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Das TV-Team entnimmt Proben bei Hyderabad

Das TV-Team entnimmt Proben bei Hyderabad© Christian Baars

Super bugs

A new TV documentary reveals that superbugs are multiplying in the polluted wastewater flowing from pharmaceutical plants in India

Journalists from NDR and infectious disease researchers from the University of Leipzig travelled to India to investigate the runoff at pharmaceutical factories. In water samples collected in Hyderabad, a city known for its pharmaceutical industry, they found high concentrations of antibiotics as well as antibiotic-resistant bacteria. The results of this research were published last week in the scientific journal Infection.

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von Hristio Boytchev

To look for antibiotic-resistant bacteria the team of scientists and journalists took water samples from 28 different sites in Hyderabad, in November 2016. The samples were taken from tap and borehole water, and from environmental sites such as those near to pharmaceutical plants, as well as from a variety of rural and urban locations.  The only sample which didn’t contain resistant bacteria came from a four star hotel.

After testing 16 samples for drug residues the team found that all of these environmental samples contained antibiotics or fungi. One sample stood out: a sample of water from a drainage channel contained an extremely high concentration of the fungicide fluconazole. The concentration of fluconazole in the sample was roughly a million times the recommended limit, and twenty times the concentration that is typically found in the blood of a patient being treated with the drug.

The scientists concluded that because the drug residue concentrations were so high, they most likely originated from pharmaceutical waste. Hyderabad is the central production site for antibiotics worldwide, and the team found that the city contained more than 40 pharmaceutical factories.

NDR Journalist Christian Baars

NDR Journalist Christian Baars

Tilo Gummel / NDR

The scientists can’t prove that the antibiotic residues in their water samples are what caused the bacteria in the samples to become resistant, because the resistant bacteria could also come from humans or animals who’ve been treated with antibiotics. However, it is obvious that the high concentrations of antibiotic residue in the environment „do not help“, said Christoph Lübbert, an infectious diseases expert at Leipzig University Hospital, who was one of the scientists on the team.

The new research also confirms the results of older studies, which have previously demonstrated both high concentrations of antibiotics and antibiotic-resistant bacteria in India (and reported on last October by Correctiv). NDR journalist Christian Baars, who worked on the new study, says that what is particularly novel about the new research are the findings relating to the fungicide fluconazole.

The research findings are very relevant to Europe, because antibiotic resistant bacteria in India are spreading globally and can be brought back tourists. Up to 90 per cent of people who travel to India return carrying resistant bacteria, scientists say, although in most cases the person will not become ill. Many of the drugs sold in Europe’s pharmacies are also made in either India or China, as a large proportion of antibiotics sold globally are produced in one of the two countries.

Osnmania Hospital in Hyderabad

Osnmania Hospital in Hyderabad

Britta von der Heide / NDR

Critics are now demanding stricter environmental standards for imported medicines. This research provides enough reasons to demand better environmental standards, says Tim Eckmanns, head of the department of Nosocomial Infections at the Robert Koch Institute in Berlin. Although forcing pharmaceutical plants to produce less waste would not make the problem of antibiotic resistance disappear, he says, it would be a relatively easy way to reduce it.

The problem won’t disappear because there are other factors causing the number of resistant bacteria to rise, including over prescribing of antibiotics by doctors, and high consumption of antibiotics by livestock.

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Reacting to the documentary, the German Federal Association of the Pharmaceutical Industry (BPI) said that the organization would take the report as an opportunity to „urge for a stricter compliance with agreed environmental directives“. But the industry „has no influence on the environmental standards set by the respective countries“, said Norbert Gerbsch, the CEO of BPI.

At EU level there are already regulations covering the „good manufacturing practice“ of imported drugs, but these only regulate the quality of the drugs and do not include environmental aspects.

Although one way of solving this could be to tighten controls and exclude manufacturers which do not limit their waste from the European market, this is not the way to solve the problem, Hermann Gröhe, Minister for Health (CDU), told the ARD. India and China must see that it’s in „their own interest not to endanger the effectiveness of the medical care of their large population,” he said.

Watch the documentary „The Invisible Enemy“ here, the work of a team from NDR, WDR and the Süddeutschen Zeitung.

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Super bugs

Why CORRECTIV tackles superbugs

We have a problem with infections. And we do not have a solution. Worldwide, Superbugs – resistant against antibiotics – are on the rise. The more humans use antibiotics and the more often we feed antibiotics to livestock, the bigger our problem gets. Already, thousands of people are dying in Europe, every year.

read more 2 minutes

von Hristio Boytchev , Daniel Drepper

Reason enough for CORRECTIV to investigate the issue. We want to make the problem accessible and we want to report on it long-term. We want to discuss solutions – and avoid fearmongering.

