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Microbial resistance to antibiotics (or “Antimicrobial Resistance”) is one of the most catastrophic trends of our generation. To date, governments and international NGOs have failed to take impactful action on this, and whilst they may do eventually, the stage is set for small, fast-moving and highly ambitious young companies to embark on meaningful, financially sustainable and scalable incursions.
This post is structured in the following way:
I. The situation (a description of the problem)
II. The opportunities (a breakdown of 4 different areas that inventors, scientists and entrepreneurs might be able to make a difference, highlighting opportunities for specific products/technologies and research)

I. AMR — the situation

The main route for antibiotics to enter the environment is through waste water treatment works (WWTWs) —taken from Dr Voulvoulis’ presentation

Antimicrobial resistance (“AMR”) is a natural process that is accelerated by human actions. Overuse and improper disposal of antibiotics and other antimicrobial substances are correlated to the rise of strains of microbes which are resistant to multiple different drugs: so-called “superbugs”.

The World Health Organisation points to drug-resistant bacteria affecting conditions such as common as gonorrhoea, E. Coli, intestinal infections, TB (3.5% of new cases are drug resistant), Malaria and HIV (drug resistance amongst those pre-treatment are estimated at 5–22%).

Drug resistant strains of these diseases represent an exceptionally grave threat to human life. To quote the Government’s Review on AMR:

“ By 2050, 10 million lives a year and a cumulative 100 trillion USD of economic output are at risk due to the rise of drug resistant infection” — Jim O’Neill, AMR Final Paper

The economist in charge of the report, Jim O’Neill, went on to highlight that tackling this issue would cost the world $40bn over the next 10 years (or “only” 0.05% of global healthcare spend).

A problem startups can affect

To reiterate, the perception that this challenge is the sole remit of governments and major pharmaceuticals is flawed. Whilst the challenges designing a new antibiotic drug are varied and require fundamental research, the growth of AMR is not solely due to a limited stock of drugs. To illustrate, here are some ways in which individuals and organisations are developing “bottom up” solutions:

  • Read about Imperial College start-up Post/Biotics, who are empowering school children to find materials with antibiotic properties
  • Companies such as Proteus BiomedicalWestRock and many others are tackling the problem of compliance (people failing to take their medication as instructed)
  • Approaches such as Neumitra, which whilst not explicitly about AMR, delineates a line of enquiry at the aggregate population level, facilitating the response of government / pharma
  • Investigate some of the ideas in The Longitude prizewhich considers lateral flow tests, micro labs, and other rapid diagnostics
  • The games “Superbugs” and “Pandemic” are examples of more accessible technologies applied to creating behaviour change
  • Take heart from the trend of investment in companies with a theory, rather than reliance on research groups which set out to answer specific question through pure empirical investigation
  • Starting at a systems level, and drilling downwards: this approach, advocated by Dr Voulvoulis* affords multiple interventions at different points, many of which are accessible to small teams reviewing existing literature. It is more of these entry points that I start to explore below

II. Opportunities for upstart interventions

Increasing antimicrobial resistance can be characterised as the result of a system of complex processes and interactions. Solutions can target:

  1. Microbiological processes leading to increasing AMR
  2. Drugs themselves and the way they are packaged and disposed of
  3. Behaviour and interaction of individuals
  4. Environmental / urban systems and infrastructure

In each of the following sections, I try to highlight possible areas that appear to afford opportunity for new products and services, within the reach of new companies.

1. Microbiological processes leading to increasing AMR

The process of transmission of drug-resistant genes between microbes is one realm which new technologies might target.

“Antibiotic resistance refers specifically to the resistance to antibiotics that occurs in common bacteria that cause infections.

Antimicrobial resistance is a broader term, encompassing resistance to drugs to treat infections caused by other microbes as well, such as parasites (e.g. malaria), viruses (e.g. HIV) and fungi (e.g. Candida)” — WHO Factsheet

In fact, antimicrobial resistance can also refer to drug resistance of otherwise benign microbes too. The spread of resistance could therefore be slowed by intervening at the antimicrobial level:

  • Opportunity: Target plasmids. Targeting the transfer of genetic information between microbes. Can we filter these, slow their transfer etc

2. Drugs themselves and the way they are packaged and disposed of

Leftover antibiotics often find their way into landfill. This sets up landfill sites to be complex systems of drugs and resistance, offering a major challenge. This challenge deepens with the eventual need to re-develop landfill sites. We might consider:

  • Opportunity: Identify drugs before landfill (and remove them)
  • Opportunity: Redesign antibiotic packaging, to increase the affordances and opportunities to remove antibiotics from domestic waste. Guidelines and advances in packaging briefly rounded up here.
  • Opportunity: Incentivise individuals to return unused antibiotics e.g. to pharmacies (and can this be connected to ensuring patients have completed a full dose?)

