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© Ivo Mayr

Super bugs

Pigs and bacteria

In Denmark, there are more than twice as many pigs as humans, and twice as many antibiotics given to the animals as well. A perfect breeding ground for resistant bacteria – to which politics have failed to respond.

read more 8 minutes

von Nils Mulvad

In November 2013, a 63-year-old man with diabetes and end-stage kidney got fever because of inflammation. Samples of blood grew the resistant pig-bacteria, methicillin-resistant Staphylococcus aureus, MRSA, CC398. Three weeks later the man died.

By analyzing the specific type of the bacteria, doctors identified the cause of the infection. It was another man. Someone carrying the same type of bacteria, staying in the same outpatient clinic at Odense University Hospital; a nasal and pharyngeal MRSA-carrier.

The dead man is proof that bacteria of animal origin now transmit directly between humans in Denmark. It does not need pigs anymore – but can jump directly from one human to another. The man from the Odense hospital is one out of two cases described May 2016 by Danish doctors in the journal Emerging Infectious Diseases.

In Denmark, the focus on resistant bacteria for some years has been especially high on MRSA coming from pigs. In humans, it can be present on the skin, commonly in the nose, without causing harm. Yet when it enters the wound of a weakened patient, as it happens after surgery, it can lead to threatening infections.

“We see a picture of an epidemic that is out of control. Authorities have done remarkably little and seem at all levels perplexed“, wrote a leading researcher in human disease treatment, Hans Jørn Kolmos from the Department of Clinical Microbiology, Odense University Hospital in late September 2013.

“The Danish Veterinary and Food Administration has now, seven years after the problem was documented, still no overview of the epidemic, and has done nothing to halt the spread of infection“, Kolmos writes.

Highest pig-man ratio in the World

Denmark has the highest pig-man ratio in the World. The country with 5.7 million inhabitants has an average population of 12.7 million pigs. The use of antibiotics in the country reflects this. In 2014, humans in total in Denmark got 53 tons of active antibiotics, while pigs got 86 tons.

In 2007, the first case of presence of humans carrying a strain of MRSA coming from pigs was recorded. Yet little was done to stop the spread of the bacteria. MRSA usually does not harm pigs.

The authorities followed the amount of affected meat at the slaughterhouses, but they did not demand farms to get their pigs tested. Then, farmers could not warn employees and visitors of the potential risk.

Today farmers and authorities say every pig should be regarded as colonized, and then workers, visitors, and neighbors should take their own precautions, washing hands and changing clothes. Hospitals should also take their own precautions, regarding humans in contact with pigs as a health risk factor.

This has consequences for the whole of Europe. According to Eurostat, Denmark is the leading pig exporter. In 2013, more than half of young pigs in Europa came from Denmark, meaning the rest of Europe can also get MRSA from the Danish pigs.

Proposal from task force denied

After growing public awareness of the problems since 2010, the Minister of Agriculture at that time, Mette Gjerskov, established a task force to propose several initiatives to stop the spread.

The main proposal was to closely follow the spread in pig farms and establish an MRSA-free trade way. Per Henriksen, head of the Danish Veterinary and Food Administration, rejected the plan silently. Instead, the authorities sat up some minor initiatives based on a strategy of accepting all pigs as carriers.

The Danish Veterinary and Food Administration and the Ministry of Agriculture rejected to disclose which farm had MRSA-carrying pigs. Only after a FOI-case and later a court-case, the authorities were forced to give out this information in March 2016.

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A main problem is that only around one in ten farms are being tested, so there is still no information on the status of MRSA in most of the farms and there is no MRSA-free trade way. Investigative Reporting Denmark has published an exclusive investigation into the numbers.

Antibiotic use on every farm

When the public awareness of MRSA rose in 2010, the Danish parliament also decided to introduce a system warning and fining farmers, when their use of antibiotics was too high. The authorities set up a system for gathering data on antibiotic use and the number of pigs on each of all 4000 pig farms in Denmark.

Since the introduction of the scheme, 130 farmers have received a warning, yet none has been fined, according to information received by „Investigative Reporting Denmark“ in September 2014.

After getting the data, „Investigative Reporting Denmark“ presented a method to calculate the amount of antibiotic used on every farm in Denmark.

Fighting six years for data

A system called Vetstat has been used to surveil antibiotic on stable-level in Denmark for more than 20 years. It is regarded as a success, because the use of antibiotics was reduced by 16 percent since 2009. The recent Danish minister of Agriculture, Esben Lunde Larsen hopes the Danish system will be part of a new EU-initiative to prevent development of resistant bacteria.

Yet the data in Vetstat is not publicly available. A request for data was delivered in 2006. The data was received for the first time six years later, in 2012. The data showed all the pigfarms with heavy use of antibiotics and was later the background for the warning system.

In 2014, the Danish Audit Agency started an investigation on the Ministry of Food and Agriculture and The Danish Veterinary and Food Administration because of a case with swine-MRSA. In October 2015, this investigation finished with a heavy critique.

The ministry administrated MRSA in pigs nearly only looking on the cost of the production of pigs, not taking care of the implications for the society – especially the health sector, concluded the agency.

MRSA in pigs has been the main focus point in Denmark for years. Another issue has been a growth in MRSA from Danish people visiting foreign countries. MRSA from pigs now count for four out of ten cases of MRSA-infection, MRSA originating from foreign countries count for less than two out of ten. Today doctors calculate 12,000 Danes are carrying pig-MRSA 398 – most without knowing.

The new superbugs

In recent years, health authorities have identified two more serious threats from antibiotic resistance in Denmark, VRE and CPE.

Vancomycin-resistant enterococci (VRE) are a type of bacteria called enterococci that have developed resistance to many antibiotics, especially vancomycin. If they become resistant to antibiotics, they can cause serious infections, especially in people who are ill or weak. Common infections include the intestines, the urinary tract, and wounds.

In 2015, VRE was found in 382 Danish patients, seven time as many as in 2012.

Carbapenemase-producing enterobacteriaceae (CRE) are bacteria that are nearly resistant to the carbapenem class of antibiotics, considered a drug of last resort. The bacteria can kill up to half of patients who get bloodstream infections. In 2014, CRE were found in 29 Danish patients – twice as many as the year before. Often these patients had been hospitalized in a foreign country before getting back to Denmark.

Both for VRE and CPE there are no screening of patients, so the total number might be much higher, warns Dr. Robert Leo Skov from Statens Serum Institut.

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Super bugs

Ten important moments in the history of antibiotic discovery

Starting in the 1930's, scientists began discovering antibiotics. These drugs have gone on to save millions of lives by killing the bugs responsible for infectious diseases. Here are the ten key moments in the discovery of antibiotics.

read more 5 minutes

von Victoria Parsons

Alexander Fleming discovers penicillin 

Image credit: Monica Arellano-Ongpin licensed under Creative Commons

On September 3, 1928, Fleming returned from holiday and sorted through some petri dishes at St Mary’s Hospital in London, where he was Professor of Bacteriology. The dishes contained a bacteria called Staphylococcus, which causes boils, sore throats and abscesses. One dish stood out. It had a blob of mold on it, and the bacteria around the mold had been killed.

