Inspired by this thread, ‘Antibiotics’, the cure-all? which gets into the subject of antibiotic resistant bacteria, I wonder why we don’t make antibiotics only available by injection.
Three things that increase the number of drug resistant bacteria are:
People who don’t take their full prescription, allowing the more resistant bacteria to survive and be transmitted to others.
People who hang on to their ‘extra’ antibiotics and take them whenever they feel a little sick, exposing more bacteria to antibiotics and again, not fully killing them.
People who run to the doctor and demand antibiotics every time they get a sniffle, again needlessly exposing more bacteria to antibiotics.
It seems to me that if antibiotics were only available by injection, we could totally eliminate groups 1 and 2, and seriously cut down the number in group 3.
The most obvious problem would be that a full course of oral antibiotics often includes taking two or three pills a day for two weeks. Even if you could reduce the frequency to one a day using IV antibiotics, that still means a daily doctor’s visit for two weeks. Compliance would probably be very low; thus, rather than totally eliminating your problem #1, it would make it much worse.
On at least two occasions I can remember, I have been asked if I want a single injection, or ‘x’ pills for ‘y’ days. I took the injection both times just to get it over with, and not have to remember to take the pills. I was under the impression this could always be a choice, but I may be wrong.
We definitely overdo antibiotics, although this particular solution is impractical. In general simpler and less expensive routes seem like better care, and fixing a bad process (overuse) by making it more expensive and unnecessarily complex doesn’t seem to be a good approach.
Having said that, and at the risk of raising a firestorm, I’ll offer the following personal opinion: concern about antibiotic overuse is just a titchy bit (dare I say it?) overblown. Yes there are siginifcant and worrisome mulitply-resistant organisms out there. However I still remember my first antibiotic lecture in Med School over 30 years ago. Subject: We are over-using antibiotics and will soon have super organisms for which there is no available antibiotic.
Barely. Soft tissue CA-MRSA infections make me tired, even though I can still knock it out (usually) with TMP/SMX or minocycline or clindamycin. But now I’m seeing strains that are resistant the minocycline and clinda in our facility. I really don’t want to have to resort to Linezolid or (even worse), Vanco.
More annoying to me is seeing our local ER docs put people on linezolid for MRSA when it is still sensitive to sulfas, cyclines, and clinda.
And I do fear the development of a MRSA strain with the virulence of CA-MRSA and the resistance of HA-MRSA.
As for the OP, while there are long-acting injectable varieties of lots of antibiotics, some critical ones need to be dosed regularly over time, and to do it via repeated IM injection would get old. Among other reasons.
I guess I’ll come back after the beatings that I took in the other thread.
Maybe you all live in a land with special doctors. In that land, I wouldn’t have a problem with what you say about antibiotic abuse. But what you say doesn’t compare with my experience with the medical community. You pretend like they are scientists calculating a precise amount of antibiotics and prescribe me that exact amount to kill the strain of whatever disease I have at that moment. Ah, but not a gram more for fear of immunity!
In my life, I have probably had 10 GPs in 3 different states. If I walk in with swollen tonsils, he gives me antibiotics without any further tests. The very last time it happened about 5 years ago, I had some antibiotics at home, but I felt like I was dying so I forced myself to go to the doctors.
His words while shining a pen light down my throat. “Yes, sir, that’s strep you got there. Let’s get you some anti-beyut kickers and get you home to bed”.
That was where I wanted to be anyways. From that day on, I have kept spares in the house.
Let the re-flogging commence.
ETA: My wife’s GP calls antibiotic prescriptions in over the phone for one course. If one course doesn’t cure it, then he needs to see her.
Your plan wouldn’t work for most antibiotics because of the length of time you have to take them. There are two different ways antibiotics kill, time dependent killing, and concentration dependent killing. With Time dependent antibiotics the goal is to keep the antibiotic above a certain threshold (The MIC [minimum inhibitory concentration], or MBC [minimum bactericidal concentration] depending on the drug) for as long as possible, how far above doesn’t matter. This normally requires multiple doses over a period of time. With Concentration dependent, the goal is to bring the concentration in your body as high as possible without being toxic.