In addition, consider: what does “planned obsolescence” look for with respect to antibiotics? Perhaps the breakdown of antibiotics can be triggered at a key stages:

  • Opportunity: Trigger breakdown at specific stages post-metabolization
  • Opportunity: Trigger breakdown at point of contact with specific cheap, abundant chemicals introduced at wastewater stage, specific temperature or light source
  • Opportunity: Trigger breakdown after lapse of time
  • Opportunity: All of the above could be located in the packaging rather than the drug

3. Behaviour and interaction of individuals

Individual behaviours, interactions and activities hold enormous consequence for increasing AMR. The greater the spread of infections, the higher the likelihood of resistance emerging and spreading:

  • Opportunity: Effective hand-washing. Technologies could focus on effective training, monitoring and compliance (reminding/prompting), more effective or comprehensive methods for cleaning the entire hands/arm
  • Opportunity: Better diagnosis of bacterial and viral infection. There is space for faster, cheaper and earlier identification of infection relating to many common infections, including influenza, rotavirus, STDs
  • Opportunity: Preventing contagion / infection. Are there cheap products or technologies that can be applied where risk of infection, cross-contamination or contagion are high, or costs of infection are particularly acute?
  • Opportunity: Taking a “full course”. More accurate dosing, behavioural/diagnostic prompts on when to cease taking medication (which may be beyond or before prescribed dose)
  • Opportunity: Divert antibiotic effluent during crises. During crises, peaking use of specific antibiotics overwhelm biofilms and other methods applied in treatment

4. Environmental / urban systems and infrastructure

For many antibiotics, an incredibly high proportion of the drug ingested passes through the body and remains active. For instance, this can reach 60% in Amoxicillin, one of the most ubiquitous antibiotics in circulation. This drug then finds its way back into drinking water and food.

Taking these drugs out of our water system would cost the UK alone billions. Whilst the regulatory landscape has not changed to mandate the removal of these drugs yet, the emerging crisis promises to stimulate regulatory change in the near future. Anticipatory technologies suggest the following solution spaces:

  • Opportunity: Cheap mass waste water filtration system, capable of removing drugs from wastewater, at the level of the wastewater treatment facility. Current solutions use enzymes, which at the mass scale proves expensive
  • Opportunity: Cheap mass wastewater antimicrobial solution, capable of killing the majority of microbes left after other treatments. wastewater treatment facilities tend to be “reservoirs” of antimicrobial resistance. Current solutions include application of UV light in areas with specific regulation
  • Opportunity: Filtration of hospital effluent, where concentrations of antibiotics predominate (this could be slightly more expensive than at the mass-water scale)
  • Opportunitydata and device focused monitoring and reporting to inform strategic response of government and pharmaceuticals

It is worth bookending this analysis by highlighting that, despite what appears to be a straightforward relationship between antibiotics in the environment and antimicrobial resistance, Dr Voulvoulis stopped short of positing a causal link, instead urging an emphasis on acceptance of the complexity of the factors involved and a need for more effective regulation.

Get involved

This post is a naive, under-informed scattershot at highlighting a minor, incomplete subset of opportunities for technologies, products and, ultimately, new companies, to counter this trend. The aim is provocative: where what I’ve suggested is impossible, correct me, where I’ve missed gaping holes, fill me in. If you are in anyway inspired by the content above, please contribute to a discussion around the article. Comment, email me, tweet at me.

Or better yet, join DSV and we’ll fund you to build a solution.

  • The content of this post was inspired by a brilliant seminar on “antibiotics in the environment”, run by Dr Nick Voulvoulis. The seminar set out to explore the relationship between high volumes of antibiotics in the environment and antibiotic-resistant bacteria. It was part of a series of talks run by the EPSRC, called “EMBRACE”. Slides below are available here.
  • Thanks too to Mark HammondJack Owen@ImperialEmbrace and the @EPSRC, Francis Lister, Erofili Kardoulaki, Dr Vouvoulis, Dr Lindsay Evans and the Imperial Department of Chemistry (@impchemistry) for their support on earlier drafts of this article.