From Professor P. M. Hawkey, MD, MRCPath, and Dr C. J. Thomson, BSc
SIR,—Following the report recently of two cases of infection caused by vancomycin intermediate resistant Staphylococcus aureus (VISA) at the Glasgow Royal infirmary, we would like to comment on what we believe is becoming an increasingly serious situation with regard to the emergence of resistance to antimicrobials among bacteria.
While antibiotic resistance has been recognised since the very first usage of penicillin in the 1940s, the rate at which resistance is emerging to all groups of antibiotics is cause for some considerable alarm. We know with the benefit of increasing research efforts recently that there are many recognised genetic mechanisms for the rapid evolution and dispersal of antibiotic resistance genes, such as transposons, intergrons and the previously unrecognised role which mutation of antibiotic resistance genes can play in rapidly leading to the evolution of new resistance genes.
While much research has been done it is also clear that, in the past 10 or 15 years, there was a perception among science policy makers that antibiotics had conquered infectious diseases and there therefore was not a need to support research and development on antibiotic resistance.
The recent House of Lords report and reports from the European Union1 draw attention to this deficiency in research and development and it is to be hoped that funding bodies such as the Wellcome Trust and the Government research councils will address this issue. It is notable that in the past some pharmaceutical companies have been generous in supporting research on antimicrobial resistance and there is a need in the future for the industry to continue and increase its support for research in these areas. If we understand the mechanisms by which antibiotic resistance genes emerge and spread we may have the opportunity then to apply novel control measures.
The impact of the usage of antibiotics not only in human medicine but also in veterinary medicine must be considered as well as the selective advantage which antibiotic resistance genes may sometimes give bacteria in both allowing them to survive in the environment and perhaps to survive as commensal flora within the general population. In short, there is a need for more and more highly co-ordinated research on the epidemiology and genetics of antibiotic resistance.
There is also a need to use those agents that we have more wisely, and the increasing recognition of the need to practise evidence-based medicine may well provide a background against which practitioners will be able to use antibiotics in a more effective way, reducing the exposure of pathogens to them and thus hopefully reducing the emergence of antibiotic resistance.
Finally the past 15 years or so saw many pharmaceutical companies stop developing new anti-infective compounds. We are pleased to recognise that this situation has been reversed and there are now many research efforts going on within the pharmaceutical industry to refine existing and to identify new classes of agent and novel targets. However, development costs are high and the lead time is long. We therefore look forward to new compounds in the future. This optimism should be tempered by remembering that many active antimicrobials in the laboratory are not suitable for clinical use as a result of toxicity.
In summary, we believe that the recent concerns among the general public and politicians over antibiotic resistance is both appropriate and timely, but we within the medical professions must utilise that interest and direct it into producing support for better research and development of new compounds and also to encourage scientist to look for novel approaches to controlling antibiotic resistance bacteria.
References
1. Hawkey PM. Action against antibiotic resistance: no time to lose. Lancet 1998; 351:1298-9.
P. M. Hawkey
Professor of Medical Microbiology, University of Leeds
C. J. Thomson
Pharmaceutical Division, Bayer Plc, Newbury, Berkshire