Fleming kept experimenting with his „mold juice“ and found it could kill a range of bacteria. He published the results of his research in 1929. Although it would be many years before penicillin could be isolated from the mold and used as an antibiotic, this marks the discovery of the first true antibiotic.

Source: The American Chemical Society

 “Wonder drug“ penicillin developed for use on soldiers in World War Two 

A glass penicillin fermentation vessel like the ones used by drug company Glaxo between 1940-45 when attempting to mass-produce penicillin. Later, the mold was grown within large industrial fermenters and able to be mass produced. Image credit: Wellcome Images licensed under Creative Commons

After Alexander Fleming discovered it, penicillin largely fell out of scientists minds. It proved very difficult to isolate the drug from the mold. But the few trials that were carried out with it showed that it was hugely effective in treating infections, in mice at least.

With the outbreak of the Second World War, it became obvious that finding a way of mass producing penicillin could save many soldiers lives and be hugely useful. So the US and British government’s challenged the pharmaceutical industry to find a way to mass produce it.

Pharmaceutical companies chose different methods of trying to mass produce penicillin, but ultimately it was Pfizer that was successful – they developed a way of using deep-tank fermentation (a process they had been using to produce citric acid) to make penicillin in bulk. In 2008, Pfizer’s work on this was designated a National Historic Chemical Landmark by the American Chemical Society.

Once penicillin could be mass produced it was given to soldiers heading to Europe; because it was known that infections, not battle wounds, claimed more lives. Scientists manufactured 2.3 million doses of penicillin in time for the D-Day landings, and drug companies in the US distributed posters which proclaimed “Thanks to PENICILLIN… He Will Come Home!“

After the war, mass-production of the wonderdrug began in earnest and it was soon available to civilian patients.

Cephalosporins isolated in 1945

Image credit: Pablo Fernandez licensed under Creative Commons

Like penicillin, the class of antibiotics called cephalosporins came from research that was mostly academic, but then led to results which had a practical, medical application.

Cephalosporium bacteria was first isolated from soil in Sardinia, in 1945, by a scientist called Giuseppe Brotzu, who isolated the bacteria from sewage runoff. However, he lacked the resources to investigate further so sent samples to scientists at Oxford University, UK. The compound was then purified by Edward Abraham and Guy Newton.

After cephalosporin C, as it was called, was discovered in 1953 by the Oxford University scientists they sent it to the United States Further work in the United States led to large-scale production of the drug.

Cephalosporins are broad-spectrum antibiotics, which mean they are effective against a wide range of bacteria. They are used to treat septicaemia, pneumonia, meningitis, biliary-tract infections, peritonitis, and urinary-tract infections. Of the other antibiotics, they are most similar to the penicillins.

Sources: A Glimpse of the Early History of the Cephalosporins, Journal of Clinical Infectious Diseases, and NHS Evidence.

Chloramphenicol discovered in 1947 

Image credit: Brother Magneto licensed under Creative Commons

Chloramphenicol was discovered in soil and compost – a natural product secreted by the bacterium Streptomyces venezuelae. The efficiency of the new antibiotic was soon proved with dramatic results, combating two typhus outbreaks in Bolivia and Malaysia in 1948.

In 1949, chloramphenicol was approved for use by the US Food and Drug Administration as the first broad-spectrum antibiotic. Its use rapidly spread worldwide and it was used extensively in the treatment of infections ranging from acne to bronchitis to bacterial meningitis.

In the 1960’s, chloramphenicols popularity waned as use of the drug was linked to fatalities resulting from its toxic effects on bone marrow. It is now rarely used, due to its toxicity and the availability of effective, alternate antibiotics.

Source: The Journal of Pediatric Pharmacology and Therapeutics

1948: The first tetracyclines

Image credit: rchappo2002 licensed under Creative Commons

Discovered as natural products from the soil bacteria actinomycete, research on tetracyclines was first published in 1948.  This new class of antibiotic was noted for their broad spectrum activity – they were effective against a wide range of infections – and they began to be mass produced in the late 1940’s and early 1950’s.

Source: New York Academy of Sciences

Discovery of colistin

Image credit: Nathan Reading licensed under Creative Commons

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Bacteria are tested for sensitivity to antibiotics. This strain of bacteria was only resistant to Colistin, eg. it was resistant to all other antibiotics tested on it.

In 1947 an antibiotic called Polymyxin, in the class of antibiotics called the cyclic polypeptide antibiotics, was discovered. Polymyxin E was produced by soil bacteria, and is also called Colistin – because the soil bacteria that produces it was first called Bacillus polymyxa var. Colistinus, before being renamed Paenibacillus polymyxa.

Colistin has been available since 1959 for treating infections caused by Gram-negative bacteria. However, because it was potentially toxic – and another class of antibiotics, called aminoglycosides, were discovered which worked on the same bacteria but were less toxic – use in humans was massively restricted.

Colistin is now considered a drug of last resort, and is usually reserved to treat bacteria which are already resistant to treatment with other drugs. However, it’s been used to treat farm animals around the world for decades, and resistance to the drug has grown.

Sources: UK Government’s Animal and Plant Health Agency

Aminoglycosides

Image credit: Sanofi Pasteur licensed under Creative Commons. Scanning electron microscope image of mycobacterium tuberculosis, responsible for tuberculosis.

The first aminoglycoside, the antibiotic streptomycin, was discovered in 1943 by American biochemists Selman Waksman, Albert Schatz, and Elizabeth Bugie. They isolated the antibiotic from Streptomyces griseus, a strain of soil bacteria. Streptomycin was found to kill various bugs, including one which causes tuberculosis.

Aminoglycosides were the long sought after remedy to tuberculosis and other serious bacterial infections. However, their potential side effects – they could be toxic to kidneys and ears – meant their use declined in most countries in the 1970s and 1980s, as new antibiotics were discovered which could be used for similar treatment.

Today aminoglycosides are once more one of the most commonly used antibiotics worldwide, because of their high efficiency and low cost. Doctors may be reluctant to use them because of the risk of toxicity, but have little choice because these antibiotics are so powerful.

Source: US National Library of Medicine National Institutes of Health 

The 1950’s: Discovery of macrolides

Image credit: Nathan Reading licensed under Creative Commons

The macrolides were first discovered in the 1950s, when scientists isolated erythromycin from the soil bacteria Streptomyces erythraeus. In the 1970s and 1980s synthetic versions of erythromycin, including clarithromycin and azithromycin, were developed.

