Antibiotic-resistant bacteria are terrorizing the planet. Hundreds of thousands of people have died from this cause around the globe — 1.2 million each year, according to a study — and the scientific community is accelerating the search for new tools to circumvent its impact before it is too late. From the front line, microbiologist Bruno González-Zorn, director of the Antimicrobial Resistance Unit at the Complutense University of Madrid and advisor to the World Health Organization (WHO) in this field, is optimistic: after years of "preaching in the desert", alone and without much attention from institutions, he has managed to convince the actors involved and has seen progress. such as the implementation of a national plan to combat resistance or greater awareness among citizens, he says. "That makes me think that in the coming years we will make more progress, there will be better prevention plans in hospitals, more awareness among the population, more optimised consumption and some preventive or treatment molecule that helps us more," predicts the scientist, who spoke to EL PAÍS after his participation in the Update Conference on the Programme for the Optimisation of the Use of Antimicrobials organised by the Mutua de Terrassa Hospital a few days ago.
Despite the enthusiasm and hope, González-Zorn (Madrid, 52 years old) admits that there is still work to be done and to accelerate the pace. The researcher looks at no one and looks at everyone. He refuses to point the finger of blame. "We are all co-responsible. The key is joint cooperation without pointing fingers at each other," he concludes.
Multidrug-resistant bacteria kill 20 times more than traffic accidents in Spain
Question. A study warns that multidrug-resistant bacteria kill 20 times more than traffic accidents in Spain. More than 23,000 deaths in 2023.
Answer. We are beginning to give a name and a voice to all those anonymous patients who die in hospitals from antibiotic resistance. We have constant deaths in all the hospitals in Spain that no one talks about. And they die because the state-of-the-art antibiotics we're giving them don't work anymore. This problem is spectacular, we already know it. What we need is for the population to know that it is not trivial to take an amoxicillin at home [without a prescription]: it prepares the bacteria to resist this antibiotic of last resort that only hospitals are available and that in the end ends up not working.
Q. Are you surprised by the death toll of 23,000?
A. We're not surprised at all. We have been deeply aware of this issue for many years. What we like is that it comes out of the strictly scientific realm and that the population is aware that, just as they put on their belts, they cannot self-medicate, they cannot keep an antibiotic just in case they use it at another time. We need zero pharmacies to give antibiotics without a prescription, but in Spain it is still 5%. And, although it may not seem like much, that 5% does a lot of damage to the other 95% because the citizen realizes that, going from one pharmacy to another, they end up getting it without a prescription and that trivializes the antibiotic.
Q. Is the antibiotic trivialized?
A. The antibiotic is trivialized in Spain. And in the end it is associated that, just as I have a paracetamol, I have an amoxicillin in my medicine cabinet and, from time to time, I use it. That can't be. We have to act against that 5% of pharmacies, against the person who self-medicates, against the professional who prescribes too much or in line with the eighties...
We need zero pharmacies to give antibiotics without a prescription, but in Spain it is still 5%"
Q. Who suffers from this resistance? What is the patient profile?
A. It's important to know that even if you don't take antibiotics, the bacteria that live in hospitals, for example, that are more resistant to antibiotics, are the ones that affect you. You may be a great young person, but when you go to the hospital, you're affected by the bacteria that has been living in the intensive care unit (ICU) for a long time and is resistant to all antibiotics. The profile is that of a person who arrives and, after surgery, for example, post-surgical infection, which is normal in all hospitals in the world, becomes so complicated that it ends up killing the patient.
Q. Is the age of antibiotics coming to an end?
A. We are beginning to enter a post-antibiotic era because mortality is increasing from diseases that we once controlled. We have more and more pan-resistant bacteria: before we talked about bacteria that resist many antibiotics and now we talk about pan-resistant bacteria, which resist all of them. These, five years ago, we only had in a few places in the world, such as India or China; Now, in practically all Spanish hospitals we have antibiotic-resistant bacteria. It's moving forward and we're very concerned. At some point, we're going to have a bacterium that transmits very well, that is very resistant to antibiotics, and that's when we're going to be alarmed. That's going to happen and we've been warning for a long time, so we need a lot of people to take important treatment and prevention measures.
Q. Will we be able to see you die, for example, from a wound you get when you fall in the street?
A. It's just that we're already seeing it. We are already seeing urinary tract infections that become complicated and, when they used to respond well to an antibiotic treatment, now the patient dies because they are not cured with antibiotics.
