The Antibiotic Paradox ”how miracle drugs are destroying the miracle”

paradox: “something that seems contradictory, yet may nonetheless be true”

though this be madness yet there is method in't

Hamlet Act II, scene 2,

Don't it always seem to go

That you don't know what you've got till it's gone Joni Mitchell (1970), Big Yellow Taxi

1952

1952

http://www.time.com/time/magazine/article/0,9171,935105,00.html

Dr. Margaret Chan, director general WHO. March 16, 2012

“A post-antibiotic era means, in effect, an end to modern medicine as we know it…… ….. Some interventions, like hip replacements, organ transplants, cancer chemotherapy and care of preterm infants, would become far more difficult or even too dangerous to undertake”

Aw

aren

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of a

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ue

Surgeon

General Practitioner

Cardiologist

ID Physicians

Thoracic Physician

• We see this as a public health crisis, others do not • Too easily seen as someone else’s problem.

The impending disaster curve

Administration

NAUSP Annual Report, 2008-9

www.safetyandquality.gov.au

drinking water sea

Animals

Poultry

Sheep Cattle

Pigs

Humans

Hospitalised

Rural Urban

Environment

Land mass

Streams Rivers

manure spreading swimming

farm effluents

offal

Animal feeds

abattoirs processors

handling processing consumption

contact

meat

Ecology of food-borne organisms c/o Seamus Fanning, UCD Institute of Food and Health, Dublin

sewage

“Civilization is the distance man has placed between himself and his (or his animals’) excreta” ~ Brian Aldiss ,adapted

India makes ~ 1/3 world’s antibiotics ($12.4 billion)

5,000+ manufacturers of generic antibiotics

In 2007 ~45,000 daily cipro doses released downstream of Hyderabad sewage plant

Jason Gale, Bloomberg Press, May 8, 2012 http://www.bloomberg.com/news/2012-05-07/ml

1.2 billion residents, >50%

defaecate in open & 23% of city dwellers have no toilets 2012 WHO report

~ >100 mill+ NDM-1 +ve based on New Delhi environmental study Walsh et al, Lancet ID, 2011

Shigella sonnei outbreak in England and Norway in 1994 - faecal contamination of Spanish lettuce - up to 10% of Norwegian households exposed E.coli from lettuce resistant to ampicillin, co-trimoxazole, gentamicin and quinolones

DANMAP

http://www.danmap.org/Downloads/The%20Danish%20approach.aspx

Dutil L. Emerg Infect Dis. 2010; 16:48-54

Relationship quinolone consumption and resistance in E.coli

Durham K. Eur J Clin Microbiol Inf Dis 29, 353-356; Cheng AS. Emerg Infect Dis (in press Sept 2012)

Fluoroquinolone Resistance in Campylobacter, Australia

Australia: 2003 - 0% (0/144) local acquired, c/w 3/7 imported. 2006 - 2.6% overall c/w USA 1999 19%; UK 2004 25%, 2009 38%, Thailand 2000 >80%.

Cody AJ. Lancet 2010. 376; Unicomb L. Emerg Infect Dis. 2003. Clin Infect Dis 2006;

Zsuzsanna Jakab, WHO Regional Director for Europe. World Health Day 2011.

“Antimicrobial resistance is a problem that goes beyond the health sector, so it

is important to involve all sectors,”

“Every government should have a national inter-sectoral plan on how to address the

issue and respond to it.”

Department of Health and Ageing (Chief Medical Officer)

Department of Agriculture, Fisheries and Forestry (Chief Veterinary Officer)

Australian Commission on Safety and Quality in Health Care (ACSQHC)

Australasian College for Infection Prevention and Control (ACIPC)

Australian Pesticides and Veterinary Medicines Authority (APVMA)

Australian Society for Antimicrobials (ASA)

Australasian Society for Infectious Diseases (ASID)

Communicable Disease Network Australia (CDNA)

Department of Health and Ageing (DoHA)

National Health and Medical Research Council (NHMRC)

NPS

Pharmaceutical Benefits Advisory Committee (PBAC)

Public Health Laboratory Network (PHLN)

Therapeutic Goods Administration (TGA)

The pump don't work 'Cause the vandals took the handles

Bob Dylan, Subterranean Homesick Blues