The other day I was reading an article about super-immune bacterial infections and how more often people are showing up at hospitals with infections that won’t respond to any antibiotic, not even the super-potent stuff like vancomycin. The article went on to hypothesize about the post-antibiotic age that seems to be around the corner. Surgery will be impossible, organ transplants will absolutely be impossible, pregnancy will be quite dangerous, all sorts of horrors. A huge step back for our quality of life and life expectancy.
Anything I read that sounds like it’s meant to be scary I take with a huge grain of salt. But I have been hearing about more and more antibacterial resistant strains for a while now, and it’s a sad fact that antibiotics are overused, overprescribed, and improperly used (for viral infections, whole Rx not taken completely etc).
I tell myself even after all these years Penicillin still works, and bacteria have had like 3/4 a century to adapt immunity to it. Some have, but it’s still a go-to drug. I’m surprised it still works at all. I know they are always developing new drugs but new antibiotics are few and far between these days, and are usually just tweaks on an old one (new patent = no generic = more money).
So, how realistic is it that we’re looking at a “post-antibiotic age” sometime in the near future?
Not gonna happen. The wold is full of antibiotics. Every organism on the planet is loaded with antibiotics. We keep finding new ones everywhere we look.
At the moment, we have so many antibiotics available that there is little research going into fully developing new ones. Most of the current research is very preliminary, sufficient to slap a patent on them.
Once it looks like there’s a market for new antibiotics, the research will start back up, but at the moment there isn’t really any market for new antibiotics. The old ones work 99% of the time. When they don’t, there’s already a slew of alternatives that work well enough when those don’t. Nobody’s going to go through the expense of licencing a novel antibiotic because there’s just not enough market to justify it.
The problem isn’t that we are going to run out of antibiotics. The problem is that we might run out of antibiotics that we can cheaply grow in a vat. We’re rapidly running through our list of fungal antibiotics, and those are the easiest to grow. The ones that we can extract from oak trees or walruses work just as well, but they are hard to mass produce. Kinda hard to grow a walrus in a vat.
However genetic modification will almost certainly allow us to vat-grow many of these antibiotics regardless of the natural source. But that’s a whole new source of expense in developing them, which is why it won’t happen until they can command more than a fraction of a percent of the market.
Even if some still work on some things, there could be a few dozen strains of highly-infectious 100% immune bacteria that are spreading around such that millions are getting sick and there are no antibiotics that will work.
I wouldn’t expect every single strain to suddenly evolve immunities to every single antibiotic.
Another related question is: why do these 100% resistant strains appear when it seems most strains are still susceptible to penicillin and other antibiotics that have been around and in use since WWII? My understanding of evolution, specifically how bacteria evolve immunities, makes that seem counterintuitive at the very least.
Antibiotic resistance is a major issue in medicine right now. The first major antibiotic. Penicillin, was first mass produced in the early 1940’s, or about 70 years ago, while the first resistance bacteria were discovered in 1947, less then a decade after the antibiotic first hit the market. in the intervening years, we have been discovering new antibiotics faster then resistance has caught up to us. The 50’s and 60’s were golden ages of new antibiotics, but the first discovery of resistance was always less then a decade after a new antibiotic came out.
More reasently, as the production of new forms of antibiotics have decreased (multiple reasons which would require a GQ thread of its own, but main problems being the easy ones already discovered, and lack of financial incentive for drug companies to invest and bring to market new ones), the spread of resistance has increased. We are now discovering Multi-Drug-Resistant (MDR) bacteria, that is resistant to many of the drugs we have. The latest antibiotic, and one of the last of the branded antibiotics, Zyvox, (That it is one of the few remaining brand only antibiotics shows how few new antibiotics come out), is now having bacteria resistant to it. There have actually been a few cases in the medical journals of bacterial infections being resistant to every known antibiotic.
