The drugs don't work - so what will?

Antibiotics have been one of the greatest success stories in medicine.

But there is growing concern that the drugs' usefulness is coming to an end.

It has been reported that antibiotic resistance has reached "unprecedented levels". Last year in Europe more than 25,000 people died of bacterial infections that were resistant to antibiotics.

As the director general of the World Health Organisation, Dr Margaret Chan, put it: "The world is heading towards a post-antibiotic era in which many common infections will no longer have a cure and, once again, kill unabated."

During the last decade, MRSA became one of the most feared words in hospitals.

The latest concern is NDM-1. It is resistant to one of the more powerful groups of drugs, carbapenem antibiotics, and has been detected in UK patients.

Why not produce more antibiotics?

One solution to antibiotic resistance is to develop new drugs.

The eminent microbiologist Professor Hugh Pennington told the BBC: "There are no new antibiotics coming along and we've run out of easy targets.

"Pessimism is the order of the day, we're holding the line, but we're not gaining."

However, Professor Chris Thomas, molecular geneticist at the University of Birmingham, says that while a degree of complacency did set in: "There is a pipeline of new antibiotics from the evidence I've seen. There are new ways of developing drugs and new drugs have come through."

Drug manufacture almost inevitably depends on the pharmaceutical industry and unfortunately there are problems with the present business model.

To take a drug from discovery to market is estimated to cost £700m.

Colin McKay, from the European Federation of the Pharmaceutical Industries and Associations, said: "It is very difficult to make economically viable models for antibiotics."

"With heart medication or anti-depressants a lot of people take them for a long time so you can make money back. An antibiotic that works is unlikely to be used for more than a couple of weeks."

He added: "A new way to promote research is needed and there is an ongoing debate into how to do it."

Virus vs Bacteria

Viruses have long been touted as a solution to antibiotic resistance.

Bacteriophage are a group of viruses which infect and kill bacteria. They were discovered in 1915 in the former Soviet republic of Georgia and have remained part of medical practice there.

However, research on them was largely abandoned in the West due to the success of antibiotics.

Clinical trials on phage are taking place, but the subject area has attracted some critics who say the field has not delivered.

Dr Martha Clokie, a microbiologist at the University of Leicester working on phage for Clostridium difficile, said: "That criticism is fair, there has been a lot of talk and hyperbole about phage, but recently there is increasing evidence that they do work."

"It's an exciting time to be in this area, I hope the criticism won't be accurate soon. I'm very optimistic that phage have a future."

Vaccines

Vaccination has also attracted a lot of publicity.

Just like for seasonal flu, a vaccine would be developed for superbugs.

This could be taken before going into hospital for surgery.

In 2008, the then chief medical officer for England, Sir Liam Donaldson, said vaccines for MRSA and C. difficile should be ready within a decade.

Surveillance and hygiene

Monitoring antibiotic resistance in the UK is the responsibility of the Health Protection Agency.

Its executive director of microbiology services, Christine McCartney, said: "The emergence of antibiotic resistance, especially against carbapenems, is a major public health concern.

"Antibiotic resistance makes infections much harder to treat and its spread underscores the need for good infection control in hospitals."

Prof Pennington said: "We need to stop patients passing bugs on. It needs very strict rules with patients kept in isolation and barrier nursing. We need to sharpen infection control practices."

Prof Thomas argues that "hygiene appears to be responsible for the reduction in MRSA cases" and that "we need to get back to careful nursing."

He concluded: "We need to pursue every possible link, having one strategy is like having all your eggs in one basket."