There are a lot of open questions. What role does the use of antibiotics in livestock play for infections of humans? How can we improve the hygiene in hospitals? How can we control the distribution and use of antibiotics? And who will develop new drugs to battle superbugs? We want this website to be a place for possible answers from different countries.

For this investigaiton we are cooperating with journalists from all over Europe. We want to learn together and from each other. Superbugs do not stop at national borders. European states have different experiences, individual problems and strategies. We should all profit from that.

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That is why we want to work together with you, whether you are a user or a journalist yourself. If you have made your own experience with resistant germs, if you want to use our reporting for your own good or want to report about our findings – just send us an e-mail.

During the followig months we will continue to publish at correctiv.org/superbugs. You will find new scientific findings, documents and data. And we will publish stories and background information about the fight against superbugs. We are looking forward to a regular exchange with you.


You can easily reach our reporter Hristio Boytchev at hristio.boytchev@correctiv.org

copy editing: Christine Coester
header photo: Ivo Mayr

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Superbugs

Dark Outlook

Since the existence of antibiotics, bacteria have been learning to deal with them. Today, there is a lot of attention on these bugs. What is lacking, however, are reliable data – and effective treatments.

read more 7 minutes

von Hristio Boytchev

In May 1944, the Scottish bacteriologist Alexander Fleming is pictured on the cover of the American magazine, Time. The title: „His Penicillin Will Save More Lives Than War Can Spend.“ Fleming is a star of this era. A year later, in December 1945, he receives the Nobel Prize in Medicine, for his role in discovering antibiotics.

But Fleming does not celebrate his own breakthrough. His speech is cautious. He speaks about the dangers that await, should bacteria learn to resist antibiotics. „The time may come when penicillin can be bought by anyone in the shops“, he says. He speaks of a man who can breed a resistant bug within himself and infect his wife  – who dies thereof.

Almost exactly 70 years have passed since Fleming’s speech. His premonitions have proven prophetic: The dangers that threaten humanity through resistant bugs are increasing. The topic is getting a lot of attention. There is a European Antibiotic Awareness Day and a World Antibiotic Awareness Week. Even Angela Merkel and Barack Obama talked about resistant bugs at this year’s G-7 summit in Schloss Elmau, Germany.

Some experts proclaim a future similar to the middle ages: That soon, more people will be dying of resistant bugs than of cancer, around ten million deaths per year. Because supposedly nothing will work against the deadly germs, not antibiotics, nothing. These prognoses should be read with caution, because they are built on a thin base of facts.


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What are the most important resistant bacteria in the world? And where in Europe are they most prevalent?

But the number of resistant germs is increasing worldwide, and it is becoming more and more difficult to discover new and effective antibiotics. Paradoxically, the success of antibiotics have made them unprofitable – with their help, infections have become much rarer in many countries. Pharmaceutical companies are reluctant to make the large investments necessary for research –  also because they may be developing a drug that will be useless in a couple of years, as the bug it targets becomes resistant.

Are we really steering towards an era in which no antibiotic is effective, in which we die of infected teeth? Or a cut from the kitchen knife?

Infections have many causes

It is not that simple. Not all bacteria become resistant. And resistant germs are not always more dangerous than their non-resistant relatives, says Gerd Fätkenheuer, infectiologist at the University of Cologne, Germany. He gives the notorious MRSA as an example. Its non-resistant cousin, MSSA, is as dangerous, and the treatment is similar. Altogether, Fätkenheuer sees a positive development over the last few years: „Earlier, we had worse and fewer drugs to choose from. This has changed.“

Antibiotics were not solely responsible for the drastically diminished number of infections, writes British infection researcher Hugh Pennington in his new book, „Have Bacteria Won?“ Better nutrition, hygiene and clean drinking water have been at least as important, he says. Infections have been retreating even since before antibiotics were introduced, says the bacteriologist, who is among the most prominent in Great Britain and has researched and fought many infection outbreaks.

He breaks with the myth that without antibiotics, every surgery would be life threatening. That is „scaremongering“ that is based on wrong prognoses, he says.

What we know

Different international initiatives are collecting data on resistance. They are organized by the WHO, for example, or in Europe by the „European Antimicrobial Resistance Surveillance Network“. It includes all states of the EU, Norway and Iceland, and tracks eight germs. Countries outside the EU are surveyed by the „Central Asian and Eastern European Surveillance of Antimicrobial Resistance“. An additional network collects data on foodborne germs.

Here we show the distribution of the resistant bacteria that the WHO has classified as most important. Without knowing how common individual resistant germs are, we can neither research the causes of resistance, nor can we know, which measures against it are working.

