The other problem with antimicrobial resistance: We don’t know what the words mean

If you don’t understand the term “antimicrobial resistance,” don’t feel bad  —  neither does anybody else. In a commentary & interview this month with the leading science journal Nature, infectious disease specialist Marc Mendelson said the term “antimicrobial resistance” is not understood by the public and should be abandoned, replaced with “drug-resistant infection” and “antibiotic resistance.” Dr. Mendelson:

The studies … highlighted the fact that the main term … that is used … “antimicrobial resistance,” less than 50% of people have heard of the term; that it’s abbreviation which is commonly used, which is AMR, less than 20% have heard of this term; and there’s a complete blank look on people’s faces often when you discuss these terms. So, without understanding of the problem, use of … terminology … that people don’t understand can have serious impact on your ability to try and take the discussions and, more importantly, the actions, further.

This matters because the problem of drug-resistant infections requires more than just scientists to solve. Mendelson: “It requires engagement from a much broader array of players, from governments, regulators and the public, to experts in health, food, the environment, economics, trade and industry. People from these disparate domains are talking past each other. Many of the terms routinely used to describe the problem are misunderstood, interpreted differently or loaded with unhelpful connotations.” Hence the need to get everyone on the same language page.

Mendelson offers a cogent example of the benefit of adopting the right words: The decision to name the cause of AIDS as human immunodeficiency virus (HIV) in 1986  —  instead of human T-cell lymphotropic virus (HTLV-III) or lymphadenopathy-associated virus (LAV)  —  helped people to understand that the disease was caused by a virus that harms the immune system. “As such,” he says, “it was crucial in tackling stigma and phasing out terms such as ‘the gay plague’, which had previously dominated communication around AIDS.”

The following video was made for the public and nicely explains what a drug-resistant infection/antibiotic resistance is. In brief, it’s a 3-part harmony between the bug, the drug, and you. As bugs like staph aureus or E. coli get increasingly exposed to our drugs (antibiotics) through rampant misuse and overuse, the bugs fight back by successfully resisting the drug’s effect, & thus we stay sick. The media coined the term “superbug” to refer to bugs that have evolved this resistance.

Et Tu Canada? Like their U.S. counterparts, Canadian doctors are handing out antibiotics like candy

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We’re getting it wrong almost half the time: 46% of Canadian seniors who saw their doctors because of a nonbacterial respiratory infection were nevertheless prescribed an antibiotic, says a study published this week in Annals of Internal Medicine.

Physicians know the rule: antibiotics only work on bacterial-driven infections, not viral-driven ones, and the classic viral infections are the common cold & acute bronchitis. Yet in a sample of 8,990 Ontario primary care physicians and 185,014 of their patients who presented with a nonbacterial respiratory infection, typically the common cold or acute bronchitis, antibiotics were given to a whopping 85,106 people (46%).

So why the huge error rate? Lead researcher Michael Silverman MD, chief of infectious diseases at Western University in London, Ontario, told the CBC there are two main reasons: (1) the time pressure to see more and more patients, which is driven by financial incentives, and (2) “decision fatigue,” the idea that physicians who have to say no all day to patients asking for antibiotics just get tired of saying no. Which comports with US research suggesting doctors tend to prescribe more antibiotics later in the day, Silverman said.

Handing out antibiotics when you shouldn’t, says Silverman, matters because they have serious side effects such as diarrhea from C. difficile, a big issue in Canada and around the world; irregular heartbeats and sudden death; tendon rupture; adverse drug interaction; and antibiotic resistance, i.e. the more you use these drugs, the less effective they become.

While the study was conducted in Ontario with patients 66 years of age and older (because researchers had access to data on nearly all prescriptions for this age group), Silverman believes these findings generalize to all age groups and to the rest of the country.

Down in the Dirt: Say Hello To Your “Old Friends”

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Children now spend less time outside than the average prisoner. Adults spend 90-95% of their time indoors in their homes, work places, or cars. Living lives increasingly separated from the natural world comes with a cost, especially for kids, writes Paul Bogart in his new book The Ground Beneath Us. In an interview with National Geographic, Bogart says children need to be exposed to the microbes in the soil to build up their defenses against diseases that may attack them later:

“Kids these days are not being exposed to dirt because they’re not allowed to play outside. Their parents think dirt is dirty. But both the newest science and the oldest traditions tell us the same thing, which is that the ground is alive. The ground gives us life.”

The parents Bogart is talking about subscribe to the theory that dirt = microbes = germs (pathogens). This gave rise to the so-called hygiene hypothesis, the idea that early-life exposure to dirt/germs produces antibodies that protects us from disease – a sort of do-it-yourself vaccination program.

