening everywhere, we as the population of New Zealand need to think about how we are going to contribute to the war against resistant bacteria – where we are going to place our battleships.

In 2000, an epidemic of Methicillin-resistant Streptococcus aureus (MRSA) appeared in New Zealand hospitals. Dr Rosemary Ikram, clinical microbiologist of MedLab South says this was “Most likely imported from the United States by patients and staff”. This is proof of how easily an epidemic can affect other countries. The World Health Organization tracked MRSA strains in several different regions of the world. In Africa, about 80 per cent of S. aureus infections were reported to be resistant to Methicillin, and 60 per cent being resistant in the European region etc. MRSA was once only a concern for people in the hospital, but now it is a problem for healthy people in the community. A 37 per cent increase of MRSA cases in New Zealand from 2010 to 2011 is the largest yearly increase there has been in 10 years. This is merely just one example of resistance uprising, and this is just the beginning of the war. What can we do to fight this resistance? How wisely are we using antibiotics?

Antibiotics are substances that kill bacteria without harming us. They target prokaryote cell processes not eukaryote cell processes which is why human eukaryote cells are not affected. Bacteria can develop resistance to antibiotics. This is called antibiotic resistance. Antibiotic resistance occurs when bacterium are regularly exposed to an antibiotic. The resistance can happen in two different ways. One method is the bacteria genetically mutates, which can produce different types of resistance, such as producing enzymes (chemicals) that can disable the effectiveness of the antibiotic. Another example is the elimination of the cell target that the antibiotics attack and also closing up entry ports that allow the antibiotics to enter.^{The second way resistance can happen is by the ‘transfer of resistance’, which can be by gaining antibiotic resistance genes from other bacteria by undertaking a mating process with another bacterium called “conjugating”. This transfers genetic information from one bacterium to another or through a virus that injects the resistance into another bacterium.}

Resistance allows a mutant bacterium to survive and repopulate, which causes the bacterial disease to become immune – making the antibiotic useless against that disease. This is a major problem, as infections that are usually easy to treat may become untreatable and uncontrollable. Resistance is a massive issue and it is increasingly becoming more and more of a problem.

The war between resistant bacteria and us is becoming more lethal. Our choices have left us with the resistance of bacteria, blunting the effect of our weapons, antibiotics. We all know that when we use something inappropriately, it is taken away from us. So are we using antibiotics inappropriately? Is that what bacteria is doing, taking away our privileges because we are not using them wisely?

There is a debate between organisations, citizens, and governments on whether or not we are using antibiotics in an appropriate and responsible manner, and how we should be resolving the resistance. The fact that antibiotic resistance is proven to be influenced by the exposure of antibiotics provokes us to wonder about whether or not we are using them intelligently and how we should be dealing with the issue.

Viewpoint 1: new alternatives

Some people believe we should be looking for new alternatives or developing new antibiotics.

At Labtimes.org, Anne Glover and Birgitta Normark express their opinions on what they believe the “remedy” could be. Anne Glover, a molecular and cell biologist at the University of Aberdeen, says that “we do need to think about new alternatives to antibiotics, like bacteriophages or viruses to attack the infecting bacteria.”

Have we gotten to the point where new alternatives are the answer as Anne Glover is stating? Are our antibiotics going to forever become ineffective? We need to think about this and decide whether or not this is true. If it is correct, then actions need to take place right now, before it is too late. If we do not have the potential of saving our antibiotics, then we need to start developing new ones and think about these new alternatives Glover is presenting us with.

 She also confronts us with an intriguing question, “Do you want to die by carelessness?” This is a powerful rhetorical question. She is suggesting to us that we are being careless with how we are using and prescribing antibiotics. Some countries do not require a prescription to get antibiotics, such as Spain, where people can purchase ‘over the counter’ antibiotics. Is this careless? Does this method of purchase and use affect the rate resistance is developing? By allowing antibiotics to be purchased without a prescription, we override the skills doctors are meant to be using, the power to diagnose people with an illness and give them the ‘right’ antibiotic of treatment. By somebody taking the wrong antibiotic, or even taking an antibiotic when they have a virus (antibiotics do not fight viruses, as they are not considered ‘living’) they are giving the bacteria unnecessary access to the building of resistance. The exposure to an antibiotic that is not going to kill the bacteria allows it to mutate providing resistance. So therefore, is ‘over the counter’ antibiotic purchasing a careless freedom? If somebody can walk into a pharmacy and purchase an antibiotic without consultation or any knowledge of whether or not it has the potential to fight their infection, then we might as well hand over our weapons and let the bacteria take over the world because that is what we are virtually doing.

