Public Health England has published a report showing that between 2010 and 2013 there was a 6% increase in antibiotic prescriptions from 25.9 to 27.4 doses per 1,000 people per day. While the proportion of resistant infections remains the same as that seen in previous years, as the total number of infections has increased so the total number of resistant infections has risen.
This matters. The more we use antibiotics, the more bacteria are able to develop resistance to the antibiotics. We need more information on prescribing patterns and variations of use, and the surveillance efforts by Public Health England are therefore very welcome. However, we also need new antibiotics if doctors are to be fully equipped to treat infections in the future. Without new antibiotics, we risk an ever-rising rate of resistance, spreading from country to country and community to community. There is a danger that over time certain bacteria could resist all available antibiotics, putting modern medicine in jeopardy – if we are unable to use antibiotics when carrying out implants, transplants and chemotherapy.
Research into new classes of antibiotics is taking place, thanks in part to companies’ research efforts and in part to public private partnerships in the US (Biomedical Advanced Research and Development Authority) and Europe (Innovative Medicines Initiative, New Drugs for Bad Bugs). But we urgently need to scale up research efforts.
We need to incentivise research and development (R&D) of new antibiotics because, despite the massive long-term value that new antibiotics will have, there is no real incentive to undertake expensive R&D in this area. Bringing a new antibiotic to market holds the prospect of a negative return on investment – because the development costs are high, the price of existing, no longer patent-protected antibiotics (to which new ones are compared) is low, and the expected use of the new antibiotic is minimal. The peculiarity of the antibiotics market is that we do not want to use new antibiotics straight away or extensively; we need to keep them in reserve until they are needed, as a last line of defence. It’s not like discovering a cure for a disease where we want to maximise access to the cure for all patients who need it.
Industry and health services can make an educated estimate about future prevalence of many diseases and plan and budget accordingly, but we have no idea how resistance will develop, which bugs, where and how fast. This provides only more uncertainty for industry and healthcare systems.
There is widespread recognition that a new approach is urgently needed and we have welcomed the UK’s Five Year Antimicrobial Resistance Strategy on as well as the Prime Minister’s appointment of the economist Jim O’Neill to look at innovative economic models to stimulate research and build support at an international level.
In terms of finding an economic model which will be successful in incentivising R&D into new treatments, the consensus is already forming around an insurance-type model. Under such a model, governments would provide a reward for innovation to companies which are able to develop new antibiotics, i.e. society pays an insurance premium for having something that wouldn’t necessarily be used straightaway but which might be extremely useful in the future. Return on investment would be decoupled from unit sales, supporting appropriate prescribing (good stewardship) by doctors.
Government and industry must work together on new ways to incentivise R&D so that the pipeline of new antibiotics can be replenished. We should do so in a way that supports the most effective and appropriate prescribing of the valuable resource of all antibiotics.
Dr Bina Rawal
Research, Medical and Innovation Director