Less than 100 years since they were first discovered antibiotics are quickly becoming useless. We’ve been over-using and abusing them for far too long and if we don't make changes now, resistant bacteria will pose such a threat that public health as we know it will be a thing of the past.

The big question is “what should we do?” – hunt for new antimicrobials to make up the deficit, or regulate the use of the drugs we’ve already got?

New frontiers

The more the problem of resistance is publicised, the more people ask: “Why can't we just invent new antibiotics?”. This is followed by a conversation about how pharmaceutical companies aren’t interested in antibiotic R&D because they don't make enough economic return. You could be forgiven for thinking the industry had given up on the war against resistance, but there is some hope on the horizon.

Cubist Pharmaceuticals (a biotech firm specialising in antibiotics) has just had FDA approval for Zerbaxa, a first-in-class compound, and two other new compounds - Dalvance and Orbactiv - have also been approved, proving that development in the field is not altogether dead. But there is another antibiotic currently in development that has caused more of a stir than all these releases put together - teixobactin.

Not only has teixobactin shown good efficacy against some of our most problematic superbugs including MRSA and C. difficile, but its ‘double-strike’ mode of action means there is little chance of resistance developing.

Sounds great doesn't it? But what's even better than the discovery of teixobactin is the way it was discovered.

Teixobactin is one of 25 compounds detected when a group at Northeastern University, Boston, developed iChip; an innovative device that puts a new twist on the old method of screening bacteria in soil[i]. It uses a lattice of tiny wells, each containing agar and one soil bacterium, all covered in a permeable membrane. When the chip is placed in soil, bacteria that produce natural antibiotics reveal themselves by killing off those in the agar.

iChip allows researchers to screen bacteria in their natural habitat (a soil sample). Now iChip has solved the detection problem, it is hoped that teixobactin is just the first step into a whole new world of antibiotic exploration.

Make do and mend

Developing new antimicrobials is all well and good, but if we continue to misuse them we won't be any better off in the long run. We need to change the habits of a lifetime.

The best way to moderate resistance development is by only using antibiotics when they are essential. This is easier said than done. Clinicians often have to make fast treatment decisions with little information about what’s causing a patient’s symptoms. Many antibiotic prescriptions are unnecessary because there is no fast, simple way of testing whether an infection is bacterial or viral. Patients are fobbed off with antibiotics whether they need them or not because we don't have enough information to do otherwise.

Last year, the Longitude Prize set out to solve this problem. It's offering £10 million to anyone who can devise a cheap, accurate, fast and easy-to-use point of care test for bacterial infections. This will allow doctors to restrict antibiotic use to people on whom it would be effective, reducing the selection pressure that causes resistance. Patients will have no argument when there is proof they have a virus, and HCPs won't need to throw antibiotics at every cough, cold or earache.

There are also alternative methods we could also use to fight bacteria. Research groups are currently exploring a number of options across the world, from ‘ninja polymers’ at IBM,[ii] to engineered liposomes at the University of Bern, Switzerland.[iii]

One option is bacteriophages (viruses that infect bacteria), which can target and destroy specific bacterial pathogens. Bacteriophages only target specific harmful bacteria, leaving commensal microbes unharmed, and there is little potential for resistance if a cocktail of phage types is used. What's more, bacteriophages are already used in humans in Eastern Europe and animals in the US,[iv] and although they’re not approved in the UK yet, phages are a potentially useful alternative to conventional therapies (especially for agriculture where antibiotic overuse is rife).

The future

I wrote the first instalment of this blog feeling despondent at the scale of the resistance problem, not to mention scared of picking up a resistant infection. It’s reassuring to know that there are potential solutions in the pipeline to help us manage our use of existing antibiotics and find new ones.

It may seem there is a choice between two options, but the key to combatting the problem is to use a combination approach - diagnosing specific infections and then using the most appropriate treatment to beat the bacteria. We’d better get a move on though; the antibiotic apocalypse is nigh.