Resistance differs significantly from country to country and from germ to germ. Trends are difficult to explain. For example, the notorious MRSA has actually been declining in Europe for years, without a clear explanation as to why. On the other hand, resistance amongst hospital bugs like Escherichia coli and Klebsiella peumoniae is increasing, worrying researchers.

Scientists still don’t understand why there are higher resistance levels in the south of Europe than in the north. One of the reasons is likely lax handling of antibiotics. In Greece, for example, the drugs can be bought without a prescription. But the more carelessly antibiotics are used, the more bacteria can adapt to them.

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Insufficient data

The clarity provided through these maps is tempting, but it is deceiving. The data is incomplete, as it is collected on a voluntary basis. There are big differences between the numbers of participating hospitals in each country. This can lead to strong distortions. For example, smaller countries primarily include university hospitals, which muddles the data as these hospitals usually see more serious cases – and probably treat more patients with resistant bacteria.

Additionally, the data has a very rough resolution. How much resistance is present in different regions, cities or even in each individual hospital, is hardly known publicly. The fact that Europe has such weaknesses is a serious problem.

Consumption among humans and animals

How many antibiotics are used on humans and animals? The data here is similarly scarce – there is little detailed information and, often, numbers are submitted only voluntarily. Yet the understanding of consumption is crucial when it comes to understanding – and fighting resistance. At the beginning of 2015, the European Commission published a detailed report, which compared the consumption between humans and animals.

The report examined, for the first time, the importance of animals in the development of resistant germs in Europe. Its conclusion: the report found a connection between the consumption of some antibiotics in farm animals and occurrence of resistant bugs in humans. The exact nature of this connection, and its relevance, is still poorly understood.

Antibiotics as growth promoters

Indiscriminate use of antibiotics in animal production is a highly controversial topic in society. For example, antibiotics are partly used to promote growth because they have the enigmatic property of leading to weight gain when used in low concentrations in animals, and probably in humans.

In contrast to the US, the use of antibiotics as growth promoters is no longer allowed in the EU. But it still happens under the cover of preventive medical care. Veterinary doctors are sometimes incentivized to prescribe more antibiotics. In Germany, for example, veterinarians act as pharmacists and doctors in one, profiting from antibiotic sales. Some even get their main income from prescriptions.

According to the report, animals in the EU consumed more antibiotics than humans. Per kilogram of body weight, animals used 144 milligrams of antibiotics, and humans 116 in one year. There were big differences between individual countries: In 15 EU-countries antibiotic consumption was lower in animals than in people, in three EU-countries it was similar and in eight EU-countries animals consumed more than humans.

Germany, Italy and Spain used the most antibiotics in farm animals – each around 1500 tonnes per year. These countries were also leading relative consumption per kilogram of produced meat – accompanied by France and Cyprus. Also, antibiotics that are especially important for human use are commonly being used in animals. Human use per capita was highest in France and Italy.

This data also has weaknesses. The researchers in the study had to group different antibiotics together, in some countries antibiotic consumption in hospitals were not included, and data was not available for individual animals. Here, there is also a large lack of transparency: The public does not know which farmers use especially large quantities of antibiotics, and therefore induce the most resistance.

Fighting resistant germs

It is hard to get a clear picture of the problem’s scale – it is even harder to make recommendations on how to prevent the spread of superbugs. Hiring more nursing staff to treat infections is expensive. Additionally, isolating patients that might have superbugs is complex and can harm these patients, as their medical care becomes more difficult.

But one thing is clear: The fewer antibiotics we use, the longer they stay effective. There is scientific evidence for this. And often it is possible to turn back the resistance of the germs, if a drug is used very seldom. If germs do not come into contact with a substance, it is not evolutionary inefficient for them to continue to fight this substance. The resistant genes within the germs become rarer.

Therefore, we should think more about the use of antibiotics. But there is a huge gap between resolution and reality, especially among people. About one in two Europeans thinks that antibiotics should be used to treat a flu or a cold, and ask to be treated with antibiotics – despite all of the campaigns and reminders. However, most cases, the flu or a cold are caused by viruses, which means  antibiotics are completely useless.


You can easily reach our reporter Hristio Boytchev at hristio.boytchev@correctiv.org

copy editing: Christine Coester
header photo: Ivo Mayr

© Ivo Mayr

Super bugs

Resistance against last resort antibiotic

In November, scientists discovered resistance to the important last-resort antibiotic colistin. Since then, events have escalated. The substance is at risk of losing its designation as an emergency medication. The probable cause is its massive use in intensive meat production.

von Hristio Boytchev

If you became infected with bad gut bacteria, like the sometimes deadly E. coli or Klebsiella, the antibiotic colistin could save your life. Researchers discovered the substance in 1947, but since the 1980s it is hardly used in humans. This is because of its strong side effects. Colistin can damage the kidneys, for example. 

