Sir, almost 20 years ago (1998) the World Health Assembly agreed a resolution on antimicrobial resistance, and subsequently there has been increasing awareness of the need to use antimicrobials more appropriately, with the World Health Organisation (WHO) publishing a global action plan on antimicrobial resistance in 2015.1 The WHO plan sets out:
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To improve awareness and understanding of antimicrobial resistance
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To strengthen knowledge through surveillance and research
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To reduce the incidence of infection
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To optimise the use of antimicrobial agents
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To develop the economic case for sustainable investment that takes account of the needs of all countries, and increase investment in new medicines, diagnostic tools, vaccines and other interventions.
Recent weeks have seen reports of microbial resistance to all known antimicrobial agents.2
In the UK itself, antimicrobial stewardship (a systemwide approach to promoting and monitoring the judicious use of antimicrobials with the aim of preserving their future effectiveness) is rightly currently under scrutiny by NICE (National Institute for Health and Clinical Excellence).
Given the above, you will understand our serious concern at the implications of the letter carried in the BDJ on 11 December 2015 (Improved gum health – p 514).3
Gingival bleeding clearly responds to mechanical or chemical means to minimise bacterial plaque accumulation. It is absolutely crucial that antimicrobials are only used appropriately and for serious infections: failure to follow such advice will inevitably put the public in serious danger, as emphasised by the Chief Medical Officer.4
Furthermore, dealing with the antimicrobial mentioned, clarithromycin is a macrolide metabolised by cytochrome CYP3A4 and which can at least precipitate or aggravate ventricular arrhythmias and the cardiac long QT syndrome as well as interacting with other QT-prolonging medications and with several other drugs (eg anti-retrovirals, calcium channel blockers, carbamazepine, cisapride, colchicine, ergotamine or dihydroergotamine, lovastatin or simvastatin, or pimozide) and it should not be used in people with renal or hepatic disease.5,6
Authors' note: Bacteria resistant to colistin, the antibiotic of last resort, have been discovered in China, followed by findings of similar resistance in parts of Africa and Europe, and now in the UK. Public Health England (PHE) found resistant bacteria in samples of human infections and on three farms. The strains carry a gene mcr-1, which can spread rapidly between species, potentially leading to a super-resistant epidemic. Professor Alan Johnson, from PHE said: 'Our assessment is that the public health risk posed by this gene is currently considered very low, but is subject to ongoing review as more information becomes available (http://www.independent.co.uk/news/science/bacteria-resistant-to-last-resort-antibiotic-discovered-in-uk-a6782331.html)'.
References
World Health Organization. Global action plan on antimicrobial resistance. Geneva: World Health Organisation, 2015. Available at: http://apps.who.int/iris/bitstream/10665/193736/1/9789241509763_eng.pdf?ua=1 (accessed December 2015).
Liu Y Y, Wang Y, Walsh T R et al. Emergence of plasmid-mediated colistin resistance mechanism MCR-1 in animals and human beings in China: a microbiological and molecular biological study. Lancet Infect Dis Published online: 18 November 2015.
Stepney R, Zalinski A, Patel K . Case report: Improved gum health. Br Dent J 2015; 219: 514.
Davies S C . The drugs don't work. A global threat. Penguin Book, 2013.
Wikipedia. Clarithromycin. https://en.wikipedia.org/wiki/Clarithromycin
Scully C . Scully's medical problems in dentistry, 7th ed. Edinburgh and London: Elsevier Churchill Livingstone, 2014.
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Scully, C., Robinson, A. & Wiesenfeld, D. Antimicrobial resistance: Dangerous abuse. Br Dent J 220, 154–155 (2016). https://doi.org/10.1038/sj.bdj.2016.115
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DOI: https://doi.org/10.1038/sj.bdj.2016.115