Candy floss, bacon butties, kiss-me-quick hats and seaside piers are hallmarks of Britain’s Victorian seaside resorts. For generations, Brits have gone to the seaside with their buckets and spades, built sandcastles with the kids and optimistically eaten ice creams under grey skies. Every year Britain’s politicians party in those same seaside resorts: spin and candy floss. In his finely observed account of coastal Britain, Notes from a Small Island, Bill Bryson caught the gist of these coastal communities.
Looking back at this week’s latest outbreak of election fever; the UK General Election, the British seaside spoke to its horizon. From John o’ Groats to Land’s End, the East coast voted 70% Conservative, while the West coast voted only 40% Conservative (X2 =12.17, p < 0.001). Could this have something do with the communities on the East coast looking out over the North Sea and the English Channel to EU neighbours, while the West Coast looks over Ireland to the more distant Americas?
But what about the candy floss resorts themselves: places where you can rely on proprietors of seaside boarding houses to speak their mind. Well, in the 2017 election mainland towns that are still blessed with a pier in England were overwhelmingly Conservative; 27 of the 33 (81%) available for assessment, compared to the one of six (17%) with piers in Scotland and Wales. You don’t need sophisticated stats to tell you that the Welsh and Scottish seaside resorts have a different outlook. But for those that worry about numbers, it is a significant difference (X2 = 7.67, p < 0.01). A pairing of maps makes this spatial correlation clear.
Seaside piers and 2017 UK election results
And here’s another piece of statistical candy floss: the number of parliamentary seats now held by Conservatives (R2=0.07) and Labour (R2=0.999) both correlate closely with the number of seaside piers per country within the UK (p=0.015 and 0.003, respectively).
So what on Earth has this to do with drug resistant infections and antimicrobial resistance (AMR)? If you’ve read this far, you’re likely to remember that the UK has led the global effort to get AMR on the political agenda. Yesterday’s retreat into Britain’s political tribal heartland, and a preoccupation with whether to separate from the EU for a stick of rock or a ball of candy floss, both risk losing the AMR plot. The drug resistant infection maps highlight the major international hotspots for MRSA, NDM1 and so on. The looming AMR crisis facing in health services may not yet be lapping at the edges of the UK’s seaside communities. But a loss of major groups of antibiotics could make a dose of sea air and a fat full of candy floss about as effective. If you take a look at the heat map for antibiotic prescribing in the UK’s coastal towns, many are doing their level best to catch up with the AMR profile of the major urban centres. These communities have yet to learn how to avoid making their antibiotic yesterdays turn into their drug resistant infection tomorrows.
Language! It sounds like something a teacher shouts across the school playground during a noisy recess. This week’s comment in the journal Nature calls us to task for our inconsistent, inaccurate and impenetrable use of language in connection with antimicrobial resistance (AMR). The authors rightly call out terms that do not communicate complicated ideas about resistance in digestible words and phrases.
Guilty, as charged.
Micrognome’s readers will be familiar with the language theme. These pages have spilled a lot of digital ink on the language of infection, its mechanisms and consequences. More recent entries have homed in on the language problems of AMR, not least the abstract nature of AMR and our need for a simple word or phrase to use in calling out its consequences; highly antibiotic resistant diseases.
Nature’s commentary gives us a good serving of bad language. We need to drop the complicated tongue twisters like antimicrobial resistance and multidrug resistant [insert your favourite bacterial name here]. How many frontline clinicians can accurately conjugate Graeco-Roman Linnean bacterial names? Even those bacterial names in common usage are often short forms that lack strict accuracy, so there is little scope for terminological pedantry. The commentary correctly identified the untreatable aspect of this phenomenon as a core feature. But if we take a look at just one common example, we can see that this is still a work in progress.
These figures shows bacteria growing on agar after incubating a sample of urine from a patient with a common urinary tract infection. These bacteria have then been cultured in a smooth lawn on a clear type of agar with disks that contain antibiotics.
E.coli growing on CLED agar, showing yellow colonies of concentrated bacteria.
Test for antibiotic resistance due to extended spectrum beta-lactamase (ESBL)
These disks are in pairs with (left) and without (right) a chemical that switches off a mechanism the bacteria from the urine specimen use to inactivate the antibiotics. If you have managed to follow the story so far you will notice how the circular halo of clearing around each disk is much larger on the left than the right. That is because the chemical added to the antibiotic protects the antibiotic against bacterial inactivation. Sometimes this approach can be used to treat a resistant infection. Complicated, isn’t it? For more information on antibiotic inactivating mechanisms read [here].
If you read this far you either live an unhealthy life away from natural sunlight in a clinical lab, or have an unusual level of fascination with the natural world. The rest of the global population don’t connect with the granular detail of AMR and its pathological consequences. Our experience of disease is usually couched in terms of illness or sickness, and does not stretch to the invisible biological processes that keep the Micrognome and his tribe gainfully employed. So if there is improvement to be made in the language of infection, it needs to be translated into the language of infectious disease. Drug resistant infection may thus need a bit of adjustment, to drug resistant disease. Happy editing.