But there was a problem: Since the 1950s, in developed countries only, rates of multiple sclerosis, Crohn’s disease, type 1 diabetes, and asthma soared by 300% or more, and there were also spikes in hay fever and food allergies. And because scientists felt that our exposure to pathogens remained the same, they re-examined the hygiene hypothesis and discovered a problem: Yes, dirt = microbes; but no, microbes do not = germs. That’s because the vast majority of them are either necessary, helpful, or neutral. And by limiting our exposure to them we deprive ourselves of their health benefits.

A seminal article in the Proceedings of the National Academy of Sciences, titled “Cleaning up the Hygiene Hypothesis,” underscores Bogart’s view of the life-giving force of “dirt,” and argues we should replace the hygiene hypothesis with what they call the “old friends” hypothesis:

Today, epidemiological, experimental, and molecular evidence support a different hypothesis: Early exposure to a diverse range of ‘friendly’ microbes—not infectious pathogens—is necessary to train the human immune system to react appropriately to stimuli.

‘We realized human beings coevolved with a whole host of organisms, and it was far more likely what was going on was that we were being deprived of organisms on which we are dependent’ … early and regular exposure to harmless microorganisms—“old friends” present throughout human evolution and recognized by the human immune system—train the immune system to react appropriately to threats. It’s not that children … aren’t subject to enough infections when they are young, but that their exposure to the microbial world is far more circumscribed than it once was.

Young children continue amassing microbiota in every contact with family members, while playing outside in dirt, getting licked by dogs, and sharing toys with friends. The developing immune system takes cues from all of these encounters.

PNAS emphasizes that sequestering children away from the natural environment is one of several factors that reduces our exposure to necessary microbes. Others include the overuse of antibiotics (they kill good & bad microbes); the rise of caesarian sections (deprives the child of microbes found only in the birth canal); and the increased use of sanitizers that view microbes as signs of dirt to be destroyed.

PNAS also says that relaxing hygiene standards would not reverse this trend of rising rates of MS, Crohn’s, etc., but only serve to increase the risks of infectious disease. For example, they say, one can teach children to wash their hands after handling raw chicken but also encourage them to play outside in the dirt: “If your child has been out in the garden and comes in with slightly grubby hands, I, personally, would let them come in and munch a sandwich without washing,” says Graham Rook, an emeritus professor of medical microbiology at University College London.

 

The Humor Page: Comedian Kitty Flanagan advises doctors how to handle patients who demand antibiotics

Antibiotics have zero effect on the cold virus, yet patients keep insisting on them and doctor’s keep caving in to those requests. So how do we stop this? The C.D.C. has one approach. And Australian comedian Kitty Flanagan has quite another. In the video below (~ 3-min. mark) she role plays a doctor who sees a patient demanding antibiotics. This is how “Doctor” Flanagan handles it:

The heat is on: Anthrax has already escaped from our melting permafrost. It probably will again, with other pathogens to follow.

Anthrax is a deadly bacterium. Inhaled, it will kill 8 in 10 people if not treated in time. That’s why, in the wake of the 9/11 attacks, it was the microbial weapon of choice sent through the mail to Capitol Hill and media figures. It affected 22 people, closed down the Hart Senate Office Building for months, disrupted mail delivery, took billions of dollars to fix – and terrorized a nation. Imagine, then, what would happen if Nature were to melt the earth’s layer of permafrost, thereby causing the release of centuries-old stored anthrax into our atmosphere.

The drip, drip, drip of Nature’s involvement in pathogen release began, perhaps, last summer in northwest Russia when it was reported that a 12-year-old boy was killed by anthrax and 90 others were sent to hospital. Officials said the outbreak was caused by an unusually intense summer heat that melted the permafrost, exposing a reindeer carcass containing anthrax that spread to the local population. The regional governor imposed a quarantine on the Yamal Peninsula – the affected area – and insisted that the situation was under control. In the Yamal, it probably was.

But the melting permafrost problem we’re left with wraps around the global north – which includes the upper areas of provincial Canada – and is growing. For example, Inside Climate News reported in February that a massive permafrost thaw is underway in Canada: that 52,000 square miles are in rapid decline and this is potentially accelerating global warming.

Permafrost acts like a giant freezer. More than 1,000 feet deep in places, it has captured, stored and kept alive bacteria and viruses for a very long time. But as the permafrost thaws those infectious agents such as anthrax will come back to life and eventually infect people and animals. That’s in addition to the more publicized effects such as methane gas emission – which warms the planet by 86 times as much as CO2 – and a heaving landscape strewn with impassable undulating roads, drunken trees, and collapsing homes & buildings.