Q. Has a point of no return already been reached, or could we go back to that antibiotic era again?
A. The issue is complex. There are some bacteria that when they are no longer subjected to the antibiotic, they become susceptible very quickly and very easily. So, in some cases, the reversal is very quick and effective. For example: colistin is an antibiotic of last resort in hospitals, which has been widely used in animals, but in this context we have gone from a very high use in Spain to practically zero, and the bacteria have immediately become sensitized to colistin. But there are other forms of resistance in which it will be more difficult to regain this susceptibility: for example, with resistance to carbapenems or third-generation cephalosporins, we are seeing that bacteria appear that are very happy with resistance even if the antibiotic is not there.
Bruno González-Zorn, director of the Antimicrobial Resistance Unit at the Complutense University of Madrid, in a laboratory of the Faculty of Veterinary Medicine.Samuel Sánchez
Q. Bacteria, for survival, will always try to resist antibiotics. Is this an indefinite war?
A. It's indefinite. Bacteria are the most prevalent living thing on earth. Antibiotics have done a lot of good, but yes, if you stop developing new antibiotics — and we haven't discovered a new family of antibiotics in 30 years — and you just use those old weapons, the bacteria become resistant. We need new families of antibiotics and as we develop them, we need new vaccines and new strategies to fight bacteria.
Q. In a television program in which he participated traveling to India, they managed to buy without a prescription in a pharmacy a carbapanema, which is one of the antibiotics of last resort, used when nothing else works. What do you do when this is happening and we live in a globalized world?
A. We have to fight against it. In the end, resistance to each country depends on the antibiotics used in the country. It's not that everything comes only from outside, everything colonizes our ecosystems and we are lost. National and local action is essential. The Dutch go to India ten times more than we do and have far fewer of these bacteria. We have a direct relationship between antibiotic consumption in a country and resistance: even if they travel, bacteria colonize when that antibiotic is present and if not, they lose that resistance.
Q. What impact did the pandemic have on the fight against antimicrobial resistance?
A. In the short term, it has had a huge impact. Due to covid, antibiotic-resistant bacteria have appeared that we did not expect to have until 2030. Many respiratory viruses open the door to secondary bacterial infections and, at first, with covid, it began to be treated with antibiotics. But, we quickly realized that covid patients were not dying from a secondary bacterial infection, but from the famous cytokine storm, so patients began to be treated with corticosteroids instead of antibiotics. In the rest of the world, the population in ICUs increased, these units were overused beyond what they could be, there were more hospital-acquired infections and more antibiotic consumption. The pandemic has greatly accelerated antibiotic resistance, to the point that I say the 10 million deaths that were expected in 2050 because of this, we are going to have them in 2040 because there has been a huge acceleration in the generation of bacteria resistant to antibiotics of last resort.
Due to covid, antibiotic-resistant bacteria have appeared that we did not expect to have until 2030"
Q. Another variable that influences resistance is wars. There are now several active armed conflicts around us. How will this affect?
A. We know it's affecting us. Patients derived from Ukraine have already appeared with pan-resistant bacteria that were not in our region. Why? Because in the sites of conflict, there is what we can practically call a perfect storm for the generation of resistant bacteria: there is no system for diagnosing diseases, there are a large number of open wounds that are contaminated with many different types of bacteria, you need broad-spectrum antibiotics en masse where you don't even have access to antibiotics and whatever you have... And all this cocktail accelerates the formation of antibiotic-resistant bacteria exponentially.
Q. To combat the phenomenon of resistance, they are attacking on several fronts. But he said it's been more than 30 years since a new family of antibiotics has been available. Isn't the pharmaceutical industry interested?
A. The economic model of antibiotic development is broken. Right now there is no pharmaceutical industry with more than 500 workers in the world that is developing an antibiotic. They've abandoned it because it's not profitable. There is a lack of economic incentive. We are developing the prize model, which is now being discussed in the European Union: to whoever brings an antibiotic to the market, I am going to give an economic prize, EUR 300 million, for example, which we have put in place among all the countries, because we need an antibiotic against these bacteria. Or we extend a patent for any molecule you have in your portfolio.
Q. At the therapeutic level, one of the ongoing investigations is the use of bacteriophage viruses, phages, to annihilate resistant bacteria. What are the most promising lines?
A. Phages have an outlet, but you have 100 times more phages in your gut than bacteria and there are mechanisms of resistance of bacteria to phages. So, phages are one possibility, but there are many others. For example, nanotechnology techniques for molecules to detect where the infection is and release a more concentrated antibiotic. Artificial intelligence is helping us a lot to know how an antibiotic is going to behave and how to treat it individually. We could also develop bacteria that introduce CRISPR, which would ideally be able to inoculate a CRISPR system inside pathogenic bacteria so that their DNA is digested and they die. There are many very original strategies, many for gut health and prevention. For example, gut health control and probiotics and prebiotics: bacteria that colonize an ecosystem where antibiotic-resistant bacteria cannot colonize.
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