World Antimicrobial Awareness Week (WAAW) November 18-26 (Part 1)

Today is the first day of ‘World Antimicrobial Awareness Week’ and we will be publishing a series of blogs during the week, intending to appropriately promote better awareness by discussing what this week is all about (and it's a complex and multi-facetted issue that demands much better public understanding). We will at some point relate it to tuberculosis control (because that's what we're about), but also examine what can be done by politicians, global authorities, farmers, doctors and vets etc. and (in one blog in the series ) offer some advice about what we can do about it ourselves.

Here’s the official WHO lowdown on WAAW:

“World Antimicrobial Awareness Week (WAAW) is a global campaign that is celebrated annually to improve awareness and understanding of AMR and encourage best practices among the public, One Health stakeholders and policymakers, who all play a critical role in reducing the further emergence and spread of AMR.”

Big words, with inherent meaningless within them unless they are properly appreciated. But before discussing anything else, we feel we have to descend to the level of semantics and wonder about the official title of this important week. We think that the title may be intrinsically misleading simply because it's no 'antimicrobial' that this is all about it's antimicrobial resistance. The word "antimicrobial" per se is a general descriptor that refers to groups of drugs that includes antibiotics, antifungals, antiprotozoals, and antivirals, and it’s patently not these drugs that we are being encouraged to be more aware of – it’s the growing RESISTANCES to them that we are all needing to focus upon. Perhaps it should have been better called ‘Antimicrobial Resistance Awareness Week’ (or WAMRAW) – though we accept this would be quite a mouthful as an acronym!

Antimicrobial Resistance – what is it?

This ‘antimicrobial resistance’ or ‘AMR’ manifests when bacteria, viruses, fungi and parasites mutate and no longer respond to medicines designed to suppress them, making infections or disorders they cause harder to treat and increasing the risk of disease spread, severe illness and death.

And as a result of such drug resistance, antibiotics and other antimicrobial medicines become increasingly ineffective. And this is the issue that this week is all about.

What causes it?

There is really only one primary cause and it’s important to appreciate that it doesn’t occur because of any sort of innate evil intelligence in the microbes (although it has to be added that on occasions bacteria do appear to be able to exchange ‘knowledge’ of how to evade drugs with other species of bacteria). AMR occurs simply because all living things (whether humans or microbes) have a tendency to mutate randomly in tiny ways as they reproduce. Most of these mutations are either of no consequence to the organism or actually confer disadvantage, but some of them confer clear advantage in respect of a specific environmental condition and so have generated evolution since the dawn of life. (In other words, as much as some mutations may pose a threat to us, we should consider ourselves lucky that these mutations occur, or we would otherwsie still be microbes in primeval slime ourselves!).

It's also important to appreciate that, as much as AMR could be much better managed (as we will be discussing), it remains an inevitability that it is provoked by exactly these same antimicrobial tendencies to randomly mutate, in this case entirely dependant on the pressure on the microbe from an antimicrobial. In other words, by definition, you can’t have drug- or antimicrobial-resistance if you don’t have the drug or antimicrobial in the first place.

Broadly speaking AMR can thus be described as an inevitable natural consequence of a targeted pressure on a microbial pathogen from a drug/antimicrobial - particularly if the targeted pathogen is prone to mutate. In such instances, any random mutations which are more resistant to the drug that might occur whilst the pathogen is actually under pressure from the drug are logically more likely to survive, while the other microbes that are still susceptible to the drug will be suppressed as normal. In these conditions, the resistant strains then survive and potentially proliferate creating a new resistant strain of disease, and if it is infectious to others, that's very bad news for modern medicine.

The key factors that might make a difference to this inevitability are: the innate frequency of any pathogen to mutate; the time it might take for the antimicrobial to effectively suppress the pathogen; and the relative strength of this suppression. Each or all of these will affect the likelihood of an antimicrobial strain developing.

This isn't new. Alexander Fleming himself identified exactly this dynamic in his Nobel acceptance speech relating to his discovery of penicillin in 1945: “The time may come when penicillin may be bought by anyone in the shops. Then there is the risk that the ignorant man may easily underdose himself and, by exposing his microbes to non-lethal quantities of the drug, makes them resistant”. And of course, we know that, 70 years later, in many countries antibiotics can indeed be bought literally by anyone in the shops – so perhaps we should be grateful that we don’t have much more AMR because of this. Certainly something more should have been done to bring this risk under better control a long time ago.

As Fleming predicted, it’s now widely accepted now that AMR can occur when courses of drug treatment don’t finish off the pathogen completely, which is why we are told that it’s so important to complete those antibiotic courses even if we’re feeling better after a couple of days. And we have an astonishing example of what Fleming called ‘ignorance’ back in 1945 from only just a few weeks ago. UK Health Secretary, Therese Coffee, was in discussion with her senior civil servants about whether to allow UK pharmacists to prescribe antibiotics as a way of taking pressure off beleaguered prescribing physicians, and in the course of it revealed how she had given leftover antibiotics to a friend. Ignorant on two counts (one not completing her prescribed course, and secondly casually passing what was left to anyone else), it provoked an accusation of ‘monumental stupidity’ from a doctors' organisation. If this isn't proof that WAAW isn't relevant, nothing is.

But this resistance doesn’t just develop when a prescribed course isn’t completed: it could equally happen because the dose is too weak – the effect in either case could leave behind a residual population of the pathogenic microbe which has endured sufficient exposure for random mutations to have occurred in the dynamic already identified in the first cause above which would favour the mutated strain

Meanwhile there are other complex factors that feed into this which may be much more significant in many cases to AMR control. One is the regular low-dose exposure to animals (including fishes) to antibiotics in industrial farming and the consequent risk of spill-over disease; and another is the terrible deficiencies in the pipeline of new antibiotics. Both of these we will discuss in further blogs this week. But before doing so, we want to promote better awareness of the context and nature of the problem which we will do in the next blog in the series, and then suggest some actions that we can take as individuals ourselves to help reduce this AMR risk.

We hope you will find it of interest.