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Physician Birgitta Evengård, who heads the infectious disease unit at Sweden’s Umea University, studies how climate change alters the spread of diseases. She told NPR there’s likely to be more cases of anthrax resurfacing because climate change is causing the temperature in the Arctic Circle to rise very quickly.

EVENGARD: It’s about three times faster than in the rest of the world. And this means that the ice is melting, and the permafrost is thawing.

NPR: A hundred years ago, there were repeated anthrax outbreaks in Siberia. More than a million reindeer died. Now there are about 7,000 burial grounds with infected carcasses scattered across northern Russia.

EVENGARD: It’s not that easy to dig to bury these animals, so they are kind of very close to the surface.

NPR: Wow. So there could be these outbreaks happening every summer?

EVENGARD: Yes, this is serious.

NPR: People and animals have been buried in permafrost for centuries. There could be bodies infected with all kinds of viruses and bacteria, frozen in time. [Evengard] says scientists are just starting to look for it.

EVENGARD: So we really don’t know. This is Pandora’s box.

NPR: There’s also likely smallpox buried up there and the bubonic plague. So the question for researchers is, could these pathogens, like anthrax, ever be reactivated?

Healthy Reading

The irony of the Information Age is that because there’s so much of it, it can be even harder to figure out what to read. For example, if your concern is better health for you & your family, what books can you turn to that will actually prove helpful? That was the very question put by Medscape to its panel of primary care physicians. In response, the doctors came up with seven books they said they wished their patients would read. Here’s that list along with their comments.

 

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Last Child in the Woods, by Richard Louv

“This book will make you really rethink the kind of activities in which your child engages and will make you want to unplug everything electronic! An iPad is no substitute for interaction with parents and nature.” —William T. Basco, Jr, MD, MS

 

Slide 4

Being Mortal: Medicine and What Matters in the End, by Atul Gawande, MD, MPH

“This book can help patients and their families to focus on what is really important in their final months. Quality of life can be more important than extending life. Our medical system is not always good at stressing this fact. This book gives insight into the medical system and better prepares anyone for difficult decisions we will all have to face someday.” —Harvey Hsu, MD

 

Slide 5

Worried Sick: A Prescription for Health in an Overtreated America, by Nortin M. Hadler, MD

“Nortin Hadler is the best MD in America at explaining complicated medical issues clearly for an aware public audience.” —George D. Lundberg, MD

 

Slide 6

Eat, Drink, and Be Healthy: The Harvard Medical School Guide to Healthy Eating, by Walter C. Willett, MD

“I have had more questions from patients about diet and nutritional supplements than any other topic. The misinformation available from quack doctors on television, junk articles in checkout line magazines, and even in legitimate publications is unbelievable. I’ve purchased many copies of Eat, Drink, and Be Healthy for my patients since I haven’t had hours to discuss nutrition extensively. It’s always been a good investment for keeping my patients healthy.” —James J. Foody, MD

 

Slide 7

How Doctors Think, by Jerome Groopman, MD

“Effective communication is critical to the patient-doctor relationship. Dr Groopman provides unique insight into the minds of how doctors are trained to think. Understanding will help patients get the care they need.” —Joseph Ming Wah Li, MD

 

Slide 2

The Art and Science of Aging Well: A Physician’s Guide to a Healthy Body, Mind, and Spirit, by Mark E. Williams, MD

“Williams weaves together solid practical advice with a great understanding of how cultural and scientific views of aging have evolved over time. Patients will feel more comfortable and knowledgeable with all aspects of the aging process.” —Arefa M. Cassoobhoy, MD, MPH

 

Slide 8

Pain Free: A Revolutionary Method for Stopping Chronic Pain, by Pete Egoscue and Roger Gittines

“Egoscue-type stretch and relaxation exercises are a fabulous way to warm up your body and stave off back and shoulder pain (and ‘computer neck’). It’s also very relaxing and de-stressing; you don’t sweat, which means you can do them any time. They can also improve your golf swing, which often gets my male patients to try them.” —Sandra Adamson Fryhofer, MD

Just how fast is climate change moving?

“Climate [change] is moving much faster than scientists will tell you…. [And] because the science is being deliberately obfuscated in the US … the consequences are being obscured as well.…”

That didn’t come from Greenpeace. It came just this week from the venerable Financial Times of London, whose very survival depends on getting their facts right: misleading powerful institutional investors would not bode well for their future.

Maybe that’s why their brief video is one of the most persuasive explanations on climate change out there – with the added bonus of some related investment advice.