Due to misuse, the rapid reproduction rate of bacteria, and the lack of new research, we are defiantly heading towards a period where antibiotics will not be the cure-all they are today… However… I don’t believe we will ever truly reach a total “post antibiotic age”. While evolution of bacteria gives in resistance to new antibiotics, when old ones loose effectiveness we stop using them, and because selective pressure is no longer being applied, bacteria start to lose some of its resistance. Even now, with UTIs, we’ve used Ciprofloxacin so much, that a lot of bacteria has become resistant… So we are using Nitrofurantin much more now. An old antibiotic that lost favor…
So eventually, as everything becomes resistant, we will develop new antibiotics, and some old ones will become effective… However, due to lag time between evolution and research, there will be a period of a decade or two, that there will be few options… While the race will survive, it will really suck if you or your child die from what is now a curable disease now, because you felt better after 4 days of a 10 day course of antibiotics and stop taking them.
If we treated antibiotics as “controlled substances” with extreme hatred and extreme punishment for doctors who prescribe them “unnecessarily” the way we treat C-II opioids i’m certain we wouldn’t be facing this problem.
Imagine hearing about a doctor who went to federal prison for 20 years for prescribing antibiotics to someone with a viral infection. A few instances of that and problem solved.
In my practice, I’ve seen many antibiotics prescribed when they were not warranted. Pediatricians prescribing amoxicillian (or as we call it, the pink placebo), just because the parents would feel they wasted money if the doctor didn’t prescribe something… Or the worse, when doctors prescribe an antibiotic and Tamiflu at the same time, to us in the profession, it looks like the doctor doesn’t know what is wrong and just want to give something so it looks like I did something…
However, one of the big problems is agricultural use of antibiotics. About 3/4ths of all antibiotics made in the USA goes to food animals, used as growth promoters, as prophylaxis due to the conditions they are kept in. These go into our water supply and food supply, leaving a low level of antibiotics that breeds resistance.
Imagine if we could just shoot someone in the face for getting our order wrong at the drivethrough!
I think you may be imagining that the process of diagnosing the start of a secondary bacterial infection is really cut-and-dried. I doubt it is. Antibiotics are certainly overprescribed and misused, but a draconian punishment regime against this would probably result in antibiotics being held back until really obvious symptoms of infection were evident - and this would mean some patients would be at greater risk of worse outcomes.
It drives me nuts when i hear about parents forcing a doctor to give TPC (their precious children) antibiotics just because the kid sneezed and because lil’ timmy is oh so precious and special he better get a full round of antibiotics “just to be safe” even if it’s clear that it’s viral or will clear up on its own. The doctor usually doesn’t give a crap, he wants to placate the parent and file the insurance claim.
But yes, putting so much antibiotics into milk, meat, cows, fish, chickens, etc is ridiculous.
The only “controlled substances” should be antibiotics. They’re the only drug someone else can use and have it actually affect me. You can take all the oxycontin you want and it will never affect me in any way, direct or remote. But you take antibiotics unnecessarily or improperly, it creates super-immune strains which does affect me. I do still believe people have a fundamental right to acquire and take whatever medicine they want without a Rx (if they want to consult a doctor good for them but we should not need a permission slip from one to get medicine). Everything should be OTC. But the ONE exception to that which I’m willing to consider is antibiotics.
The economic incentive for pharma to do the R&D on antibiotics just is not there. It is long and expensive research at this point. Does it make business sense to invest that sort of resource to possibly create a product that will be used off and on for a few days at a time for a limited time vs investing the same resource on a new medicine to be taken daily for the rest of many people’s lives (like better blood pressure medicine, anxiety medicine, cholesterol, etc.)?
Better stewardship of the resource is indeed critical and is becoming a greater focus. Medicine is increasngly becoming a world of metrics and incentives for quality performance however such gets defined. Larger groups are already beginning to define staying within guidelines for antibiotic use as one of those quality metrics. For their part parents are becoming more receptive, grateful even, for the discussion of “watchful waiting” rather than leaving with a script for a mild to moderate ear infection or earlyish possible sinus infection. Yes it still takes more time to do nothing than it takes to just prescribe something, but not as much extra as it used to. Parents just want to know that if the ear or sinus worsens during watchful waiting they can call for the script without having to come back in. It is a work in progress and what needs treatment and admittedly what does not is not always so cut and dried.