Macrolides are used to treat infections caused by the bacteria Streptococcus in people who are allergic to and so can’t be treated with penicillin. Macrolides can also be used to treat penicillin-resistant strains of bacteria.

This family of antibiotics includes erythromycin and clarithromycin, which are particularly useful for treating lung and chest infections. Macrolides are well tolerated, orally available and widely used to treat mild-to-moderate infections.

Source: Encyclopædia Britannica

The emergence of MRSA 

Image credit: NIAID licensed under Creative Commons. Scanning electron micrograph of a human neutrophil ingesting MRSA (purple).

Methicillin-resistant S. aureus was first reported in the UK in 1961, just a year after the antibiotic methicillin was introduced in the country. S. aureus was already resistant to penicillin, and when the bug became resistant to methicillin as well it became the first superbug – a bacteria that is resistant to multiple antibiotics.

MRSA remained uncommon in the UK for several years after it was first discovered, but then slowly the number of cases increased. In the 2000’s there were several outbreaks of MRSA infections in UK hospitals, causing thousands of deaths.

It’s hard to put a figure on how many cases of MRSA there are globally, and how many deaths. But in the US alone the Centers for Disease Control and Prevention estimates there are more than 80,000 invasive MRSA infections and over 11,000 deaths every year.

Source: Journal of Antimicrobial Chemotherapy

The quinolones – not isolated from soil but made by chemists

Image credit: Marc Perkins licensed under Creative Commons. A slide of gram-stained Bacillus megaterium seen at approximately 1,000x magnification. This bacterium is a gram-positive bacillus that is in the streptobacillus form (growing in long chains).

Unlike many of the other antibiotics discovered during the middle of the last century, the quinolone class of antibiotics was not isolated from bacteria in the soil but made, synthetically, by chemists.

The discovery of the quinolones began accidentally, in 1962, as a byproduct of some research on the antimalarial drug chloroquine. The accidental discovery led to prolific research on quinolones and the development of a library quinolone compounds.

The quinolones are a very useful class of antibiotics which can be used against both gram positive and gram negative bacteria.

Source: The Quinolones: Past, Present, and Future, Journal of Clinical Infectious Diseases

bacteria

Super bugs

Seven things YOU can do to combat antibiotic resistance

Antibiotic resistance is one of the biggest public health threats of our time. CORRECTIV reporters have been covering superbugs for more than two years. Here are the seven things they've learned that we can all do to help fight drug resistant bugs.

read more 5 minutes

von Victoria Parsons

1. Wash your hands

Photo credit: Jar [o] licensed under Creative Commons

Wash them properly. Every time your hands look visibly dirty, after every time you use the bathroom, and every time before you eat or prepare food.

Washing your hands reduces the spread of bacteria and protects you from infections. Cleaning them regularly is one of the best ways to avoid getting sick, and stops the spread of bugs from you to the people you come into contact with.

Read more of CORRECTIV’s tips on hand washing here.

2. Do what your doctor says when you’re prescribed antibiotics

Photo credit: freestocks.org licensed under Creative Commons

For decades, the advice has been that it’s essential that you finish taking your prescribed course of antibiotics, even if you feel better and your symptoms have gone away.

This was said to be because if you stop taking an antibiotic partway through the treatment it gives the bug an opportunity to develop resistance to the antibiotic. This resistant bug can then spread, making the antibiotics less effective in treating them.

However, some scientists are now questioning this longstanding refrain. They say that actually, you should stop taking the antibiotics as soon as you feel better – because any exposure of the bugs to the drugs creates resistance.

Our take on this? Follow the instructions your doctor gives you when he prescribes antibiotics. And maybe ask him what he thinks about the debate over this bit of science.

Source: UK National Health Service

3. Cook and handle meat properly

Photo credit: Kyle Brammer licensed under Creative Commons

Some antibiotic-resistant infections come from food – like salmonella, campylobacter and E. Coli. When farm animals are given antibiotics, bugs that are resistant to the drugs can survive treatment. These resistant bugs can multiply in the animals guts and remain on the meat.

Raw meat can contaminate your meal with resistant germs. When cooking meat, wash your hands before and after. Handle the meat properly: don’t use chopping boards or knives that have touched uncooked meat on other parts of the meal.

Raw meat must be stored at a low enough temperature. Don’t handle raw meat if you have open cuts on your hands. Read more of CORRECTIV’s tips on handling raw meat here.

Source: CDC

4. Take care when visiting friends and family in hospital

Photo credit: dreamingofariz licensed under Creative Commons

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You should wash your hands before you enter their room and after you leave it. This helps avoid spreading germs around the hospital.

Doctors and nurses should also wash their hands before touching every patient – and it’s okay to check that they’ve done this. In fact, in the United States, hospitals encourage patients to ask their doctors if they’ve washed their hands. Some doctors and nurses even wear badges to show they want to be asked and reminded.

Be aware that wearing rings or fake fingernails gives bugs a good spot to hide. Make sure you wash these very carefully.

Read more hospital visiting tips from CORRECTIV here.

5. Think twice before requesting antibiotics for a cough or a cold

Photo credit: Rebecca Brown licensed under Creative Commons

Viral infections like coughs and colds, flu, sore throats and bronchitis cannot be treated with antibiotics. Antibiotics do not fight infections that are caused by viruses directly, only those that are caused by bacteria.

To combat antibiotic resistance we all have to use antibiotics appropriately and responsibly. If you take antibiotics for a cough, sore throat or flu, they usually won’t make you feel better. They also won’t stop other people from catching your cold, and you may end up contributing to the problem of antibiotic resistance.

This is because you’ll kill harmless bacteria when you take antibiotics for your cold, and leave antibiotic-resistant bacteria behind. These resistant bugs can then spread.

Source: CDC

6. Stay up to date with vaccinations

Photo credit: NIAID licensed under Creative Commons

Staying healthy and preventing disease is key to fighting antibiotic resistance. It’s better to prevent a disease than to treat it.

Vaccines protect you and the people you come into contact with. Many of the infectious disease that were once common – like polio, measles, whooping cough, German measles, mumps and tetanus – are now controlled with vaccinations. Vaccines have prevented countless cases of infectious disease and saved millions of lives.

Keep your vaccines up to date, and if you travel abroad check to see if you need vaccinations. Make sure you get them in time.

Source: CDC

7. Prevent the spread of Sexually Transmitted Infections

Photo credit: Jenny Koske licensed under Creative Commons

Common sexually transmitted infections (STI’s) like chlamydia, gonorrhea and syphilis are caused by bacteria and usually treated with antibiotics. However, these STI’s are becoming more difficult to treat. This is because they are often undiagnosed, and because the antibiotics used to treat them are beginning to fail.

Resistance has increased rapidly in recent years, especially with gonorrhea. Strains of multi-drug resistant gonorrhea that do not respond to any available antibiotic have been detected by doctors. Untreated or untreatable STI’s can have serious, long term consequences on your health.