Anne Glover says, “The side effects for you as a patient might be quite small, but the side effects for all of us could be quite large.” What most people are not aware of is that by them taking an antibiotic, there is a side effect on all of us. This lack of awareness can cause our population to suffer, to lose the battle. Resistance is everywhere, all over the world. It spreads fast, and it is a hard opponent. Resistant bacteria know more than we do, they have a fair idea where we have placed our ships, and we do not have any clue to as where they have placed theirs. They have the advantage; we give them the advantage by not knowing these side effects.

Birgitta Normark, head physician at the Swedish Institute for Communicable Diseases, has spoken about successful clones of resistant bacteria. She says, “we think some factors within the bacteria are important for how successful they are” and that “if scientists could target these factors, new vaccines and treatments would be just around the corner.”

Normark believes that we should be discovering how we could take down bacteria so that we can be developing new vaccines and treatments for our war. This could be a great strategic for the battle against bacteria, as new treatments means new ways of fighting the bacteria that is resistant to other antibiotics. By destroying these bacteria, we can eliminate the resistance of some infections. Also, by developing new vaccines, we can increase the prevention of infections in the first place, which means we do not even require the antibiotics, decreasing the amount of medication required worldwide. This could be a worldwide evolution, a slow elimination of resistance.

Although we will never fully eliminate resistant bacteria, decreasing the number of resistant strains means that we have more antibiotics in the battlefield.

Researchers at Oregon State University believe that a lab synthesized form of DNA or RNA that goes by the name Peptide-conjugated phosphorodiamidate morpholino oligomer (PPMO) could be the answer. Their research suggests PPMO is able to silence specific genetic targets, and the researchers say they can actually function better than an antibiotic, without the risk of bacteria becoming resistant to them.

If this can be developed further, this could be the answer to the resistance challeng. By instituting PPMO, resistant bacteria would wither and run short of ammo to hit our battleships. PPMO works by disrupting the bacteria’s genes and attacking a bacteria cell’s functions.

Bruce Geller, a microbiology professor at Oregon State says, “the mechanism that PPMOS use to kill bacteria is revolutionary.” So far, PPMO has been tested in animals against infections caused by Acinetobacter (A. baumannii), which creates respiratory infections and sepsis that can be deadly to people with weak immune systems. The researchers involved at Oregon State University say that PPMO functioned better than ‘broad spectrum’ antibiotics. Although this alternative has not been used in humans yet because of further testing required for issues of toxicity, Geller says, “molecular medicine is the way of the future.” He may hold this viewpoint because he has the insight to what has been going on, the tests run and the trials of PPMO which gives him a fair idea of whether it will work or not. So is it?

Viewpoint 2: Use antibiotics more wisely

Although some people believe new alternatives to antibiotics or the development of new antibiotics is the way to recovery from resistance, others believe that using antibiotics wiser and more appropriately would make a massive difference within the problem of bacteria resisting to antibiotic treatment.

Dr Keiji Fukuda, the assistant director-general for health and security at the World Health Organization, says, “unless we take significant actions to improve efforts to prevent infections and also change of how we produce, prescribe, and use antibiotics the world will lose more and more of these global public health goods and the implications will be devastating.”

He may hold this viewpoint because he has access to world resistance files and can see trends and the increasing resistance cases that are being seen around the world; therefore he knows we need to take action. Fukuda is saying we need to be more alert with the prescriptions and the use of antibiotics within society.

On bpac.org.nz, we can see a data set of antibiotic prescriptions dispensed per 1000 population from 2009 in New Zealand. Penicillin resistance, for example, is 69 per cent in an area where over 1000 prescriptions of penicillin are made (Counties Manakau in the North Island). In comparison to the penicillin resistance of 55 per cent in an area where there are 500–600 prescriptions of penicillin made (West Coast in the South Island). This clearly shows that there is less antibiotic resistance in areas where fewer antibiotics are used. Although this seems low in comparison to the 69 per cent of resistance, 55 per cent represents over half of all penicillin prescriptions shown to being resisted by bacteria.

As Fukuda has said, significant actions need to take place and we need to change how we prescribe antibiotics. An intriguing website called kickthatbug.co.nz has been created to raise the awareness of antibiotic resistance and to help people make the right decisions when dealing with antibiotics to reduce the amount of resistance seen in the community all around the world. This website, specifically dedicated to New Zealand is a reliable source as it is managed by PHARMAC, with support from the following partners: Pharmacy Guild, ESR, RNZCGP, Pharmaceutical Society, and Plunket. This website clearly believes that raising awareness of behavior we should have and providing knowledge of things that can reduce the amount of bacterial resistance when having an involvement with antibiotics can assist our problem of resistance.