Yet, these side effects are exactly what make the substance so valuable: Because it is rarely used, hardly any resistance has developed in humans. The drug can be used when other antibiotics, like cephalosporin and carbapenem, fail. In 2012, the WHO put colistin on its list of „critically important antibiotics.“

Superbug Atlas

You can see the resistance against different antibiotics in Europe in our suberbug atlas.

In meat production, the situation is different. Here, colistin has been one of the most popular antibiotics for years. Veterinarians predominantly prescribe it to treat gut infections in farm animals. Experts estimate that the total consumption worldwide is 12.000 tons per year.

The justification for such extensive use? The drug is seldom used to treat humans. And arising resistance would be limited to bugs that infect animals. It was assumed that colistin is one of the few antibiotics whose resistance genes cannot move from germ to germ.

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This notion was knocked down by Chinese scientists. They saw more and more bugs developing resistance to colistin and became suspicious: Is there a resistance gene that can jump from bug to bug after all?

It turned out that yes, there is: The scientists collected E. coli from pig farms and demonstrated that the bacteria can transmit the resistance, even across species. The culprit is a gene, called mcr-1, that makes changes to the bacterial wall, preventing colistin from docking onto it. The researchers discovered that mcr-1 is widespread among animal bugs. Even more concerning is that the gene was also found in some germs which infect humans.

In December 2015, events escalated: The European Medical Agency announced it will reconsider its recommendations regarding the use of colistin in farming. And scientists started looking for the resistance gene in their regions. They discovered the gene in Thailand, Denmark, Holland and France — and at the beginning of January in Germany. The Federal Institute for Risk Assessment investigated old samples and found the newly discovered colistin gene most frequently in E. coli from poultry.

Another German research group was also successful. They found the new gene in four samples: Three of them stemmed from pigs, one from a human wound.

© Ivo Mayr

Super bugs

Gambling with profits

The pharmaceutical industry’s demands: The international community should pay for the development of new, highly efficient antibiotics. It is true: These drugs are not profitable and the demand is justified.

von Hristio Boytchev

Antibiotic resistance has entered on the global stage. Barely an international political summit passes without the problem being mentioned. The refrain: We need more, we need new antibiotics. 

Pharma has now put the ball back in the politicians’ court. Almost 100 members of the pharmaceutical and medical device industries, including heavyweights such as Pfizer, Merck and Bayer, published a resolution that coincided with the World Economic Summit in Davos. 

The central statement of the resolution: Yes, we can develop new antibiotics, but you politicians have to pay the bill. 

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The paper clearly states the pharmaceutical industry’s concerns: Antibiotics are too cheap. Research efforts are difficult, and therefore costly. Normal methods of development have largely failed. “We call on governments to commit to allocating the funds needed to create a sustainable and predictable market“, wrote the industry representatives. Consumption of antibiotics and their remuneration should be delinked.  One possible solution: Instead of paying for antibiotics per dose, there should be a flat rate. „Presently, the situation is like paying firemen per fire“, says John Rex, Vice President of Global Medicines Development at the pharmaceutical company AstraZeneca. That is not sustainable, he says. 

Pharma has a bad reputation. Among politicians and citizens, the industry is notorious for being greedy. But in this case, the demand for more money is justified. It makes sense to find alternative ways to finance new drugs. When politicians insist that new drugs are needed, but the drugs don’t turn a profit — as new antibiotics are used very sparingly — then they should provide the necessary cash.

That is one side of the coin. 

The other side: How realistic are the horrific scenarios painted by politicians and scientists? How justified is the talk about a supposed post-antibiotic era, in which antibiotics no longer work, and every cut or bladder infection can turn deadly? When we look at the evidence, these scenarios are probably exaggerated. The data to support these claims are weak. Maybe we don’t need new miracle drugs in the near future. What we do need, however, is better research into antibiotic resistance, clearheadedness and responsible use of the antibiotics we have today — on the farms, in doctors’ offices and in hospitals. 

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Super bugs

Short Sleeves to fight Germs

The hospital chain Asklepios plans to get rid of the traditional long-sleeved white coat, arguing that doing so will help fight infections. Experts are skeptical.

von Hristio Boytchev

Amidst fresh publicity, the hospital chain Asklepios announced it wants to put away the long-sleeved white coat. The chain’s doctors will wear short sleeves in the future. Their reasoning? Germs could stick to the long sleeves of a doctor’s clothing and be transferred from patient to patient.

Asklepios cites recommendations from experts at the World Health Organization (WHO) and the Robert-Koch-Institute, Germany’s national agency for infection control. 

A nice side effect of the measure would be incredible cost savings. The new short-sleeved coats are cheaper and could save hospitals millions of Euros. 

If the advantages are so compelling, why haven’t more hospitals ditched the long sleeves?