Reduce your risk of catching an STI. Use protection with your partner, get tested regularly, and know the symptoms. Learn more about drug-resistant STI’s and what you can do to combat them here.

Source: WHO and CDC

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.

read more 5 minutes

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.

Superbugs

Deadly Superbugs

Each year, thousands of Germans die from superbug-infections. The reasons: too many antibiotics, poor hygiene, political reluctance. And the numbers are growing. Scientists caution that a tsunami is coming our way, a disaster “greater than climate change”. Regardless, those involved do nothing but shift blame – almost no one is willing to fight the superbugs with full force. We show that there are already many more incidents than officially reported. And we are launching a long-term international investigation. For this, we need your help.

read more 15 minutes

von Daniel Drepper

Andreas H. is 49 when he is admitted to the Helios-Clinic in Duisburg. The doctors suspect cancer and remove a part of his pancreas, puncturing his abdominal wall in the process. Six weeks later, Andreas has undergone twelve operations. The wounds won’t close anymore, his body is riddled with holes like a sieve. Andreas H. dies with the multi-resistant pathogens MRSA, VRE, and ESBL in his blood. Antibiotics – normally the magic weapon against pretty much anything – didn’t stand a chance against these superbugs.

In October 2012, 71-year-old Christel B. is lying in the intensive care unit of the hospital Philippusstift Essen-Borbeck. Her diagnosis: grave inflammation of the pancreas, caused by a moving gallstone. After three surgical procedures within three days, she has caught MRSA. Two weeks later, Christel B. is dead.

Rainer F. has a serious smoker’s lung, he can hardly breathe. The doctors at the hospital perform a tracheotomy. „Without complications“, states the record. But Rainer F. contracts MRSA, shortly after that with the intestinal pathogen VRE. A few days later, he suffers a septic shock, then his heart gives in. At 57.

And then there’s Matthias Sammer. At the height of his career in 1997, the professional soccer player has surgery on his left knee, once again. This time it only involves a small crease which is corrected. Everything went well, promises the professor at the Martin-Luther-Hospital in Berlin. But a few hours later, Sammer’s knee begins to hurt and swell. Back at home, a fever erupts. The doctors don’t have an explanation: it just can’t be. A second examination of Sammer’s knee leaves them speechless: they’ve never seen something like this before. And once again they claim to have no idea where it came from.

Sammer spends three weeks in a hospital in Dortmund. His life is at stake. „The doctors had serious talks with my wife. She only told me about them much later. All alternatives where equally horrible. That I could become well again was the least likely.“ The germs raged through the soccer player’s body and no antibiotic could help. Then came one last hope, one last antibiotic. And it worked. It saved Sammer’s life.

That was 1997 and it was the end of Matthias Sammer the soccer player, at 30 years of age. To date, he can’t jog, says Sammer; even a job as a coach would be hard, two hours of training daily, too problematic. Today, Sammer is the athletic director of the FC Bayern Munich.

Why is Matthias Sammer speaking out about his terrible infection? „It was that final antibiotic which saved me. I don’t want to produce headlines, that’s the last thing I want. But I’m talking to you because I want people to know about my experience. Maybe it can help others.“

supermarkt2-2.jpg

Every year 7500 to 15 000 people die from infections, says the German Ministry of Health. That’s higher than all drug and alcohol-related deaths combined – terrible news in itself. But the official numbers should be much higher.

The ZEIT, ZEITonline, the FUNKE Media Group and CORRECTIV have collected and evaluated the billing data of all German hospitals. The data shows that doctors have invoiced one of the most common superbugs MRSA, ESBL or VRE over 30 000 times in deceased patients in the past year. Whether all of these people actually died as a direct result of their infections can’t be conclusively determined. But experts are certain that the number of infections is much higher than the Ministry of Health admits.

“We have at least one million infections and more than 30 000 to 40 000 deaths, probably many more“, says Professor Walter Popp, Vice President of the German Society for Hospital Hygiene. During the past year, Popp and his colleagues publicly questioned the official numbers. Pope writes that the Ministry of Health numbers are much too low and are „based primarily on studies that where conducted almost 40 years ago.“

A majority of the superbugs aren’t just ignored in the invoicing process, they’re not even noticed. Hospitals aren’t required to report every case of MRSA. According to the Infection Protection Act, only MRSA infections that are detected in blood or spinal fluid samples by labs have to be reported to the RKI. In addition, only certain risk groups are tested for these superbugs upon entering a hospital, leaving many infections undetected.

  • Multi-resistant pathogens are bacteria that are difficult or impossible to treat with antibiotics. The more antibiotics are used, both in quantity and strength, the more these resistances develop. Doctors differentiate between carriers and infected people. Carriers have been colonized by germs on their skin or their mucosa. An infection occurs when germs enter the bloodstream. The result: inflammations and blood poisoning. Particular groups are especially vulnerable: people who often undergo hospital treatment, who require intensive care, who often use antibiotics, who have catheters, chronic wounds or burn injuries.
  • The most well-known multi-resistant pathogen is MRSA – a methicillin-resistant staphylococcus aureus. At this point, around every fifth German carries the germ on their skin. Symptoms are wound infections and respiratory or blood inflammations. Scientists differentiate between livestock germs (la-MRSA), hospital germs (ha-MRSA) and germs in the general public (ca-MRSA). Around ten epidemic strains have been found throughout Germany.
  • VRE are vancomycin-resistant enterococci. These germs are naturally found in people’s intestinal flora. When too many antibiotics are used, only resistant enterococci will survive. This can lead to wound and urinary tract infections, to abscesses or heavy infections. Patients with weak immune systems are especially vulnerable.
  • ESBL refers to extended-spectrum beta-lactamase. These are enzyme that make antibiotics ineffective by splitting them. ESBL building bacteria are resistant against a lot of antibiotics.
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There are few reliable numbers out there. Each statistic tells a different story. And in light of the increasing number of infected people, the people in charge remain stumped. „I wouldn’t know how we could possibly record all germs. There are so many people out there who are carriers“, says Susanne Glasmacher, spokesperson for the Robert Koch Institute.

A first step would be to at least record all infections centrally. But this only happens in the case of MRSA, „since we have an obligation to report“, says Glasmacher. In contrast, the even more dangerous intestinal pathogens VRE and the enzyme-building bacteria ESBL don’t have to be reported. Most of the time, they are only treatable with special last-resort antibiotics. Especially very young, old, and weak patients die due to these superbugs. And they are rapidly spreading through Germany year by year.

German hospitals have invoiced VRE over 33 000 times in the year 2013. This includes patient infestations as well as actual infections. The group of ESBL-bacteria were even invoiced over 120 000 times, 50 percent more often than four years ago. The most widespread germ in Germany is still the methicillin-resistant staphylococcus aureus (MRSA), which is registered in German hospitals over 140 000 times each year.

