Antibiotic treatment in Barcelona

With cold season well underway, and another bout of flu imminent, it may be tempting to head to the nearest farmàcia to stock up on antibiotics. While the chemists are happy to take your money, antibiotics have no effect on the viruses that cause colds and flu, and using them wrongly against these diseases may actually be contributing to their ineffectiveness.

The widespread misuse of antibiotics sparked a national campaign by the Ministerio de Sanidad y Consumo in October 2006. Its aim was to slow down the rate of antibiotic resistance by educating the public. The campaign’s slogan warned of the dangers of antibiotic abuse: “Bacterial infections that we have a cure for today, may not have [a cure] tomorrow”.

Antibiotics are mostly used against bacterial infections. Once the bacteria—or pathogens—enter the body, they begin to multiply and cause illness. Antibiotics work by either stopping the bacteria from multiplying (bacteriostatic drugs) or killing the bacteria (bacteriocidal drugs). The most common are bacteriocidal drugs and they usually work by inhibiting the function of essential proteins, often enzymes, inside the bacterial cell.

This system is fine if all the bacteria are killed, but people often misuse antibiotics unknowingly, either by not completing the course, or by taking antibiotics that have been hanging around the medicine cabinet for too long. In these cases the bacteria will not be completely killed off—leaving the strongest, most resistant to live on and multiply, passing on their resistance to their progeny. The result is a population that has a higher resistance to antibiotics.

Imma Garrell Lluis, a Barcelona physician at CAPSE (CAP Salut de l’Eixample), tries her best to educate her patients about antibiotics. It’s a never-ending task, considering the two thousand or so patients she has on her register, but she feels it is part of her job to try to change the mindset of people when it comes to using medicine properly. She thinks the role of the Ministry of Health is important, and was a big fan of last year’s campaign.

“I loved it. It was funny and accurate, it should be repeated every year to educate people. Changing people’s attitudes is slow and difficult. It’s not so bad with patients I have been seeing regularly for years, but it’s those who don’t come to the doctors very often that go straight to the pharmacist and self-medicate.”

Strictly speaking, pharmacists should not give out any medication that reads ‘By Prescription Only’, but they often do. Garrell strongly disagrees with this practice. “It undermines the effectiveness of the drugs, and it also undermines my job as a GP.”

She often has patients who come to her after having bought and taken antibiotics, simply to ask her to prescribe them officially so that they can claim the money back. She said that most of the time she refuses to do this; it makes her feel like a ‘secretary’, but it is more or less tolerated at her surgery.

Doctors should use the lowest dose of antibiotics first, and progress to the stronger drugs if there is no improvement, but Garrell is also seeing abuse of the new generation antibiotics that should be saved for extreme cases. “For example, someone goes to the emergency room and they get prescribed a new generation drug. It works, so next time they feel ill they go straight to the pharmacy and buy it again, regardless of whether it’s good for them or not.”

Using the strongest ones initially is like using your last line of defence first, because if bacteria become resistant to them there is nowhere else to go. But why do chemists still have the power to recommend antibiotics when we now know it’s so dangerous? “Probably a question of money,” Garrell told Metropolitan.

“The law needs to change but big pharmaceutical companies would lose a lot. They are the same pharmaceutical companies that fund extra training courses for general practitioners. It’s a political question.”

As long as bacteria have existed they have been evolving resistance to anything that will try to kill them. Like any living organism, they evolve through natural selection. The weakest die while the strongest live and pass on their genes to the next generation. The problem for us is that if we want to fight infection efficiently, we have to try to keep up with this ‘evolutionary race’; the new generation of antibiotics needs to evolve at least as fast as the bacteria’s resistance.

Lluis Ribas, of the Barcelona Science Park, is a researcher trying to keep us ahead, or at least neck and neck, in this race. He said that in the big picture of antibiotic resistance, the main culprits are overuse in farming and proliferation of multiresistant bacteria, or superbugs, in hospitals. “Before EU regulation kicked in five years ago, antibiotics were being used in vast amounts in animal feed and were filtering into the environment, water, and people. The more widely distributed antibiotics are, the more likely it is that resistant strains will form.”

In Ribas’s lab they work on understanding how protein synthesis machinery works in cells: if they can disrupt the way a pathogen’s protein works, they can debilitate it. While studying these proteins, Lluis and his colleagues came across something else—an entirely new way of developing antibiotics. He has started a company called Omnia Molecular to make new antibiotics, and he estimates that whereas they used to cost $7 million and take eight years to produce, they will now only cost about $300,000, and take three months.

“Traditionally, pharmaceutical companies identify the enzyme, or protein, that they want to destroy and then set about finding a molecule that will kill it. The problem with this method is that once the molecule has been found, extensive tests then have to be done to make sure it doesn’t have an aggressive effect on other proteins in the body. This new way puts the target enzyme in the context of all the other enzymes that must be respected, and within that context finds a drug that will only kill the target, without affecting the other proteins.”

Antibiotics are vital and medicine relies on them. But at the end of the day they are flawed: the day will come when bacteria will defeat any new, strong antibiotic that we can formulate. Clearly, we need alternatives, but apart from natural remedies like homeopathy, the only alternative is something called ‘bacteriophage’ , or simply ‘phage’, technology. Bacteriophages are the naturally occurring viral enemies of bacteria, and are said to destroy them while leaving human tissue unharmed. As yet they have not been developed, or even acknowledged properly by many scientific communities, and Ribas smiles at the suggestion that phage technology may be an option. But then again, he would.

Whether or not phage technology will take off, or Ribas’s system of producing new antibiotics will be just what medicine needs, the message is still the same, he said. “Misusing antibiotics has three main problems: it causes antibiotic resistance in the long term; it can have detrimental side effects, and apart from that it’s simply a waste of money.”

You can’t argue with that.