Because doctors are accustomed to their white coats. They are a convention, a uniform that provides security and authority. Plus the effect of long-sleeved coats on hygiene is not as clear as Asklepios claims. Countries like England and Holland have gotten rid of doctors’ long sleeves, but the measures are still controversial. Several studies fail to show a clear effect of short-sleeved coats on infection rates.

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“German hospitals would be well off to first implement measures which have proven to be effective“, says Petra Gastmeier, director of the Institute of Hygiene at the Charité University Hospital in Berlin. Short-sleeved white coats don’t belong in that category, she says.

There is also confusion surrounding official recommendations of short sleeves. German newspapers widely reported that the Robert-Koch-Institute recommended doctors wear short sleeves. 

The institute told us that there is no such recommendation. Meanwhile, dpa, Germany’s press agency, corrected a news story where they attributed the recommendation to the Robert-Koch-Institute.

The WHO has not yet replied to our question of whether they recommend short sleeves. Asklepios quotes a document by the organization that reads: „Although evidence to formulate it as a recommendation is limited, long sleeves should be avoided.“

“I am not against the measure“, says Gastmeier, „but I am against the hype.“

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Super bugs

Contagious Chickens

In Britain’s poultry farming the use of an antibiotic that is important for humans has risen by 59 percent. This is proven by an investigative research conducted by the non-profit bureau TBIJ in London. correctiv.org cooperates with TBIJ in its report about resistant germs.

von Hristio Boytchev

In Britain’s poultry farming the use of an antibiotic that is important for humans has risen by 59 percent. This is shown by an investigatioton by the non-profit bureau TBIJ in London. CORRECTIV cooperates with TBIJ in its report about resistant germs.

It is well-known that the use of antibiotics in animal feed produces resistant germs on the long run. These germs could possibly infest humans as well. This is why those responsible are eager to use as few antibiotics in farming as possible – also in Britain. According to our colleagues from The Bureau of Investigative Journalism the use of antibiotics in poultry farming indeed decreased by roughly 30 percent during the years 2013 and 2014. However, these numbers are not valid for all antibiotics. The use of for humans extremely important Fluorquinolones, of all antibiotics, increased by 59 percent.

In Germany, the same process can be observed: New regulations should reduce the total consumption. This why the use of highly potent substances, that already have an effect in low concentration, rises. These substances, however, are, like Fluorquinolones, extremely important to human medicine. The WHO keeps this medicine on a list of “critically important antibiotics“.

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The increased use of Fluorquinolones is worrying, as these antibiotics belong to a group of substances reserved for the „last defence“. They should help when no other medicine takes effect anymore. Their advantage is, in contrast to comparable preparations, that they can be taken orally. They are able, alongside other scopes, to save people’s lives when they are infected with E.coli, which causes diarrhoea. Or with salmonellas and campylobacter. These germs are particularly transferred when people eat contaminated meat. Also, they can be transferred when people do not wash their hands after they touched raw meat in the kitchen. Or when they cut tomatoes and chicken with the same knife.

There are hints indicating that antibiotic resistances are able to jump from animal germs to germs that infect humans. This means: resistances that are bred among animals will affect humans on the long run.

As a consequence, the association „Alliance to save our Antibiotics“ demands a ban of Fluorquinolones in poultry farming. The USA already banned its use for farming in 2005.  

Super bugs

Effective Briefing

With a simple brochure, researchers were able to convince a large group of doctors in Britain to prescribe less antibiotics. In the scientific journal ‘Lancet’ they are talking about their experiences.

von Hristio Boytchev

Most antibiotics taken by patients are consumed at home, not in the hospital. In Britain, the proportion is roughly 80 to 20. However, a large part of the antibiotics swallowed at home could be done without.

Why? On the one hand, patients ask their doctors for antibiotics when they actually are not useful – for example, when they have a cold. On the other, doctors are too careless when prescribing antibiotics. A British study shows that roughly one in four antibiotics is prescribed in cases where the doctor is not sure whether it is necessary at all.

How can we end this abuse? According to researchers led by Michael Hallsworth at London’s „Behavioral Insights Team“ this is surprisingly easy. First, the researchers visited those 20 percent of the British medical practices that prescribed most antibiotics in their region. In order to get the data, the researchers referred to public databases.

After that, they separated the band of almost 1600 medical practices into two groups. The scientists wrote a letter to every second medical practice explaining to the doctors that they were prescribing a particularly large number of antibiotics. The researchers said that this was a simple psychological trick because it moves the affected doctors to the position of an outsider. Also, they added a note by the British „Chief Medical Officer“ to the letter.

This simple measure already had its effects: The prescription of antibiotics in those very medical practices decreased by three percent in comparison to the group of doctors who did not receive a letter.

