The XXIe century mark the end of the era of antibiotics, one of the most beautiful and most effective medical discoveries? Their misuse has drastically reduced their effectiveness. And despite repeated alarms for ten years, the disaster seems inevitable. This very disturbing scenario is told in a very precise way in a long documentary of Arte – broadcast Tuesday at 20:50 and available on Libération.fr . Professor Pierre-Marie Girard, head of the department of infectious diseases at the Parisian hospital Saint-Antoine, is one of the best specialists in the use, but especially the misuse of antibiotics. He looked for Libe Arte's documentary. He too believes that the time is serious.
This documentary predicts very soon the end of the effectiveness of antibiotics. Should we be worried?
Very worried. These cries of alarm are largely justified, and the phenomenon described in this documentary is faithful to the reality. The question is not whether we are likely to arrive at therapeutic anti-infectious impasses, but rather when they will occur, for lack of global and multidisciplinary mobilization. It is no exaggeration to fear the onset of a post-antibiotic era as announced by the World Health Organization (WHO), where antibiotics would no longer be effective. And here, the impact on health would be considerable, with its attendant suffering, decompensations of chronic underlying pathologies, serious sequelae and deaths. Not to mention the wide diffusion of resistant bacteria. The terrifying estimate of 10 million infectious disease deaths related to antibiotic resistance in 2050, based on assumptions and modeling, is plausible. The mortality of infectious diseases would exceed those of cancer, as at the beginning of the XXe century.
This scenario is predictable?
It's a forecast. But it would be irresponsible to remain blind, locked in a blissful optimism based on the hypothetical arrival of new, overpowering antibiotics. As of now, it is estimated that 700,000 people die each year worldwide (including 5,500 in France) directly or indirectly from an infection resistant to antibiotics. According to the World Health Organization, by 2050, resistant bacteria induced by overconsumption of antibiotics and environmental exposure [via les eaux usées par exemple, ndlr] will be responsible for the death of 2.4 million people worldwide. Once again, Asia and Africa will pay the highest price. The fact remains, however, that the expert debates surrounding the figures are mainly due to the difficulty of proving the direct accountability of antibiotic resistance. The effects of a multidrug-resistant infection are variable and, for short, vary depending on the clinical condition of the infected patient. Multidrug-resistant bacteria can be harbored without consequence in the host patient, but the situation can become dramatic on weakened sites.
That is to say ?
We could not live without harboring millions of bacteria on and in our bodies. The skin, for example, is naturally in contact with staphylococci among many other species – called bacterial flora – that settle there, and can remain there. Thirty years ago, we experienced a major problem with the emergence of resistance of these staphylococci, which were largely controlled by two types of measures. First, a better use of antibiotics in the sense of a restriction to only active infections and not mere portages. It was urgent to stop prescribing antibiotics widely promoted by pharmaceutical companies, but sometimes also prescribed by facility. Second measure: the hydroalcoholic solution, which changed everything. A few seconds of friction of the hands are sufficient. Its universal access to health care has drastically reduced the spread of staphylococcal resistance to the point that the mere consumption of hydroalcine solutes is the best marker of effectiveness in controlling resistance in the health care setting.
What about other bacteria?
These bacteria are universally present in the digestive tract, enterobacteria, which today pose a huge problem of resistance as much by their potential severity as their global expansion very alarming. To date, no line of antibiotics escapes the risk of developing bacterial resistance against them. And even an antibiotic like colistin, the last line of rescue, recently came out of the closets of pharmacies becomes ineffective in Asian patients.
So it's too late …
It is never too late, especially when we know the effective ways to contain this pandemic of bacterial resistance. We can now, by an early diagnosis of the bacterial origin – and not viral – of the infection and also by the presence or not of resistance, give the right antibiotic. In other words correctly target early in the infection rather than use for simplicity so-called broad-spectrum antibiotics that will quickly induce a strengthening of the bacteria. Rapid diagnostic tests for resistance are coming. Another lever of action, reduce the duration of treatment. For a long time, the use taught at the faculty was mainly not to interrupt the treatment too soon after the disappearance of symptoms. Thanks to large-scale comparative studies, demonstrations of the identical effectiveness of shortened treatments are accumulating. Finally, there is this problem of black market antibiotics which is a very important driver of the emergence of resistance of bacteria. In Africa and some Asian or South American countries, these drugs are often sold over-the-counter and dispensed by parallel channels, especially in markets. They are poorly dosed, ideal situation to promote resistance, not to mention the lack of efficiency.
Hence these therapeutic impasses …
In 2019, almost total impasse situations remain limited in France, but the threat is real. In these situations, we then only have antibiotics that are difficult to use, with potentially severe side effects.
But what about the massive administration of antibiotics in animals?
This remains terrifying and deeply shocking, since the sole purpose of this widespread use is to accelerate the growth of animals for the sole purpose of improving profitability. It is a huge consumption, and all countries without exception are affected. In some of them, 90% of antibiotic production is for this purpose alone. Despite WHO's cries of alarm, restrictions remain marginal. Animals – livestock, poultry – directly or indirectly through environmental contamination, have thus become the main source of multidrug-resistant bacteria in humans.
Is it true that the pharmaceutical industry is abandoning this area of research?
This is not new. Since the 1980s, large firms have divested themselves. The reasons ? Infectious diseases were becoming scarce in rich countries. We had then a consistent panoply of antibiotics. The resistances were exceptional or rare. Business was running well. The so-called new antibiotics were in reality only very close cousins of those already on the market whose patents were expiring.
But why this abandonment?
Essentially because the market was very small. When the outbreak began, it was mostly about serious, life-threatening patients. This market was often insecure, since resistance to certain antibiotics was predominant in low-resource countries. In short, the innovation in the field of antibacterials has fallen asleep like that of antiparasitics whose market was almost exclusively located in developing countries. Let's hope that the current emergency will revive not only basic research, but especially the development and development of new antibiotics. Convincing companies to re-engage in these drugs is a difficult task because it involves developing drugs whose use will be restricted by definition to avoid the acquisition of resistance to these new antibiotics. The UN has just posted antimicrobial resistance in development priorities.
To hear you, the future remains dark …
It's like with global warming: if nothing moves, it just misses the date of the disaster.