However, experts such as Bernd Beyrle from the Techniker Krankenkasse (TK), a statutory health insurance provider, are certain that these numbers are much too low. Beyrle is in charge of the inpatient division at the TK. „Not every infection is relevant for invoicing. Therefore, we can assume that only a third of all infections and infestations can be identified in this data.“

Without an amendment to the Infection Protection Act by the Ministry of Health, the poor data basis likely won’t change. But a legal reform doesn’t seem to be on the political agenda. The ministry writes that „several specialized instruments for the identification of multi-resistant pathogens“ exist and that the inspection of these is a „permanent task“. In other words: everything is great, no need for action for the time being.

These are unparalleled chaotic circumstances for such a controversial subject matter.

When analyzing the invoicing data of health insurance providers county by county, it quickly becomes clear that the common MRSA superbug is especially prevalent in the northwest of Germany, especially in Lower Saxony where huge fattening stables of the animal industry are located. The intestinal germ VRE and the bacteria group ESBL are spread more evenly, with hotspots in middle and eastern Germany. This roughly corresponds to the observations of the experts who have spent years researching the matter.

The invoicing data of the health insurance companies doesn’t provide any clues for the reasons behind this dispersion. But it does show the magnitude and extent of the problem.

Multi-resistant pathogens in hospitals

MRSA questionnaire

What the data doesn’t show: the suffering that victims and their relatives must face. For that reason we want to hear from you. Do have experience with hygiene problems at hospitals or in other health facilities, with infections and multi-resistant germs? Fill out our questionnaire – the more people participate, thing more we make ourselves heard, the more will be done about these problems.

The questionnaire helps us collect your experiences. When we publish the results we will cooperate with various media outlets, including local media. We hope people will share the questionnaire.

If you want to talk to other people affected by this issue, you can join our Facebook group. We use it as a forum to discuss, share information and advice and let people know with whom can get in touch. You can sign up here.

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The Deceased

Andreas H. is operated on for the first time on November 30th, 2011. His doctors suspect cancer, the head surgeon removes the left part of his pancreas. During the difficult operation, his abdominal wall is punctured. A week later, Andreas suffers a perforation of the stomach. The next procedure follows, 48-hours later another. Tracheostomy, artificial respiration. Peritonitis.

It’s Christmas and Andreas is back on the operating table every two days. Parts of his stomach are removed, including the spleen. A problem: the doctors can’t close his wounds. After the procedures, body fluids enter his abdomen.

One time, over 0.3 liters of milky fluid comes out at once. And the leaks just continue to grow. Time and time again, the doctors attempt to stitch him back up.

“Due to the initial operation, this surgical step is proving difficult“, states the record of the fourth operation. At this time, the patient still has seven more operations to go. Open the stomach, suck out the fluids, rinse, close the stomach. After a procedure spanning three hours, a chief resident notes under P.S.: „Due to the many previous operations, this procedure was conducted under extremely complicated conditions“. When the lesion will no longer close, the doctors turn to glue.

After a dozen procedures within six weeks, Andreas H.’s stomach is porous like a sieve. „Every sip that he took ran directly back out of him and into bed“, remembers his mother. But her son wants to live. His weak body wants to fight. Slowly, very slowly, things are looking up. The patient is transferred from intensive care to the general ward.

“In four weeks I can leave this place“, says Andreas H. on March 17th, 2012. It’s his 50th birthday. What his friends and family have to endure in the next three months, they will never forget.

Once, they are greeted by the smell of excrements when entering the room. Andreas H. is lying in his own tarry stool, blood running from his mouth. He is unable to make himself heard.

His mother and brother are „completely shocked“. They run to the nursing staff to ask for help. Sure, later, right now she has to distribute dinner in the station, says one nurse. After distribution, the nursing staff begins to collect the dishes. Only then do they attend to Andreas H. and clean him up.

It soon becomes clear: Andreas H. has been infected with vancomycin resistant enterococcus (VRE). The multi-resistant intestinal bacteria, which can only be combatted with two types of antibiotics, are detected in his blood.

Family members begin to intervene. It’s the mother, a former nurse with over 26 years of experience, who saves Andreas from suffocating during an episode of respiratory distress. A spell of pneumonia and an impending ulcerous lesion are only looked into at the urge of the family. The protective clothing required for those in contact with open wounds is seldom worn by the staff, disregarding hospital policy. The brother complains, asks for „the care and monitoring required for recovery“, and demands „continuous monitoring through a senior physician“.

The mother slowly begins to lose hope. „Eventually, in the face of his ongoing agony, I said my goodbyes to Andreas“, she explains.

On the morning of June 21st, 2012, when the news of his death reached her, „I was simply relieved that God had put an end to this“.

At the time of his death, Andreas is carrying the multi-resistant superbugs MRSA, VRE, and ESBL in his blood. This is the case for more and more people. And the doctors and hospitals are partly to blame.

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The Doctors

There are two things that make it possible for these superbugs to spread in the first place, to settle down in our midst, to kill more and more people. Number one: too many antibiotics. Number two: poor hygiene. Let’s start with the medication. The mechanism is simple. Inherently, every living being also carries some resistant pathogens during an infection. They develop accidentally through natural mutation. When antibiotics are prescribed, these resistant germs are suddenly at an advantage compared to their non-mutated relatives. The more often antibiotics are prescribed, the more carelessly they’re swallowed, the higher the chance that these resistant germs will multiply and spread – making the antibiotics ineffective.

That’s why it’s so important that antibiotics are only handed out extremely responsibly. Doctors should be required to create an antibiogram before prescribing anything in order to test what a patient reacts to. It should be better monitored and recorded which patient receives which antibiotic for which problem. There should be an antibiotic passport, similar to vaccination records, but for antibiotics. And it should be centrally recorded how many antibiotics are prescribed and for what. To improve usage, to curb it. All these measures currently do not exist.

Even Georg Baum, managing director of the German Hospital Federation, demands restrictive guidelines for antibiotic therapies, already common in neighboring Holland, as well as a prescription register.

All of this should prevent these superbugs from developing. To keep them from spreading, doctors, nurses, and medical aides have to strictly abide by hygiene guidelines. They have to properly disinfect their hands, for example. This doesn’t happen nearly enough. Roughly two-thirds of all patients contract infections in hospitals. Studies show that doctors and nurses disinfect their hands only half as often as necessary. This is a huge problem because hospital germs spread mostly thanks to the staff itself.

In a hospital in northern France, scientists from Lyon equipped around 450 patients and 350 nurses with sensors which recorded every contact with another person. In the course of nine months, the scientists where able to compile a contact profile of the entire hospital. At the same time, they took weekly samples from the nasal mucous membrane and let a lab test them for bacteria.