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Three percent, that does not sound like much. However, taking into account the number of almost 800 practices, this amounts to more than 70,000 less prescriptions of antibiotics in half a year, as experts estimate. This would cost the NHS almost 100,000 pounds less at an expense of not even 5000 Euros for printing and sending the brochures. And yet the researchers do not even know how many of the doctors opened and read the letter at all.

Since the measure worked that well they sent the letters to the other half of the practices that served as a comparison group as well. Immediately their usage of antibiotics declined, too.

The study, however, also portrays more obstacles to a reduced consumption of antibiotics: It is much more difficult to explain the problem of thoughtlessly swallowed antibiotics to patients. Again, the researchers separated the 1600 practices into two groups. One half received posters and brochures in order to inform patients.  Yet, nothing happened and the rate of antibiotics prescriptions remained high.

The conclusion of the researchers: Either the participants of this study are unwilling to listen to reason or they are that packed with information on antibiotics already that a brochure does not make a difference. As a major part of the global efforts to reduce consumption of antibiotics aims at the individual responsibility of patients, this is anything but a good message.

Doctors, in contrast, seem to be more receptive regarding advice. The British scientists expect the awareness campaign to be able to reduce consumption of antibiotics outside of hospitals by almost one percent in the short run. This would be a major step in the direction of those four percent the government aims at in its struggle to reduce consumption of antibiotics in the UK.

Whether this path makes sense for other countries as well remains unclear: The British scientists profited from the fact that in the UK, data of prescriptions in each practice are made, thanks to the NHS, available to the public in a single location. In Germany, for example, this is not the case.   

Super bugs

Tricking the immune system to fight germs

A new substance could help fight malicious infections. The substance activates the endogenous defence.

von Hristio Boytchev

Antibiotics do not differentiate between „good“ and „bad“ bacteria – between those that sicken people and those that are good for humans. Antibiotics destroy them all. They destroy, therefore, also vital bacteria in the bowel that enable digestion, produce vitamins and protect against infections.

Anyone who swallows antibiotics hence alters his intestinal flora. This can lead to easier distribution of germs in the bowel. One example is enterococcus bacteria which infect the blood through the bowel if they occur in high concentrations. Especially for patients who are already weakened they can become particularly dangerous as they can trigger blood poisoning.

There are strains of enterococcus called VREs which are resistant against the antibiotic Vancomycin. VREs are dreaded germs in hospitals. If they infest a patient who has just had an organ transplant this can be life-threatening.

How can we stop VREs?

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Doctors can try to save the patient with the help of emergency antibiotics. A new method that is still in the experimental stage is the so-called faecal transplantation. In order to restore balance among bacteria the faeces of a healthy person is inserted rectally to the bowel of the sick person. However, inserting external faeces remains little studied and might hold dangerous side effects.

Scientists led by Michael Abt from New York’s „Memorial Sloan Kettering Cancer Center“ have now tried out a different strategy: They infested mice with the dangerous hospital germ VRE. At the same time they infested the mice with noro viruses. They are particularly dreaded in schools, kindergartens and retirement homes as they are easily transferred. In addition, they cause severe diarrhoea and vomiting.

However, the double infection has a totally different effect: the mice recover faster. The noro virus helped to contain the infection. The reason: The immune system was additionally activated with the help of the virus.

A similar effect occurred when the scientists gave them Resiquimod which is an experimental drug against herpes. It pretends that a virus has entered the body. The immune system is activated and reacts.

Like other new methods, this method has to be further explored. In case the immune system is overactivated, severe side effects might occur.   

© Ivo Mayr

Super bugs

Young Resistance

Children’s immune systems have yet not matured, which makes them more prone to infection than adults. Antibiotics are therefore crucial drugs for the young, but even children are plagued by antibiotic resistance, an analysis shows.

von Hristio Boytchev

Children are often ill. This is not only the impression of overly-concerned parents, but a medical fact. A child’s immune system is not fully developed, meaning the immune system has not yet learned how to fight off intruders effectively. 

This makes antibiotics even more critically important for children. Scientists led by Ashley Bryce at the University of Bristol recently discovered that when treating infections of the urinary tract, some antibiotics failed to help. The researchers presented their findings in the „British Medical Journal“, a research magazine.

The scientists took a systematic approach. First they screened for studies that dealt with antibiotic resistance in children’s urinary tract infections caused by E. coli. The scientists found 58 such studies from 26 countries.

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When the researchers analyzed the data, they reached an unsettling conclusion. In richer countries, or OECD countries, every second sample analyzed had resistance to the antibiotic ampicillin. Children that received treatment with an antibiotic before were more likely to have from resistance. 

In nations outside the OECD, generally poorer countries, the resistance quota for ampicillin was as high as 80 percent. The difference could be explained by more frequent use of ampicillin in these countries. Resistance to other antibiotics were also found, but at much lower rates.

