By Colleen M. Flood
and Bryan Thomas
University of Ottawa
In 1928, a Petri dish in Alexander Fleming’s lab was accidentally contaminated by a mould spore, leading to the discovery of penicillin and, in time, a revolution in medicine. Almost a century later, that revolution faces a menacing challenge.
With the discovery of penicillin, deadly infectious diseases like pneumonia, meningitis and tuberculosis could be reliably treated. Everything from childbirth to transplant surgery to chemotherapy was made safer through the use of antimicrobials to prevent infection.
However, bacteria and other pathogens are constantly evolving into ‘superbugs,’ capable of resisting our cache of antimicrobials, which include antibiotics like penicillin as well as antifungals, antiparasitics and antivirals. The World Health Organization (WHO) warns that “a post-antibiotic era – in which common infections and minor injuries can kill – is a very real possibility for the 21st century.”
Studies predict that by 2050 antimicrobial resistance will claim more lives annually than cancer, dragging down the global economy by as much as 3.5 per cent of gross domestic product. Even now, as many 18,000 patients are infected with superbugs every year in Canada, adding $1 billion to health-care costs.
In the arms race between germs and medicine, the global community has two complementary strategies: develop new antimicrobials, and slow the emergence of resistant strains through judicious use of current antimicrobials.
Neither strategy is being executed effectively. Very few antimicrobials have been brought to market over the past 30 years – they are unprofitable for drug companies. As well, we continue to squander the available cache through overuse and misuse in health care and animal agriculture.
The bulk of antimicrobial prescribing is done by general practitioners for outpatient treatment of things like coughs and sore throats. Although there is an element of guesswork in treating these symptoms, there appears to be a great deal of overprescribing. GPs admit to prescribing antibiotics to placate pushy patients – two-thirds of whom wrongly believe that antibiotics are effective in treating colds and flu. That physicians bow to patients in this way is understandable because there is little regulatory pressure pushing them to be careful stewards.
Other countries have more rigorous national strategies that require accountability. Last year, U.S. President Barack Obama announced a system of monitoring and incentives to reduce inappropriate use of antibiotics in outpatient settings by 50 per cent by 2020. In England, the National Health Service has set targets for reduced outpatient prescribing of antimicrobials, backed by financial incentives. Senior officials with the country’s National Institute for Health and Clinical Excellence (NICE) have mused that doctors who overprescribe antibiotics may face disciplinary action.
Superbugs kill over 700,000 people a year worldwide by Roslyn Kunin
Where is Canada on this issue?
There is consensus that the federal government must play a leadership role on antimicrobial stewardship, co-ordinating efforts by provinces and health professionals. Yet according to a 2015 report by the auditor general of Canada, nearly two decades of study and consultation have yielded little by way of actual targets and deadlines.
Instead, we see heavy emphasis on information gathering and awareness-raising. For example, the Public Health Agency of Canada’s Framework for Action on antimicrobial resistance, released in 2014, acknowledges the problem of over-prescribing, but the only concrete proposal mentioned is an annual Antibiotic Awareness Week. A bewildering array of initiatives by the provinces and non-governmental agencies is also engaged in surveying and raising awareness about antimicrobial resistance.
There appear to be no firm Canadian targets for reduced antimicrobial prescribing, let alone clear lines of accountability for their achievement.
A key challenge is that responsibility for health is shared between the federal government and the provinces, with the further wrinkle that physicians are self-regulated by the Colleges of Physicians and Surgeons. Unsurprisingly, a search of the Ontario College of Physicians and Surgeons’ database turned up zero cases of doctors investigated for poor antimicrobial stewardship.
The federal government needs to ensure that the provinces and in turn physicians make tangible progress.
The most straightforward path through this jurisdictional morass would be for Ottawa to offer the provinces financial incentives for targeted reductions in antibiotic use.
Colleen M. Flood is a professor at the University of Ottawa and a university research chair in health law and policy. She is inaugural director of the Ottawa Centre for Health Law, Policy and Ethics. Bryan Thomas is a research associate with the Centre for Health Law, Policy and Ethics, University of Ottawa.