“There’s no such thing as an isolated room in a hospital. All bacteria can spread to all rooms and stations“, says the leading scientist Eric Fleury. After only a few days or weeks in the hospital, many patients had bacteria in their blood or mucous membranes that patients from other stations had dragged in. Thirty percent of patients were contaminated with multi-resistant pathogens by the end of their stay. „Almost every patient comes into contact with germs from other patients through nurses, medical aides, and doctors.“ The bacteria are spread through the entire building by contaminated lab coats, dirty hands, and serving trays. Nurses meet in the cafeteria and exchange the bacteria on their skin through shared water bottles and hello kisses. During the night, nurses and doctors often have to tend to several floors at once. „Almost everyone has contact with everyone“, says Fleury. A nurse has contact with around 100 people a day.

Of all things, the hospital staff thus becomes a safety hazard for its own patients. Some epidemiologists such as the Parisian researcher Didier Guillemot even go as far as declaring doctors and nurses „superspreaders“ – as „the largest possible circulator“ of the deadly superbugs. They can only protect their patients by better sterilizing their hands and instruments, such as blood pressure gauges or bandage trays. Guillemot also advocates only letting essential personnel have access to a patient – not entire teams, just the attending physician and as few nurses as possible should make rounds. Single rooms can also protect against high bacteria traffic.

In order to improve disinfection practices, some hospitals in Holland have video cameras above their dispenser. Just one example that coerces doctors into actually using them. In Germany, hospitals only voluntarily take part in studies on the rate of disinfection. An external control mechanism, for example through unannounced random sampling, does not exist.

It’s important for doctors to sterilize their hands before coming into immediate contact with a patient. Not in the hallway, not after a procedure, but directly next the bed of the patient. Patients can demand this on their own.

  • Don’t panic: Multi-resistant pathogens aren’t an invisible danger, but a daily companion. The problem must be treated visually. It’s not a crime to talk about it.
  • Before you stay: Before going into the hospital for treatment you can inform yourself about hygiene. Try the German Society for Hospital Hygiene, the Clean Hands Campaign or – if you want expert knowledge – the RKI’s KRINKO guidelines.
  • In the hospital: When you go into the hospital, inform yourself about hygiene measures. Ask for flyers and information about proper hand disinfection. Let your visitors know.
  • Make yourself known: Ask for the nurses or medical aides who are in charge of hygiene in your unit. Make yourself known.
  • Self-desinfection: Wash your hands as often as possible. Disinfect your hands. Pay attention to the disinfectant’s minimum contact time. Count slowly to 30. That ensures for the disinfectant’s maximum effect.
  • General desinfection: Make sure there’s disinfectant in your room. That increases that possibility that disinfectants will be used.
  • Check doctors and medical aids: Pay attention to medical aides and doctors. They should always disinfect their hands immediately before touching you. This is especially important before and after interventions under the skin.
  • Cleaning: Make sure that cleaners don’t use utensils that were previously used in isolated rooms.
  • Clean bed: Insist that you are given fresh sheets several times a week and that the surroundings are kept clean. Everything that you can reach from your bed should be cleaned every day.
  • Fresh air: Make sure to air out. That can help against germs. Even the World Health Organization recommends natural ventilation.
  • The proper antibiotics: Only take antibiotics when absolutely necessary. Antibiotics are often unnecessarily prescribed. If you need to take antibiotics, never end the treatment early – always take your medication as directed. Taking antibiotics incorrectly can foster the development of multi-resistant germs.
  • Monitor your own isolation: Do you carry MRE or are you infected? Ask for flyers about dealing with the germ. Observe the correct measures of disinfection and isolation. Let your visitors know about the problem.

Another possible way to contain the superbugs: screening every single patient for multi-resistant pathogens upon entering the hospital, as is done in Holland. Just one of the reasons why our neighbors have hardly any more MRSA patients.

Georg Baum, managing director of the German Hospital Federation, says that the German clinics would like to screen every new patient for pathogens. But in order to do this, the Robert Koch Institute would have to expand the circle of patients it screens. And the health care providers would have to pay. Baum says such measures could cost up to a billion Euros.

“In some cases we still have rooms with three or four beds and one toilet“, says the hospital representative. His clinics don’t even receive half of the six billion Euros which are „generally recognized“ to be necessary. Baum says that an investment program for prophylaxis would be helpful. He criticizes that clinics, doctors and the agriculture industry don’t work together against the problem. Instead, they try to blame the superbug problem on each other.

It’s true that not only hospitals are to blame for the prevalence of deadly bacteria. We must also look to veterinarians and the intensive use of antibiotics in industrial livestock farming. Gerd-Ludwig Meyer sees this more and more often in Nienburg, a town in southern Lower Saxony. Year after year he is losing hope.

The animals

“You see how a person suffers. And you can’t do anything, not anything.“ Gerd-Ludwig Meyer runs a dialyses practice with several other doctors. He tells us about an old lady whose urinary tract infection didn’t improve through treatment, but kept getting worse and worse. Meyer prescribed the first antibiotic – no reaction. He prescribed the second antibiotic, the third, the fourth, the fifth: Gentamicin. Tetracyclin. Ciprofloxacin. Amoxicillin. Over twenty in all. Nothing helped. After terrible days of agony the old lady had to die. Her death is one among many. Four more patients died in Meyer’s practice only in the past months. With all four of them antibiotics showed no effect. „It’s a shitty feeling when you’re helpless as a doctor“, says Meyer. He likes to express himself directly, is a man who makes things clear. First he was a farmer. As the oldest son he took over the family farm. Then that world became too small for him. He finished school and studied medicine.

Meyer’s hair is shaggy, his life is reflected in his face. He explains how he has recently noticed that more and more patients need to be isolated due to infection with bacteria that don’t react to antibiotics. And that farmers are not only pig or turkey breeders, but high-risk patients. „When a farmer comes into a clinic, they basically need to go straight into quarantine.’

By Meyer’s perception, this began around four or five years ago. He was quick to realize the invisible connection between his two jobs: farming and being a doctor. The connections are called Cephalosporine, Fluorchinolone, Colistin or Carbapeneme. These are the names of reserve antibiotics, the last medicine that can be used against multi-resistant bacteria in our bodies. The last medicine that can kill these superbugs. But doctors and farmers use the same substances: on sick humans and on livestock.

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What Meyer found in Nienburg is happening more and more frequently throughout Germany. Doctors at the University Hospital Münster have found that in regions marked by livestock farming, almost 80 percent of farmers are affected by superbug colonization. They carry the germs on their skin; the germs can enter the bloodstream through a wound or during surgery.

Doctors note that more and more people are becoming infected with a strain of MRSA used in pig farming called CC398. According to a study that is yet to be published, over 30 percent of patients infected by germs have a pig germ in their body. This is a significant increase from previous studies. The problem: many of these patients have had no direct contact with animals. Accordingly, the germ is already spreading in the population. And people are starting to die from it.