The scientists conclude that antibiotic resistance should be taken seriously when considering to treat children with antibiotics. For example, before selecting an antibiotic, a physician should consider the medical history of the young patient and possibly even test for resistance bacteria.

Super bugs

Where the MRSA pigs live

MRSA is arguably the most well-known of the resistant bacteria. Many people even have them on their skin without even knowing it. However, it is only when the bacterium gets into the body through an open wound that it becomes dangerous. In hospitals, MRSA can cause severe wound infections in patients with weakened immune systems or after surgery.

von Hristio Boytchev

In Denmark, MRSA is found on two-thirds of all pig farms. The investigative newsroom „Investigative Reporting Denmark“ recently won a legal trial, forcing the Danish Farmers Association to disclose every farm where MRSA has been found. The association had been reluctant to release the data arguing it was a breach in privacy.

In Germany, the number of farms positive for MRSA could be similar, but data on resistant bacteria and antibiotic consumption are not publicly available at the individual farm level. This makes a transparent analysis of possible threats impossible.

MRSA are bacteria of the species Staphylococcus aureus that are resistant to the methicillin, a commonly used antibiotic. MRSA is one of several different MRSA-strains. Some infect primarily animals, others humans; other strains infect both humans and animals, like the strain MRSA CC398. This strain of MRSA can jump from animals to humans through direct contact, such as when farmers care for their pigs.

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Non-resistant Staphylococcus aureus strains can be as dangerous as the resistant MRSA and generally speaking, MRSA is not as deadly as many expected it to be. Luckily, methicillin was not the only antibiotic that could kill MRSA.

Take for example Denmark: Over the course of 2013 and 2014 only four people have died from the notorious MRSA CC398 – which led to broad coverage in Danish media. During that same time period, Investigative Reporting Denmark reported that nearly 700 people died of other Staphylococcus aureus strains, citing the Danish Farmers Association.

While MRSA may not be considered the most dangerous resistant bacterium any more, the danger of resistance should not be underestimated. An MRSA infection makes treatment more difficult and expensive in the long run. Additionally, patients infected with MRSA are often stigmatized. The germ is feared by the general public and hospital staff; infected patients are sometimes treated in isolation, which can decrease the quality of care.

© Ivo Mayr

Super bugs

Constant threat

Israel has endured several heavy outbreaks of resistant germs. The nation’s response has been exemplary. Despite the peculiarities, other countries are following its model.

von Hristio Boytchev

In Israel, politics permeate through ever facet of the country including the health care system. The authoritarian structures, built for defense against external and internal enemies, have shown benefits in infection control.   

In 2006, a resistant germ was ravaging the country’s hospitals. A bacterium, of the Klebsiella pneumoniae variety, was introduced from New York. Almost no drug can fight the germ, not even carbapenem, an emergency antibiotic. It seemed like the bug’s spread was unstoppable. At its peak in March 2007, 185 hospital patients were infected. The bug sickened more than 1000 people; half of them died. In hospitals, the bug has a mortality rate of up to 50%.

It took months until the outbreak was contained. And even now, the bug has not disappeared completely. It’s lurking, waiting for the next attack.

What has Israel learned from the epidemic? What can others learn from Israel?

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The Hadassah hospital in Jerusalem

At first everyone was fighting the outbreak on their own, says Mitchell Schwaber, an infectiologist at the Sourasky Medical Center in Tel-Aviv.  There wasn’t a network connecting the different hospitals. It was only at an informal meeting of the country’s infectiologists when they realized that everyone was facing the same problem. They set out to establish a task force, the National Center for Infection Control. Mitchell Schwaber became its director. 

The task-force got to work: Patients were to be screened for the bug, and infected people were to be isolated and treated by dedicated staff. What was special about the task force was that its recommendations were binding. „We got legal authority“, Schwaber says. His team could demand information and enforce directives. 

Those same directives are still in place today. Schwaber’s team is still collecting data daily on resistant germs from every hospital – unimaginable for big, decentralized countries, such as those in Europe or the US.

Despite the benefits that come with collecting this data, Schwaber’s directives are controversial. For example, there are questions surrounding if and when patients carrying a resistant germ should be isolated. Some argue that the measure is laborious and can stigmatize the infected patients and their nurses. Schwaber is convinced that the orders are justified at least when it comes to this particular germ. His team’s protocol has since been adapted internationally. 

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Mitchell Schwaber, Leiter des National Center for Infection Control in seinem Büro

Secret weapon

State authority is not the only tool Schwaber uses to fight infection. He has a special weapon. Her name is Ester Solter; she is a nurse. The jovial woman comes into play, when hospitals are not following Schwaber’s directions.  