The antibiotics where you get one shot to kill something are normally concentration dependent, while most oral medications are time dependent (one reason it is so important to take the drug as directed, and not skip doses). So, it would be pretty much impossible to just do injection for all antibiotics. Now, the most you could hope for would be something like they do with TB patients, where they require the patient to come in, and take the dose in front of a health care or social worker in order to prove they are taking their drugs as directed.
Qadgop HA-MRSA scares me too, when doing my IPPE’s at the local hospital this summer, I saw a bunch of C&S reports, and saw WAY too many cases of MRSA that were resistant to Vancomycin. If MRSA is resistant to Vanco now, who knows what it will be resistant to in 10 years or so.
jtgain One thing you have to realize is that the doctor knows what the common strains of bacteria are that infect people in their area, and what antibiotics are used to treat them. Not all antibiotics are created equal. For example, Strep throat is pretty easy to diagnose by looking at it, you can normally see the white bacteria colonies in the back of the throat and on the tonsils. Strep is a gram positive bacteria, so the doctor would have prescribed an antibiotic that is effective against gram positive bacteria. If you decided not to go to the doctor and took one of these left over antibiotics, how would you know if it would be effective against the organism in question? Also, by not taking a complete course, you are only killing off the weaker of the bacteria, letting the stronger ones survive. These stronger bacteria will then grow, and might then have a resistance to the antibiotic class you were taking.
You don’t want a simple infection to get out of control due to your misuse of the antibiotics requiring you to take a trip to the ER and get IV antibiotics do you?
Sorry, untrue. Definitive dx requires culture or assay. Many viral pharyngitis cases are indistinguishable from strep by exam. Same pus-laden tonsils, same fever, same swollen glands, same glassy-eyed stare, same breath that would choke a donkey.
But the only way to know if it is strep or not is to do a strep test. Either a culture or a rapid strep assay.
It doesn’t even make sense to treat with antibiotics while waiting for results. Strep throat resolves just as fast with or without treatment. The reason to use antibiotics is to prevent the infrequent complication of strep throat leading to rheumatic heart or kidney disease. And to prevent that, it doesn’t matter if one waits a few days before starting antibiotics or not.
Sorry for making an untrue statement then. Here in pharmacy school we learn mostly about the drugs and what they treat, not as much about making diagnosis. In fact the limit of our training in diagnosing someone is to know if it is something that can be treated OTC, or something they need to see a doctor about. I’ve seen many pictures about strep throat, and they were all pretty obvious when we saw them, but then we were talking about bacteria and antibiotics in that class, so they didn’t really go into any of the other possible causes.
However once you make the dx, I can find and tell you the best drug to treat it.
(You as in the generic doctor you, not you as in the great and powerful Qadgop the Mercotan)
And more on strep: aside from antibiotics (at best) shortening the course of acute strep tonsillitis (assuming rheumatogenic strains are not reported), the antibiotic of choice is an injection of penicillin. It’s not some broader spectrum antibiotic. And yet this is one of the least-prescribed antibiotics and regimens…
Nitpick: IIRC, antibiotics have not been shown to reduce the incidence of post-streptococcal glomerulonephritis, so it doesn’t reduce the incidence of kidney disease to treat strep with antibiotics.
While I am on one of my favorite topics…you cannot diagnose acute strep tonsillitis accurately with anything but changing Anti-streptolysin titres, which is basically never done. It is very common to have carrier states for strep, with incidences reaching over 30% in some groups (children in school, e.g.) during outbreaks. Therefore a positive strep screen–or even a positive culture–does not mean the patient has acute streptococcal tonsillitis.
It is for this reason that strep throat represents a beautiful example in modern medicine of overtreatment with antibiotics. For that verv very very a couple more very rare case of rheumatic fever, we treat a bazillion patients for strep throat. And the nuances around why we do it are so complicated that to teach a patient all of them is damn near impossible.
Throw in a discussion of mono and CMV on top of strep, and you have an even more spectacular example of the problems facing us on the physician side.
Here’s the skinny: your sore throat is gonna do fine even if it really is strep and the odds that you have EVER been academically tested with serial ASO titres is close to nil. The odds that you will be annoyed (not you, QtM, but you the patient) if I don’t treat you or your kid are quite high, especially if the next bozo treats you, or worse–does a “strep test” and confidently tells you it’s “positive.”