At a conference in October the doctors from Münster described a patient who lived on a pig farm. She died three weeks after a simple injection to the shoulder. The resistant germ CC398 had infected the heart. Another member of a family of pig farmers had a septic shock after a lung transplant and died due to organ failure. Doctors suspect that a relative brought the pig germ into the hospital and infected the patient.

In Denmark at least five people have died in recent years due to germs from pig farms. Authorities confirmed four cases in court, a further case was discovered this fall. The victims: a 51 year old patient with blood poisoning, a 63 year old dialyses patient, an 86 year old diabetes patient and a 74 year old resident of a nursing home who contracted pneumonia.

None of the people who died in Denmark had a direct connection to pigs.

Experts are observing the same situation in Germany. „We have also found the germs in people who were not involved in livestock farming. The resistant superbug must already be spreading among the population“, says Karsten Becker, senior physician at the University Hospital Münster, in conversation with the Swiss newspaper Sonntagsanzeiger.

In Germany more pig farms are infected with the resistant germ than in any other European country. According to the most recent studies, up to 70 percent of farms are contaminated in some regions. Compared to other European countries, Germany is the fifth largest user of antibiotics in meat production. By the kilo, German farmers pump 60 times more antibiotics into animals than the Norwegians. A breeding ground for resistant germs.

This massive dispensing of medication is provoked by a structural deficiency. In veterinary medicine doctors are not only doctors, but also pharmacists. They profit from prescribing antibiotics to animals in large amounts. Farmers call the larger practices highway vets – they drive from farm to farm selling their products instead of examining and healing animals.

While 26 percent of ecologically bred pigs are hosts to MRSA, scientists at the TH Hannover university found that 92 percent of conventionally bred pigs had the germ in their noses. And this development continues. In the past 25 years, the number of farms in Germany has decreased from almost 700 000 to under 300 000. The number of pig fattening stables, which are especially affected by these germs, has even decreased by 80 percent according a recent report from the Ministry of Agriculture.

All this fosters the development of resistant animal germs. And they jump back onto people.

Studies show that germs are even found more and more often in frozen supermarket meat. Some of the scientists who deal with these developments only handle their chicken filets in the kitchen with rubber gloves to prevent infection.

“In some regions around ten percent of patients are bringing animal germs into hospitals“, says Michael Kresken. For Kresken this development is alarming. He must know: the professor has studied resistant germs for over half his life.

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The Future

When Michael Kresken began his life’s work over three decades ago with his former boss, his colleagues laughed at him. Studying the resistance of bacteria against antibiotics? What good could that do? The numbers where insignificant at the time and most people didn’t expect them to increase. Most doctors followed the slogan: the more the better. Antibiotics were the silver bullet. When Michael Kresken now talks about the time when antibiotics were still used for prophylaxis, he speaks as a highly respected expert on multi-resistant pathogens. Based at the Bonn-Rhein-Sieg University in Rheinbach, the professor writes up everything to do with resistances every two years in a report entitled „Germap“. The prevalence of dangerous pathogens has steadily increased in recent years. Kresken says that something must be done.

“The effectiveness of antibiotics wears down when they are used. The more antibiotics we use, the more we select resistant strains and foster their circulation“, says Kresken. „These medicines have significantly increased our life expectancy. They’re a resource that we must protect.“

Experts are especially worried about the rarest resource, the reserve-antibiotics. „General practitioners and internists use too many broad spectrum antibiotics. That’s especially noticeable in comparison to other countries“, says Kresken. Broad spectrum antibiotics remove everything, making it easy for doctors – but they also help resistant pathogens. If the toughest antibiotics are used to treat small infections, there is little left to fight multi-resistant superbugs that don’t react to other types of antibiotics.

Wolfgang Witte, 69, was the director of the national staphylococci reference center at the Robert-Koch-Institute for many years and is a leading expert on MRSA in Germany. He is a microbiologist, a scientist of the old school; a slender and careful man. A visit to his office at the Robert Koch Institute in Wernigerode turns into a microbiological history lesson as he talks about great teachers and scientists. He cites one of them: „Bacteria always have the last word.“

He says that antibiotic-resistant germs are a significant threat that we must face with scientific reason. He sees little value in human doctors and veterinarians blaming each other. Witte wants to maintain an overview of the situation and see where the real dangers are. We have to monitor how the pathogens evolve. How they jump between humans and animals. The dangerous animal germs originally came from humans.

If this continues the pathogens will evolve in the animals and develop new properties: they could spread quicker and increase infections. They would come back to humans even more dangerous. According to Witte, this could lead to a „microbiological apocalypse“ if pathogens emerge that no medicine can treat. „If that happens, God help us.“

If antibiotics are no longer effective we return to the Middle Ages where a tooth or bladder infection can kill a person. The suffering we would face without antibiotics is inconceivable, for instance in the case of a sepsis. First comes the fever, followed by the shivers. The blood vessels expand, the heartbeat increases, the skin can turn yellow or blue, blood ceases to clot, and finally blood runs out of all orifices. Necroses form at the extremities, the organs start to fail.

Such times might be closer than we think. In January 2014 the German Federal Risk Assessment Office reported for the first time that a new form of E. coli bacteria had been found in three pig fattening stables and in one chicken farm that are even resistant to reserve antibiotics of the carbapenem group. Carbapanems were seen as the last hope. The fact that new pathogens are resistant to carbapenems is bad news.

And who is at fault?

Everyone.

The meat industry points to the hospitals, berates the insurance companies, the government and the doctors until the problem shows up again. Hospitals neglect hygiene, insurance companies don’t pay, laws are not harsh enough, doctors are ill informed and factory farmers pump antibiotics into their animals by the ton. Those are the allegations. But little is changing.

Pathogens develop in cozy and dark conditions. It doesn’t look like pathogens will get uncomfortable in Germany anytime soon.

Many of the dangerous germs are not even recorded at a national level. There is no central register for multi-resistant superbugs. While germs spread across international borders, the fight against them is largely organized at a state level in Germany. Hospitals only participate voluntarily in studies that the Federal Ministry of Health cites.

And it’s difficult for anyone who want to shed a light on this situation. Nobody is allowed to know how many infections there are in which hospitals. The hospitals are fighting tooth and nail against stricter inspections. For the germs, the situation remains the same: cozy and dark.

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What can be done?

A view across the border.

Holland: every patient is screened for multi-resistant germs before they are admitted to a hospital, if necessary they are isolated and given special treatment. As such, MRSA is barely an issue in Holland.

Denmark: A law is in planning that will prohibit children’s excursions to pig farms, even though MRSA is much less prevalent in Denmark than in Germany.

USA: In September US President Barack Obama signed an order to undertake a number of measures. This includes an improved national surveillance system and a 20 million dollar prize for the development of a rapid test for dangerous pathogens.

