When Antibiotics Stop Working

Generated Summary

This policy paper from the Ontario Medical Association (OMA) addresses the critical issue of antibiotic resistance, a growing concern in Ontario and Canada. The paper explores the mechanisms by which bacteria develop resistance, the impacts on human health and the healthcare system, and the role of antibiotic use in animal husbandry. The authors advocate for prudent antibiotic use, enhanced surveillance, and policy changes to mitigate the risks associated with antibiotic resistance. The paper employs a policy analysis approach, synthesizing scientific evidence, clinical observations, and regulatory information to inform its recommendations. The scope of the document is broad, touching on issues related to the overprescription of antibiotics in human medicine and the practices within animal agriculture. It argues that a multifaceted approach involving healthcare professionals, policymakers, and the public is crucial to preserving the effectiveness of antibiotics.

Key Findings & Statistics

• The paper highlights that antibiotic resistance is an under-recognized problem in Ontario and the rest of Canada.
• It mentions that some resistant bacteria, like Methicillin-resistant Staphylococcus aureus (MRSA) and Vancomycin-resistant Enterococcus (VRE), often make news headlines, but many others do not get the same amount of attention.
• The paper points out that the increase of antibiotic resistance represents the need for a change in thinking and that some antibiotics have stopped working.
• It also states that resistance to antibiotics is growing among a multitude of bacteria, with increasingly harmful effects on human health.
• The impact on patients has reached a dangerous level, with examples of urinary tract infections with extended-spectrum beta lactamase (ESBL)-producing bacteria, and pneumococcal bacteria becoming increasingly resistant to macrolides.
• The paper gives an example of a patient who had pneumonia was prescribed macrolides and was reasonably expected to get better at home, but became seriously ill and was discovered unconscious by a family member.
• The document mentions that in a recent instance, a patient with pneumonia was prescribed macrolides and was reasonably expected to get better at home, but became seriously ill and was discovered unconscious by a family member. The presence of resistant bacteria required hospitalization and an intense round of treatment with more powerful (and more toxic) antibiotics.
• For example, one patient who had Escherichia Coli (E. Coli) growing in her urine but had no symptoms (a condition called asymptomatic bacteriuria) was given antibiotics. The patient began to suffer from diarrhea 10 days later. The treatment of the E. Coli, which was unnecessary, led to a resistant infection with Clostridium Difficile (C. Diff). The patient spent a total of four months in the hospital recovering from the C. Diff infection.
• The document states that resistance to second-line or third-line antibiotics is an important warning sign that bacteria could already be, or quickly become, resistant to their first-line relatives, and cause serious problems for human health.
• The document also mentions that three of the most obvious results of antibiotic resistance are beginning to be experienced by physicians in Ontario: the need to use unfamiliar antibiotics to treat patients, the need to use more toxic antibiotics to treat patients, and the longer duration of illnesses in patients.
• The fourth result of antibiotic resistance is a greater risk and higher rate of death. Patients are now dying from infections that physicians have been successfully treating for decades.
• Health Canada found that people with infections resistant to antibiotics were more likely to be hospitalized than those with susceptible infections, even after the patients’ different underlying illnesses were taken into account.
• The total direct cost over a two-year period was $525,108.5.
• Canadian rates of having this strain of bacteria (either being infected or being “colonized” – having the bacteria in the body but not having a clinical infection) were 4.2 cases per 1,000 hospital admissions.
• In 2010, the National Collaborating Centre for Infectious Diseases (NCCID) estimated that direct health-care costs associated with MRSA and resistant enteric bacteria in Canada would reach between $104 million and $187 million annually.
• In Denmark in 1994 the year that the Danish ban on extra-label antibiotic use in farm animals was introduced – 24 kg of the antibiotic vancomycin was used for human treatment, while 1,000 times more of the related antibiotic, avoparcin, was used in animal feed.
• By 2009, Denmark’s total volume of antibiotic use for farm animals was reduced to 65 times the total volume of antibiotics used for humans.
• In 1997, the estimated total consumption of antibiotics across the European Union (EU) and Switzerland was 5,093 tonnes shared between therapeutic use in all food animals and non-therapeutic use in poultry and livestock.
• In the same year, approximately the same volume of antibiotics was used for humans, bringing human use of antibiotics slightly above the rate of use for animals, at 52% of the total EU use that year.
• In 2007 study of pig farms in Ontario and British Columbia found that E. Coli bacteria had 24% resistance to tetracycline, 17% resistance to sulfamethoxazole, and 16% resistance to ampicillin.
• In retail chicken meat in Ontario, Salmonella strains were 40% resistant to Ampicillin, Streptomycin and Tetracycline, with over 20% resistance to a variety of first-line and second-line antibiotics.
• In pigs on farms, Salmonella isolates are 40% resistant to four important antibiotics, and abattoir surveillance found similar levels of resistance.
• In abattoir surveillance of beef cattle, E. Coli isolates were over 20% resistant to second-line antibiotics.
• Surveillance of retail beef in Ontario yielded the same results, and resistance is trending upwards in the province.
• In farm surveillance of pigs, E. Coli isolates were over 75% resistant to Tetracycline (a third-line antibiotic), and 40% resistant to Ampicillin and two other antibiotics.
• In retail meat surveillance of chickens in Ontario, Campylobacter isolates were 40% resistant to Tetracycline.
• Samples of species of Campylobacter except C. Jejuni and E. Coli taken from chicken were 100% resistant to Ciprofloxacin, a first-line antibiotic, and Nalidixic Acid.
• Retail meat surveillance of chicken in Ontario revealed that Enterococcus bacteria are over 50% resistant to second-line antibiotics, and over 80% resistant to some second-line and third-line antibiotics. Specifically, Enterococcus Faecium was 100% resistant to Lincomycin (second-line), and over 60% resistant to at least six other first-line, second-line, and third-line antibiotics.