Hirka, in my neck of the woods if only the problem was only Amox. A bigger problem is that not only do some docs use antibiotics in circumstances that doing nothing (but doing it well) would do ust as well, but they then skip over Amox and use Augmentin, Zithro, or Omnicef to do it (and in cases in which Amox clearly is the appropriate choice as well).
Preventative immunization helps. The biggest gain on what was a rapidly growing problem with multiresistant pneumococcus leading to a huge increase in kids who needed many courses of antibiotics for bad ear infections and ear tubes (surgery) was not new meds or even better stewardship. It was the development and wide usage of the 23 valent pneumococcal vaccine (Prevnar) given in infancy. Mind you the main goal of that vaccine was targetting the more serious overwhelming infections like pneumonia and meningitis, but the more common benefit and the greater one in terms of emerging reistance, was in ears. Even broader use of flu vaccine in childhood will have an impact. Keep kids from getting the flu and you keep them from getting bacterial complications of it and/or from gettiing unneeded antibiotics along with their unneeded Tamiflu. Keep them from getting it and you prevent the higher risk adults from getting exposed and the same consequent use of antibiotics.
Yes, antibiotic use in farm animals is a major issue. The fact is that it is profitable to use them. Animals grow bigger faster and in more crowded conditions. And the fact is that the antibiotic resistant germs created get spread even by crows that feed on the waste. We need better regulation.
I got educated 'bout antibiotics back in '96 when I was pregnant w/my first.
I’ve restricted all my kids from antibiotic 'scripts, have refrained from buying hand sanitizer for myfamily-as well as antbacterial soaps, and don’t use germ killing cleaners on my kitchen counters & sinks, unless I’m making fowl of any sort (I’m not a fanatic after all).
All the above notwithstanding, I think that the most effective preventative action I’ve taken towards the health of the little ones has been letting them get good & dirty when they are outside playin’.
I was told all those years ago that letting the bad germs we come into contact with in everyday life strengthens the 'ol immune system, and all that I can say is that my family is pretty damn healthy-knock wood.
Yeah, but I think that when someone has a cough, a LOT of doctors take a rather shotgun-like approach that involves suspecting that it’s probably viral, but figure it’s easier, cheaper for the patient, and just as effective to just give them a course of azithromycin and turn them loose.
Beyond that, they really need to stop doing things like using antibiotics as a routine supplement in agricultural situations. I can’t help but think that causes a lot more resistance than the situation I mentioned above.
Also, from the way I understand resistance in people to develop (uncompleted treatment courses mainly) maybe once a day or single-time injections would be a better approach than “Take these 3 times a day for 2 weeks”, which is bound to be complied with more in the breach than in reality for the vast majority of people.
Oh, and hand sanitizer and antibacterial counter wipedowns aren’t really an issue; they’re more likely to keep you from getting sick than anything. However, antibacterial soaps aren’t effective and could contribute to some form of resistance.
I appreciate this follow-up. Your earlier post lead me to believe you were one of those “there ought to be a law” imbeciles. We already have way too many laws on the books for too many things. But the above clarifies it in a rational manner. More therapeutic drugs should be available without having to go to the doctor and generate a $100 visit bill - OTC, as you say, as in lots of other countries.
I’m not sure the antibiotic scare is quite as horrible or impending as some fear, however. I think doctors and parents are making strides to reduce unnecessary overuse. And I have some measure of faith in medical research to come up with alternatives as time goes by, tempered by the ever-present issues of profitability and tort liability limiting innovation.
As I always say, there should NEVER be a law. My only point is IF we’re going to have “controlled substances” and severely restrict their prescription, opioids and drugs with recreational potential shouldn’t be the ones controlled. Antibiotics should. I’d feel a lot better if the DEA were going after unnecessary antibiotic prescribers as opposed to pain mgmt doctors. But that’s a different topic.
The proper use of antibiotics is a huge collective action problem, all the way down to the doctor who prescribes them when he suspects they aren’t really needed to make an ignorant patient happy (if the doctor won’t, those patients will go find a doctor who will). So far, humans have not been particularly adept at solving collective action problems. I’m not very confident that we’ll come up with effective controls on antibiotics that meaningfully reduce the unnecessary use of them that leads to resistant bacteria.