France: Every year all hospitals undergo a deep 14-day investigation conducted by a team of ten people. As a result, lengthy reports are published on the internet that provide grades for individual units ranging from A to F. Bad results can shut down a hospital.

Quality reports for German hospitals are practically worthless. The hospitals fill these out themselves and most reports claim flawless standards.

The hospital invoices that we analyzed for this investigation could be used to improve the quality of the health system. „The goal must be to publicize this data for every hospital“, says Bernd Beyrle, head of in-patient care at the Techniker Krankenhause insurance company.

“Analyzing this data is a first step to gaining an understanding of the magnitude of this situation“, says Beyrle. The Institute for Health Quality which the federal government is currently establishing plans to pick up on this.

According to Beyrle, Germany needs „proper hospital inspections like they have in France. Whoever remains below standard should receive a warning or even be removed from the market.“

People can die in hospitals, they say. That’s the way it is. But that’s what they used to say to women giving birth. Until Ignaz Philipp Semmelweis came up with the idea that doctors should wash their hands before moving to the next patient.

Hygiene is key in the fight against infectious diseases. Along with reducing the use of antibiotics. If everyone would participate in the fight against deadly superbugs, patients like Andreas H., Christel B. and Rainer F. might still be alive today.

CORRECTIV proposes:

Infection surveillance and control should be centrally organized by the federal government at an infection agency. Pathogens don’t respect state borders. This central agency should not only monitor MRSA infections, but also look at VRE, ESBL and other dangerous pathogens.

Following the French example, hospitals should undergo independent inspections. Every unit should be evaluated individually. This could be done using a grade system from 1 to 6 as in schools. The results should be published on the internet. If necessary, hospitals with bad grades should receive warnings or units should be shut down.

The results of these inspections, including the relevant data and documents, should be made available online as quickly as possible and should be transparent to the public. The general public should know if a hospital has serious problems with infections and receives a hygiene grade of 5 or 6.


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In Charge: David Schraven

Editorial Staff: Annika Joeres, Benedict Wermter and Daniel Drepper, in cooperation with ZEIT, ZEITonline and FUNKE media group

Database Development: Stefan Wehrmeyer

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Header Animation: Ivo Mayr

Art Direction: Thorsten Franke / mediaPolis

Realisation: Mr. Jet Lag

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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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CORRECTIV ist das erste gemeinnützige Recherchezentrum im deutschsprachigen Raum. Unser Ziel ist eine aufgeklärte Gesellschaft. Denn nur gut informierte Bürgerinnen und Bürger können auf demokratischem Weg Probleme lösen und Verbesserungen herbeiführen. Diese Recherche wurde mit der Unterstützung unserer Fördermitglieder realisiert. Jetzt spenden!

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. 

© Ivo Mayr

Super bugs

Withdrawal symptoms

The American meat industry uses antibiotics as fattening agents indiscriminately: farmers can even mix the antibiotics into feed themselves. A new piece of legislation should help reign in the use of antibiotics – ten years after the EU first took action.

von Christine Coester

Since the 1950s, antibiotics have been used in the US as fattening agents. It is still not completely understood how antibiotics cause weight gain in farm animals, but one theory is that antibiotics change the intestinal flora of the animals, which alters the feed’s efficacy.

The use of antibiotics as fattening agents – it is extremely controversial and extremely problematic. Continuous use of antibiotics causes antibiotic resistance to build more quickly in animals and in humans. However, in the US, there is little regulatory control. Even today, farmers can mix antibiotics into feed without any oversight.

“Farmers never needed expertise or advice to use these antibiotics“, says epidemiologist Linda Tollefson. She dedicated her career to fighting the misuse of antibiotics. She previously worked for the US Food and Drug Administration (FDA), where she had the opportunity to work with representatives of the European Commission. She says “there is a whole lot the United States can learn“ from the European example.

Tollefson remembers how in 1996 the FDA set out to establish a monitoring system before the incredibly potent antibiotic fluoroquinolone was approved for use in broiler chickens. The organization feared that resistance would spread rapidly if the antibiotic was distributed to tens of thousands of chickens through their drinking water, even if only a handful of animals were sick.

“And guess what happened?“ asks Tollefson, before answering her own question. One hundred percent of the chickens showed resistant bacteria.

A new law should finally regulate the use of antibiotics in intensive animal agriculture. Called Guidance 213, the measure was adopted in 2013 and will be in full force by the beginning of 2017. The law prohibits the use of „medically important“ antibiotics as growth promoters and in some cases even medicinally.

In other words, antibiotics can be used but only with veterinary approval. 

Experts like Carmen Cordova, a microbiologist at the non-profit Natural Resources Defense Council, worry that „Guidance 213“ is not enough to reduce the consumption of antibiotics as fattening agents. Her fear is that the use of antibiotics will simply be declared differently: Instead of labels reading „growth promotion“, labels will say „disease prevention.“

Cordova is also concerned that veterinarians are not required to collect data on the use of antibiotics. The FDA says they will soon implement a way to collect this data, but did not mention a specific date. This information is extremely important for establishing a clearer link between antibiotic use and the development of antibiotic resistance.

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Dimtri Drekonja, an infectiologist at the University of Minnesota, says that lack of data is largely responsible for the continued high consumption of antibiotics. Doctors need evidence that antibiotic consumption leads to resistance, but there is often no reliable consumption data.


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


Although “Guidance 213” is a law full of loopholes, the pharmaceutical industry sees plenty to protest. 

“Their representatives said there is no problem at all,” says Linda Tollefson – despite the fact that issue of antibiotic resistance is high on the global health agenda.

In the EU, according to 2009 estimates, approximately 1.5 billion euros were spent annually to combat infections caused by resistant bacteria. In the US, the figure is likely to be ten to 20 times as high — most likely because the US health care system’s costs are higher.

Worldwide the majority of antibiotics are used in animals. In the United States it is estimated that 15,000 tons of antibiotics per year are used in beef cattle, compared to under 4,000 tons in humans. According to a recent report, around half of the global consumption of antibiotics is unnecessary or improperly administered.

In the European Union the use of antibiotics for growth promotion in livestock has been prohibited since 2006. Antibiotic use is monitored and reported allowing EU countries to compare their consumption. With „Guidance 213“, the US is finally catching up.

Why so late? Because it is incredibly difficult to transfer the European model to US agriculture. „Europe does not have intensive animal agriculture like we do“, says Tollefson. In the US, factory farming is widespread and more dense. In 2014, the US produced about 11 billion kilos of beef, while the EU produced about 7 billion kilos.

While legislators are struggling to implement reforms in the face of powerful industry lobbying, change is coming in other ways: Fast food chains, like McDonald’s and Subway, are reacting to consumer concern by announcing they will minimize the amount of antibiotics used in their products.

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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.