In 2012, during another frightening Klebsiella outbreak, a hospital in eastern Jerusalem contacted Schwaber because newborns were getting sick and dying of a mysterious infection.

Eastern Jerusalem is the Arabic part of the city and its exact governing status controversial. The tight control that Schwaber has over other hospitals was of no use here. However, he still asked for the data. When he got it, he was worried.  

“My God, something had been going there“, the doctor says. At the peak of the outbreak every third child in the hospital had the bug. Schwaber sent nurse Solter to help the doctors on site immediately. The biggest problem turned out to be the language barrier.

Solter did educational work: How are samples taken correctly? How is the laboratory equipment used? 

It is unfortunate that it took an outbreak at a neonatal station for this exchange to happen.

At the end, however, Schwaber’s team was successful. His recommendation? „Have a system in place before an emergency comes. Don’t let yourself be surprised.“

Schwaber knows that his nation is special: It is small and has a strict, centralized bureaucracy. In a country that lives in permanent state of emergency, reactions are swift and effective. 

On the other hand, its hospitals are always full. „We are over 100 percent capacity all the time“, Schwaber says. The nation’s population is growing. In the last decade, it assimilated more than a million immigrants, most of them from the former Soviet Union. This makes population growth higher than ten percent. And yet, the hospitals capacities have remained the same, Schwaber complained.

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Bug tourism

Additonally, Syrians and patients from abroad, with infected wounds or who are taken up for humanitarian reasons, such as survivors from the Bucharest discotheque fire of 2015, are being treated in Israel. They often bring resistant bacteria with them and upon arrival have to be isolated, Schwaber says. Because of Israel’s high standards of medical care, the country is a destination for the global medical tourism industry. But when humans travel, so do the germs.

Schwaber is always on alert. Every day he is prepared for a new outbreak. MRSA, Acinetobacter or a gut germ? It could be anything. His worst nightmare? Not having enough money, doctors and hospitals beds when an epidemic breaks out, he says. Because in reality he is not only fighting resistant germs, but also against limited resources and politics. Every year seems more difficult. „We live in tough part of the world. Money that goes into defense is missing somewhere else.“

The Nobel Prize winner

About halfway between Tel-Aviv and Jerusalem lies the renowned Weizmann Institute. More than 2500 people do research there. The institute has produced three Nobel Prize winners in chemistry.  

Ada Yonath is one of them. The 76-year-old sits in a black T-Shirt in a tiny seminar room and explains why she antibiotic resistance is an enormous threat to global health.

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Nobel Prize winner Ada Yonath researches novel antibiotics

She wants to use her insights of the molecular structure of bacteria, for which she was awarded the Nobel Prize, to develop novel antibiotics that target parts of the bacterium with exceptional precision. She introduced her ideas to pharmaceutical companies – being a Nobel laureate gets you invited everywhere, she says. She told the companies that people were going to die young unless new antibiotics were developed. Nobody ever got back to her.

Now Yonath researches the concept on her own. It would not be the first time that she ends up surprising the scientific community.

The hidden infectiologist

Allon Moses is a leading infection control specialist in Israel. He is not easy to access. His office in deep in the catacombs of the Hadassah Hospital in Jerusalem and nobody is around to help show the way.

Despite also being one of the world’s most renowned infectiologists — he played an important role in contains the 2006 epidemic — nobody seems to know him. This is typical. Infectiologists work in the background, without much attention.

Eventually a young doctor leads the way up and down stairwells, through corridors, and finally to Moses’ modest office. Inside is a desk with a computer and on the shelves are microbiology journals and textbooks. Moses’ team is also in attendance. Carmella Schwarz, head nurse, and Shmuel Benenson, infectiologist, sit on office chairs.

Moses is a friendly man with a white beard and receding hairline. He sits behind the computer screen on which he shows presentations and data on infections. He is proud of this system because it shows every infection reported at the whole hospital.

What has he learned from the outbreak? That good infection control is difficult, he says. That there is not one solution; many small steps make the difference.

One of the main tasks of Moses’ team is to convince the doctors to report infections and nurses to thoroughly wash their hands. They even make sure that cleaning personnel scrub more thoroughly. 

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Allon Moses, on the left, and his team: Carmella Schwarz and Shmuel Benenson

Any prospective hire for Moses’ team needs to be an infection control expert with charm and diplomatic skills. Being able to participate on a team is essential. „Infection control is no job for a single person“, Moses says. Everyone needs to be included, from the clinic boss down to the cleaners.

Since 2006, a lot has gotten better, Moses says. It is easier to get the doctors’ attention; they are more interested in hearing his advice. Still, psychological intuition is necessary in his team’s daily work. Moses remains alert. The constant threat, he says, is an inherent part of living in Israel.