Rumours of the Micrognome’s demise have been gathering for some time. So a search party was sent out to locate the missing gnome or confirm his fate. Fortunately our efforts have not been wasted. True, there were a few false trails, but we can now reveal that we have been able to verify recent sightings in northern Europe.
Frightened of resistance?
According to our gnomefinder-general, the Micrognome took to the woods at the news of resurgent antimicrobial resistance. At present Europe is at the forefront of the battle against resistance, bringing global attention to the subject. So no quiet retirement for the Micrognome, his colleague the MicroB, located on a mossy birch stump, or their friend the Lab Rat seen here boxed in at the Nobel Museum.
Taking AMR seriously
For those who have been waiting patiently for reassembly of our intrepid team, the wait is almost over. But there are a few skeptics out there who still don’t think antimicrobial resistance is anything worth bothering about. Well, our three bug-busters respectfully suggest they take a look at what the adults are saying about untreatable infection:
Tragedy of the commons
The Micrognome’s considered opinion is that there may be a consensus on AMR strategy, but there is still a long way to go on the application at ground level. We are missing a plan. Good ideas from the great and the good rarely percolate down from the lofty mountain heights to the the murky depths of pine forests and birchwoods where micrognomes are at home. The specific tasks to control, turn back and eventually eliminate AMR are going to take more than just the micrognome and friends to set in motion. It needs to be a giant effort to conserve the dwindling stock of effective antibiotics, reserve them for evidence based use so that their benefits are preserved for those in most need. Conserve. Reserve. Preserve. These will be the watchwords for the coming fight to overturn the AMR tragedy of the commons.
So don’t leave it to infection to test how much you’re missing on AMR. You really don’t want to end up like this interesting specimen.
You’ve got to take your hat off to those brave souls with ice cool nerves who cross canyons, waterfalls and other natural obstacles on the narrowest of paths possible. There’s something about a tightrope walk that lifts the human spirit and inspires us beyond the sheer insolence of personal risk taking. Determination, concentration, skill or unique challenge all come to mind. But without a doubt, there is a fundamental need for a finely tuned sense of balance.
The tightrope walker is a useful picture of what is missing in the growing clamour over what we need to do about antimicrobial resistance (AMR). At one extreme, we have an urgent need to reduce every imaginable measure of antibiotic use in order to slow the emergence of resistance. That is not a matter for debate. We are up the creek with only half a paddle. Unfortunately, the complete removal of all or any currently used antibiotic from clinical use is not an option. They are just too useful to us. How can we justify restricting antibiotic use where they are clinically indicated, let alone potentially life-saving?
There is really no dilemma for the clinician faced with a serious infection: the immediate needs of the patient will win out every time. The long term consequences of escalating AMR are a problem postponed. The expectation that there will be an effective antibiotic for every infection; a pill for every ill, has a pervasive effect on every medical engagement with infection. The most minor infection might just morph into something much more serious. Even when the odds are heavily stacked against that eventuality, it is often easier to weigh in with an antibiotic just in case. After all, we’ve all heard of cases that have gone badly for lack of an early intervention.
This is why the O’Neill report cites better diagnostic tests as the circuit-breaker in the fight against AMR. The report spells out in detail the rationale for early resolution of the physician’s dilemma with better point of care tests. Those tests must address a series of three questions front line clinical staff must answer when handling any infection:
- How sick is this patient
- Why are they sick
- And what do we need to do about it?
Or to put it another way; better tests are needed to take the guesswork out of prescribing antibiotics. Escalating AMR will make that balancing act all the more difficult, lie a tightrope walk on a windy day.
If you would like to help us make AMR history, go to the website and join the campaign.
You must have been hiding under a stone for a long time if you missed the news on AMR. It’s that acronym that’s taking up space all over the media right now, since the World Health Organisation raised it up the flagpole in 2012. [AMR: antimicrobial resistance is the formal name for resistance to antibiotics] This year the World Health Assembly gave it another push and now it’s flavour of the month in government circles the world over. The reason for all this concern is the grim reality that we’re running out of options for some of the most challenging infections. The prospect of being up the creek without a paddle is drawing closer.
The British government has weighed in with a detailed report from the O’Neil Commission. They calculate that in just 35 years, deaths due to antibiotic resistance will overtake cancer deaths. Worldwide, they estimate 10 million deaths due to AMR each year and a loss to the global economy of trillions of dollars.
Now the Micrognome likes an occasional paddle in the waters around Perth, and has been known to go a bit further afield for more challenging kayaking. Nothing like the Avon Descent, though. Imagine what that would be like without a paddle? So when the gnome got roped into the launch of a serious campaign to Make AMR history, the image that came to mind was straight out of the kayaking lexicon – up the creek with only half a paddle. You see, the current AMR state of affairs might be bad and getting worse. But it’s not as bad as it could be. We have half the antibiotic paddle, and have to use it twice as hard. Awkward though that might be.
We’ll get into the task ahead, how we’re going to implement and coordinate it in future posts. But for now, we’d like to reassure loyal readers of this Blog that we have not been drifting in the quiet upper reaches of the Swan River for the last six months. We’ve assembled a first class international group to help us make AMR history. For a few clues on how to turn the tide on AMR, have a look at the O’Neill Commission’s report on Rapid Diagnostics.
Our plan is ready to roll.