Other Important Findings

• The paper emphasizes that resistance to antibiotics is growing among a multitude of bacteria, leading to increasingly harmful effects on human health.
• It highlights that antibiotics have stopped working for some infections, and some infections are self-clearing and do not require therapy.
• The document notes the negative effects of antibiotic use on human health and mentions that bacteria have been gaining resistance to antibiotics since they were first discovered.
• The paper underlines that the health impact of antibiotic resistance has only recently begun to be felt.
• The document also suggests that the increased use of unfamiliar and more toxic antibiotics, and longer duration of illnesses in patients are some of the obvious results of antibiotic resistance.
• The paper discusses the potential implications of antibiotic resistance in medical settings, including community, emergency, hospital, and nursing home settings, and notes the need for changes in these practices.
• The role of veterinarians, regulatory bodies, and the public in promoting the prudent use of antibiotics.
• The document discusses the impact of antibiotic resistance on patients, including more severe illnesses, longer hospital stays, and increased mortality.
• The paper emphasizes that resistance to antibiotics in animals can be linked to the use of antibiotics in animals and provides the case study of Salmonella Heidelberg in St-Hyacinthe, Quebec.
• It highlights the risks associated with the widespread use of antibiotics in animal husbandry, including the use of antibiotics in non-therapeutic ways.
• The document points out the need for a surveillance system to monitor antibiotic use in food animals.

Limitations Noted in the Document

• The paper does not provide specific details on the methodology of the studies cited, thus limiting the ability to evaluate the quality of the evidence.
• The document acknowledges limitations in the availability of data regarding antibiotic use in animal husbandry, particularly in Ontario, which impedes a complete assessment of the problem.
• The document does not describe the surveillance or regulatory mechanisms in place in Ontario for the use of antibiotics in animal husbandry.
• The paper’s focus on Ontario may limit the generalizability of its findings to other regions or countries.
• The document is limited by the scope of available information. The paper primarily relies on the information presented within the document itself.

Conclusion

The Ontario Medical Association’s policy paper on antibiotic resistance presents a comprehensive analysis of a critical public health issue. The document argues that antibiotic resistance is an under-recognized problem in Ontario and highlights the need for urgent action. Key recommendations include establishing surveillance systems for antibiotic use in food animals and human medicine, utilizing electronic health records, developing optimal antibiotic use guidelines, and banning the prophylactic use of antibiotics in animal husbandry. The paper stresses the importance of prudent antibiotic use, emphasizing that the overuse of antibiotics leads to resistance. The authors underscore the need for a collaborative approach, involving physicians, patients, and policymakers. One of the most impactful quotes from the paper is, “Patients are now dying from infections that physicians have been successfully treating for decades.” This statement underscores the severity of the issue and highlights the devastating consequences of antibiotic resistance on human health. The paper’s emphasis on the link between the overprescription of antibiotics, and the rise of antibiotic resistance in human health is crucial. This document strongly advocates for a shift toward more judicious antibiotic use, acknowledging that the evolution of antibiotic resistance is a biological process. The policy paper also highlights the significance of reducing antibiotic use in animal husbandry to protect the effectiveness of antibiotics in treating human infections. The policy paper’s final recommendations for action are a clear call to action to address the critical issue of antibiotic resistance. The overall implication is that, without significant changes, the effectiveness of antibiotics will continue to diminish, leading to increased morbidity and mortality. The authors’ key takeaway is that a concerted effort is needed to ensure that antibiotics remain effective in the future.