Research into new antibiotics is mostly a market failure problem. There’s little financial incentive to develop new antibiotics because (a) we want to keep new antibiotics in reserve so that resistance doesn’t develop as quickly, so there are very few buyers, and (b) unlike many other medications, there’s a serious public backlash against charging a market-clearing $thousands price for a new antibiotic, since it’s literally necessary to keep someone from dying (and maybe to stop a major public health problem). I have a lot more confidence that we’ll find ways around this problem. Institutions are increasingly experimenting with offering prizes for accomplishments, which bypasses a lot of the problem there. There’s still a collective action problem in figuring out who pays how much, but it’s a manageable one.
I work in the environmental industry. We sampled the Ohio River a few years ago and detected 10 antibiotics in the river. This is a river that at “normal pool” flow is moving about 10,000,000 gallons per minute (Cincinnati area). The concentrations were in the ng/L range, but it still amazes me that we can detect these in a river that large!
Every single strain doesn’t suddenly become resistant to every single antibiotic. But bacteria pass around plasmids, DNA loops that carry the instructions for resistance. That allows the resistance to spread through unrelated bacteria. They can even swap between species.
What happens is that in environments where antibiotics are in constant use, non-resistant bacteria are killed, leaving resistant ones to take over the local real estate. When bacteria aren’t exposed to antibiotics, strains with no resistance can reproduce faster and take over. This is entirely what standard evolution theory would predict. At no time is every bacteria resistant to all antibiotics.
I’m not clear on what you mean by “most strains”. Bacteria can be divided into Genera, Species, and strains. Are you saying that you think that all genera of bacteria are developing resistance? That all species within certain genera are? Or that all strains within certain species are? In certain locations or all over?
Because even in hospitals with an outbreak of resistant infections, there will be bacteria of the exact species that are not resistant (different strain). There may even be strains of that species that are not causing disease, or that are only causing disease in patients who have had their microbiome reduced by antibiotics.
There have been hospitals that have identified the species causing the outbreak and fought it by identifying a non-virulent strain and, say, swabbing patients’ noses with it, in order to completely colonize the patient with harmless competitors. It’s not a popular treatment, but it has been used successfully.
Also, bacteria will be more likely to be resistant to the typical antibiotic used in its area. That will include penicillin. When people are worrying about resistant bacteria, they usually don’t worry about bacteria that are resistant to other antibiotics, but that still respond to penicillin. What they’re worrying about are the bacteria that are resistant to penicillin and other easy antibiotics, so that harsher and harsher antibiotics, with more side effects, have to be used.
I said most strains are not resistant, pointing out that most are still susceptible to penicillin, something that’s been in use for 70 years. Why are most bacteria (at least the infectious ones we treat with antibiotics) not immune to penicillin? It amazes me that a 70 year old antibiotic still has any use at all. Meanwhile there are these super-strains that are not only immune to penicillin but also everythign else including stuff like vancomycin, which is not used all that frequently… more of a last line of defense drug. As far as I am aware vancomycin is not used in agriculture/farming either. I’m not questioning the reality of it, only saying it doesn’t make much sense. I’m sure i’m missing/not understanding something.
As of 2013 what percent of bacterial infections do not respond to first line antibiotics? It seems to be a small minority that currently do not respond to at least one cheap antibiotic with few side effects. Aren’t there about a dozen classes of antibiotics, each with several antibiotics in it? Even if an infection doesn’t respond to ‘one’ drug, there are still several dozen others to try. If so, isn’t the worst of this issue going to be 50+ years away? That gives us enough time to invent new ways to fight bacteria.
Even when you have a drug resistant infection, that doesn’t mean that you can’t treat it. It just costs more, has more side effects, and takes longer. However if everyone who has surgery or gives birth is expected to be on a cocktail of expensive antibiotics for months afterwards, that could be a problem.
Have bacteriophages started coming back as a research topic? Those were dropped when antibiotics showed up.
Also you can also work on making the immune system stronger as well as making the infection weaker/smaller via antibiotics. That could be a route used that currently isn’t done very often.