Superbugs - why they matter to Singapore

The problem of bacteria that resist antibiotic drugs is a growing one, which an upcoming UN meeting seeks to address

The more antibiotics are used, the greater the pressure on bacteria to evolve and become resistant to the drugs. PHOTO: ST FILE

Unlike other infectious diseases such as Sars, pandemic influenza and Zika with seemingly greater pandemic potential, antibiotic-resistant bacteria have spread relatively slowly, though relentlessly. Because of the slow rate of transmission, they seldom capture the public imagination as more high-profile infectious diseases such as Zika do.

Yet, the total number of infections from "superbugs" globally exceeds that for Sars or Zika and causes more deaths than dengue each year. While some of these viral outbreaks abate weeks or months later, it is far more difficult to contain the spread of antibiotic-resistant bacteria. Clearly, more attention is needed to fight antimicrobial resistance (AMR), which occurs when the drugs that are used against pathogens - disease-causing microbes - become ineffective.

It is critical for Singapore to take immediate action to educate the public about the appropriate use of antibiotics and risks of AMR, in order to curb the rising tide of AMR both nationally and globally.

Indeed, on Wednesday, the United Nations General Assembly will convene a high-level meeting on AMR in New York with the primary objective of summoning and maintaining "strong national, regional and international political commitment in addressing antimicrobial resistance comprehensively and multi-sectorally, and to increase and improve awareness of antimicrobial resistance". Singapore will be one of the many countries taking part.


Antimicrobial drugs are used to treat infectious diseases caused by microbes such as bacteria, viruses, fungi and parasites. The illnesses range from food poisoning, the common cold and ringworm infections to pneumonia, tuberculosis and HIV. Until now, the drugs have proved to be a major boon to modern civilisation - health, mortality and food safety hinge on the continued effectiveness of such drugs.

However, the more antibiotics are used, the greater the pressure on bacteria to evolve and become resistant to the drugs, and for these antibiotic-resistant bacteria to spread (while the antibiotic-susceptible strains diminish).

Thus, there is a great need to reduce inappropriate use of antibiotics - for instance, when they are prescribed unnecessarily, or when patients do not complete a full course of appropriate antibiotics. There is also a need to develop cost-effective and easily implemented alternatives to take the place of antibiotics as growth promoters in the agriculture and aquaculture industries.

Whenever a new strain of drug-resistant pathogen emerges and spreads, our existing arsenal of antibiotics to treat the resulting infections shrinks. Stakes are raised further when doctors fall back on "last resort" antibiotics that come with hefty price tags and serious side effects.

This problem is exacerbated by the paucity of novel classes of antibiotics in the drug- development pipeline, because the development of new antibiotics has been, on the whole, far less profitable for pharmaceutical companies, compared with drugs for treating cancer or chronic diseases.

Consequently, we are now witnessing isolated reports of infections throughout the world, including in Singapore, where the causative bacteria have developed complete resistance to all previous life-saving antibiotics. This worrying phenomenon will only grow more serious if no collective action is taken now to keep pace with the resistance-developing ability of many of these pathogens.

AMR is a global public health and medical concern, threatening to undo many key medical advances of the past century. Medications that are currently effective against infections, both benign and life-threatening, could cease to work in the future. If there is no access to effective antibiotic treatments, treatments such as surgery and chemotherapy might no longer be viable because of the increased risk of life-threatening infections.

Yet, very few people are aware of the many hospital-acquired infections caused every day by superbugs such as methicillin-resistant staphylococcus aureus (MRSA) or carbapenem-resistant enterobacteriaceae.

Fortunately, global awareness of AMR is increasing. The 2013 Global Risks Report of the World Economic Forum highlighted the risk of antibiotic resistance to health, social and economic systems. The British government commissioned the Review on Antimicrobial Resistance in 2014 to study the global economic effects of AMR and explore solutions.

Estimates say that up to 300 million lives will have been lost to drug-resistant infections by 2050, with a projected cost of US$100 trillion (S$137 trillion) in productivity losses during this period. Both the British and US governments have put forward national strategies for combating antimicrobial resistance, preceding the World Health Organisation's call for all countries to do the same.


How can Singapore contribute to efforts to combat AMR both at home and globally?

It is in Singapore's interest to work with regional and global partners to strengthen and share AMR surveillance data and capabilities.

Sustained efforts to inculcate good personal hygiene habits will help minimise the spread of infectious diseases in the long run, thereby reducing the need for antibiotic use. Increased transparency by food suppliers regarding antibiotic use in their products will help consumers make safer choices. The local agriculture industry should be encouraged to minimise antibiotic usage. One local producer, Kee Song Group, has taken the much-lauded lead by using probiotics - live microbes thought to benefit animal health by improving gut microbial balance - rather than antibiotics in its chicken feed.

Above all, continuous efforts to educate the public about the appropriate use of antibiotics and the risks of AMR remain critical. Success will depend largely on educating individuals to ask relevant questions and make informed choices, as both consumers and patients.

Doctors must also be educated to make prudent treatment decisions in terms of antibiotic prescriptions to minimise AMR, to safeguard patients' health. Just as broad-based education proved vital to garnering local and global support for efforts to deal with climate change and global warming, we should incorporate AMR-related content into local school curricula and public education campaigns.

Britain successfully lowered its MRSA rates by 50 per cent over a five-year period starting from 2004. As part of its national anti-MRSA campaign then, it made public reporting of MRSA rates mandatory for each hospital trust; other punitive and facilitative measures were also implemented. The rates are still declining today.

AMR poses a major global threat that can be tackled only through close cooperation and collaboration between nations. No doubt, it will be a complex process, but there is an increasingly robust international consensus that:

•It is possible to stem or even reverse the rising tide of AMR.

•It will take no less than a concerted effort nationally, regionally and globally.

•Ultimately, if all members of society take responsibility, AMR can be minimised successfully.

•There is a need to act now, because the cost of acting later, or not at all, would be that much greater.

•The writer is an associate professor and programme leader of the antimicrobial resistance programme at the Saw Swee Hock School of Public Health, National University of Singapore.

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A version of this article appeared in the print edition of The Straits Times on September 19, 2016, with the headline Superbugs - why they matter to Singapore. Subscribe