So you see me in the ED. I give you penicillin based on clinical grounds (acute exudative tonsillitis, fever, anterior cervical lymphadenopathy; no other nodes) and you stay sick (because it takes a couple days to improve). The next guy gives you a “broad spectrum” antibiotic (because “we are going to hit it hard”). You get better (because you would have gotten better if we had both given you snake oil).
What gets credit? The broad spectrum antibiotic and the guy who prescribed it. Who gets panned? The first doc who gave nothing or who gave the narrow spectrum.
Long rant; not unusual for the Pedant, I know. And longer when I’m on a roll in the ED about it.
Bottom line: it’s never as simple as it seems, and nearly every mechanism we have reinforces Antibiotics.
But enough of strep. What about Otitis Media? Oh yeah…even worse. What about a cough? Worse again. What about a skin infection? Antibiotics for dirty wounds…very very tricky…
In the end, only a system where there is some sort of incentive for minimal treatment will be effective.
In the meantime, I respectfully, tenderly, timidly, kinda sorta disagree with QtM. It is my personal opinion that the overuse problem of antibiotics is not much different than it was 30 years ago. The bugs have kept up with the meds, and the meds have (just barely, as QtM notes) kept up with the bugs.
I raised a handful of children through 70 cumulative years of kidhood without a single–not one–antibiotic pill. Not so when treating patients.
I feel better now. Not. I confess to the world there have been times when I took the easy way out.
“Qadgop the Mercotan slithered flatly around the after-bulge of the crashed tranship. One claw dug into the meters-thick armour of pure neutronium, then another. Its terrible xmex-like snout locked on. Its zymolosely polydactile tongue crunched out, crashed down, rasped across. Slurp! Slurp! At each abrasive stroke the groove in the tranship’s plating deepened and Qadgop leered more fiercely. Fools! Did they think that the airlessness of absolute space, the heatlessness of absolute zero, the yieldlessness of absolute neutronium, could stop QADGOP THE MERCOTAN? And the stowaway, that human wench Cynthia, cowering in helpless terror just beyond this thin and fragile wall…”
[sub]I gotta stop believing my own press releases. Cynthia says hi.[/sub]
Already, the days of LR-MRSA are peeking over the horizon.
As a future veterinarian (I hope!), this is a topic that interests and concerns me. Veterinarians are also guilty of antibiotic abuse (although it may not be as ubiquitous a problem as in people), e.g., horses with minor URI’s (like people, usually viral) being put on TMP-SMX or doxycycline “just in case”. Multiple antibiotics are even available OTC for animal use, leaving decisions about antibiotics in the hands of lay people. Besides endangering human health from the potential transfer of resistant bacteria and resistance genes, vets who do this are shooting themselves in the foot, as many of the newer antibiotics are financially out of reach for animal owners, who usually pay out of pocket and thus are sensitive to price.
I know what you mean, I love them too… And I really love that I finally have enough schooling to be able to understand, and actually participate in them! For the longest time I was just a lurker on these boards, now I have something to contribute and finally increase my post count, 640 posts is very low for someone that’s been here for as long as I have.
ETA: Thank you for that informative post, Chief Pedant. That’s what I get for getting distracted while composing a post. You are right that you have to give people an incentive to use antibiotics wisely, since the easy way out for both doctor and patient is a prescription and out the door, instead of a discussion which the patient may ignore anyway. I’m starting to think that we should legalize narcotics (a whole 'nother issue) and make antibiotics controlled.
That reminded me of another veterinary example that probably interests no one, GROSS ALERT but I’ll pass it on anyway. Strep equi or “strangles” causes nasty looking submandibular and/or retropharyngeal abscesses and miserable looking horses, but the typical horse will not benefit from antibiotics unless you know that strangles has been going around and your horse has a fever but NO abscess yet. For the rest, it just takes time, but people don’t like to hear that there’s nothing you can do about the pus pouring out of the horse’s jaw.
From the chemistry side of things, I’ll have to agree with QtM. Until about a decade ago, research on new antibiotic classes had all but come to a halt. We went about 40 years without a single new class of antibiotics being dicovered.
The fact is, it doesn’t make good fiscal sense to pay billions of dollars to research a drug that becomes less effective the more you sell. By the time your drug is needed, the patent has run out.