According to Kick That Bug, antibiotics are very effective when they are being used at the right time, for the right length of time, in the correct dose to the right person. They reinforce the importance of finishing courses of antibiotics, as if you don’t, bacteria may continue to grow and develop resistance to the medicine till it gets to the point that a stronger or different antibiotic may be needed to kill the bacteria. This website appeals visually and has several different promotion videos saying things like “Take the lot, no matter what” and “Antibiotics don’t do colds and flus”.

By providing this sort of knowledge to people, the appropriate use of antibiotics becomes better known, which stops people making silly mistakes and giving bacteria an easy fight. The visuals and simple phrases make the important information easy to remember and catchy, which means people are unlikely to forget it. The promotion of using antibiotics wisely by Kick That Bug states that we do not need alternatives, and that we can combat the resistance by just making smarter choices. But can we?

My viewpoint

From the information I have read while discovering whether or not we are using antibiotics wisely – and how we should be dealing with it – I believe that we do need to change the way we are using antibiotics. However, I don’t think that just doing this will be enough to win the battleship war against resistant bacteria.

The use of antibiotics in New Zealand, or even in the whole world, is not what it should be to protect our weapons; in fact, it is definitely not up to standard. But it is too late to just change that; we also need to think of new alternatives for a secure future. The research made at Oregon State University really made me realise what options we have and could have if more effort was put into this research. By opening my eyes to PPMO, I have started considering all the possible solutions that could be out there, if we really did decide that this was the way to a future of strategic thinking as to where the bacteria have placed their battleships, and as to what their next move is.

I believe that PPMO would be a great solution, as having something that cannot be affected by resistant bacteria would be the answer to a safe guarded future of health. But it makes me consider, if PPMO is in the process of being tested, then what else could be out there that is also a possible option? Is there something else just like PPMO? Are there more new alternatives yet to be discovered? This could be an intriguing path to follow. The possibilities are endless but we have limited time before the bacteria have the ability to beat us. In the meantime, following a plan of action and raising awareness of things we could be doing to improve this situation could help extraordinarily with this ongoing battle, while we create our new missiles.

Plan of action

To fight in this war of resistance without being disadvantaged, we need to have a plan of action. Resistance is an issue because of the inappropriate use of antibiotics, careless antibiotic prescriptions being made, and antibiotics that are not being used in the right environments – e.g. courses not being finished. The resistance is ruinous to the success of treatments such as surgery, chemotherapy, and organ transplantation. The cost of treating resistance is high, and it results in prolonged illness and a higher death rate. For example, people with MRSA are 64 per cent more likely to die than people with a non-resistant form of the infection. We need to tackle this resistance and reduce the effect it is having on our nation.

The World Health Organization recommends basic systems to track and monitor the resistance, such as the one we have in New Zealand monitoring resistance rates per 1000 prescriptions. This can help us recognise the core places where resistance is a problem so we can stop it spreading to other parts of the world. It will also allow us to take other factors into consideration, such as the medicinal use and the prescriptions that are made, and also whether the population is ageing or youthful. Ageing populations tend to be wiser and use less antibiotics, as parents tend to panic when their children are sick and get antibiotics straight away, even when they are probably not needed. This could provide helpful data as to what we could do to improve it, such as provide more education and information on antibiotics to those particular populations.

By preventing infections from happening in the first place, the rate of illness and antibiotics would reduce, which would also reduce the resistance. This can be done by doing simple things such better hygiene – e.g. washing hands frequently, access to clean water, infection control in healthcare facilities, and promotion of vaccinations.

Vaccinations reduce the need for antibiotics and reduce the chances of you getting the infection in the first place. They are highly recommended for everyone, especially those who are travelling overseas as they can easily be a transporter for bringing bacteria into different countries, which can result in a pandemic.

Every country and every individual needs to do all of these things. We all need to step up and work together to hit bacteria’s battleships. We have a limited amount of missiles; therefore, we need to think carefully about where we are shooting them. Through simple measures such as those outlined above, and by appropriately using antibiotics and finishing courses, we can be well on the way to dominating bacteria, although we will never completely eliminate them. Developing new tools and new diagnostics will provide a great foundation for future generations and hopefully will provide a long-term solution to the battle of antibiotic resistance. Now the question is: are your battleships ready?

Kristen Blaber-Hunt is a Year 11 student at Darfield High School.