A dramatic rise in global antibiotic consumption has led public health experts to call for fresh strategies to rein in excessive use of the drugs, and for major investments to provide clean water, sanitation and vaccines in countries where infectious diseases are rife.
The unrestrained use of antibiotics is the main driver for the rise in drug-resistant infections which now kill more than half a million people a year worldwide, including 50,000 in Europe and the US combined. Left unchecked, the spread of drug resistance could claim millions of lives a year by 2050, according to a 2014 report for David Cameron, the former prime minister.
Despite efforts to encourage more prudent use of antibiotics, an international team of researchers found a 65% rise in worldwide consumption of the drugs from 2000 to 2015. The sharp upturn, revealed in sales figures from 76 countries, was driven almost entirely by rising use in poorer nations, the study found.
“We saw a dramatic increase in antibiotic use globally and this is mostly from gains in low and middle income countries where economic growth means they have greater access to the drugs,” said Eili Klein, an author on the study at the Center for Disease Dynamics, Economics and Policy in Washington DC.
“While it’s generally a positive that there’s better access to effective antibiotics in these countries, there’s the potential for serious problems down the road from overuse. We know there’s a lot of inappropriate use in high income countries, and many of these lower income countries do not have the same controls in place.”
Last month, Public Health England reported that at least a fifth of antibiotics prescribed by GPs in England for coughs and sore throats were unnecessary. A panel of experts convened by PHE found that while only 13% of people with a sore throat should get antibiotics, 59% did when they visited their GP.
The danger posed by drug-resistant infections is so serious that England’s chief medical officer, Dame Sally Davies, has added antimicrobial resistance to the UK’s national risk register of civil emergencies. Five years ago, she warned of an “apocalyptic scenario” where people die of common infections and simple operations because antibiotics no longer work.
“As access to antimicrobials improves it is inevitable that overall use will increase,” Davies told the Guardian on Monday. “It is crucial that we concentrate on appropriate use of quality-assured medicines in both humans and animals. The importance of clean water, sanitation and vaccination must not be forgotten to avoid infections occurring in the first place.”
The latest study, published in Proceedings of the National Academy of Sciences, found that on average poorer nations still use antibiotics far less intensely than richer ones. In low and middle income nations, the number of “defined daily doses” handed out per 1,000 people rose 77% from 7.6 to 13.5 over the 16 years studied. But richer nations consume antibiotics at nearly twice that rate. According to the study, consumption rates in high income countries fell on average by a modest 4%, to 25.7 doses per 1,000 people.
Of particular concern, the report states, is the steep rise in global use of antibiotics of last resort, such as colistin, a drug that has been reintroduced despite being all but abandoned in the 1970s because of its toxicity. Colistin has been used to treat infections that cannot be shifted with other drugs, but in the past decade bacteria with colistin-resistant genes spread around the world after they emerged in a Chinese pig in the mid-2000s.
Klein and his co-authors criticise the global response to the public health crisis as “slow and inadequate”. They call for a “radical rethinking” of policies to reduce antibiotic consumption, and advocate major investments to boost hygiene, sanitation, and vaccinations in countries where antibiotic use is rocketing. Without fresh interventions to curb overuse, the number of antibiotics handed out globally could rise more than 200% by 2030, from 42bn doses per day in 2015 to 128 billion, the researchers predict.
“In high income countries, the most important thing that reduced mortality from infectious disease in the 20th century was infrastructure,” Klein said. “Separating waste from drinking water and chlorinating it was one of the most important things we did.”
Beyond clean water supplies, Klein said vaccination programmes could also help to curb excessive antibiotic use, and so drug-resistant infections. While antibiotics are not effective against viruses, vaccines that protect against the flu and viruses that cause diarrhoeal disease would reduce the number of people being handed antibiotics unnecessarily. “The reality is that a lot of antibiotic overuse is for viral infections,” Klein said.
“Our modern medical system is built on effective antibiotics,” Klein added. “If our antibiotics stop working, if bacteria become resistant to most of them, medicine will be in trouble. The worry is that people don’t do anything about it.”