The United States at its Best

On May 25, 1961, President John F. Kennedy stood before a special joint session of Congress and uttered these now immortal words:

“I therefore ask the Congress … to provide the funds which are needed to meet the following national goals:

First, I believe that this nation should commit itself to achieving the goal, before this decade is out, of landing a man on the moon and returning him safely to the earth. No single space project in this period will be more impressive to mankind ….”

Today, there’s another visionary space project taking place in the U.S. which has the potential to be even more impressive to mankind: nothing less than the creation of a whole new field of science that can revolutionize health care – indeed, our lives – here on earth.

Imagine – you’re sitting at home and begin to feel ill. Reminiscent of the infamous medical scanner used on Star Trek, you pull out your home medical scanner called Gene Radar, a device that fits in your hand. In step 1, you draw a drop of blood. The scanner conducts a genetic analysis which yields an immediate diagnosis for any RNA or DNA-based disease, i.e. any infectious illness and even, it’s hoped, cancers. In step 2, once you have the disease’s genetic fingerprint, you know which drugs to use to target that fingerprint.

So why a space mission? Because of the almost zero-gravity environment in space, it’s thought that cells – the experiment uses staph aureus – will mutate faster allowing you to record a fuller mutational spectrum. If you know the complete mutational patterns of disease cells in advance, you can then develop algorithms that will tell you how the cells will mutate from any particular starting point, for instance, at the point of the genetic profile taken in step 1, above. These algorithms thus become the basis for novel drug development. In step 2, above, you’re then able to select the (novel) therapeutic based on what the current genetic fingerprint is, how it will mutate, & over what period of time.

We’ve written about this paradigm-shifting work before. Here’s the short version (“MRSA’s ‘Moon Shot'”), and here’s the earlier long read (“Minority Report 2: Pre-Disease”). After we came out with those articles NASA published a brief video, below, along with a short narrative that further explains their groundbreaking work.

Understandably, no time frames are given for when NASA & the team of Harvard scientists who’re running the experiments expect to fully complete their work. We note, however, that 8 years after President Kennedy’s dramatic space announcement, that on July 20, 1969, Apollo 11 astronauts Neil Armstrong and Buzz Aldrin fulfilled his vision by landing on the moon and, four days later, returned safely to Earth.

The Antibiotic Prescription Problem: A message from the honeybees

HoneybeeEvidence continues to mount that antibiotics have a significant downside. A study published this month from researchers at The University of Texas at Austin found that honeybees treated with the common antibiotic tetracycline were half as likely to survive the week after treatment compared with a group of untreated bees. That’s because in addition to killing bad bugs, antibiotics also kill your good ones – those that aid immune function and nutrition. And in addition to that loss of function the problem is compounded because with the good bugs out of the way the bad ones proliferate, increasing your chance of getting sick. The authors explain:

Studies with vertebrate models and human subjects suggest that antibiotic treatments greatly perturb the native gut community, thereby facilitating proliferation of pathogens. In fact, persistent infections following antibiotic treatment are a major medical issue. … [T]hese results suggest that dysbiosis [imbalance in gut bacteria caused by too few beneficial bacteria and an overgrowth of bad bacteria], resulting from antibiotic exposure affects bee health, in part due to increased susceptibility to ubiquitous opportunistic pathogens.

The researchers recognize the need for antibiotics. Their message, however, is one of caution: use only when necessary. However, we insist on getting it wrong: around a third of all antibiotic prescriptions handed out in the US are done so in error. But to heed the message of being careful, we have to know when to use an antibiotic and when not to. So here’s a handy chart put out by the Pew Charitable Trusts that shows us where we typically mess up:

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It Takes a Village: IDSA’s Statement on the Executive Order on Travel to the U.S.

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Last night two U.S. federal courts issued orders putting a stop to President Trump’s executive order prohibiting travel to the U.S. from six Muslim-majority countries. The courts said the order is discriminatory because it’s a religious test that violates the separation of church & state doctrine, which flows from the 1st amendment to the constitution.

That’s front-page news. What’s less well known & also vital, is that the U.S. science & medical community is up in arms about the ban. That’s because they recognize that disease threats are global (think Ebola or the bird flu virus) & therefore believe the solutions are also global. Take, for example, the World Health Organization’s plea last month for world governments to coordinate their efforts to combat 12 “priority pathogens,” MRSA among them.

But for world-leading governments to be at their best they need the best people. And so the Infectious Disease Society of America has also weighed in with a statement condemning the ban. Notice that IDSA frames infectious disease as a national security threat. Essentially saying we need medical “soldiers” from across the globe, over here, standing shoulder-to-shoulder with us, to combat the problem – otherwise the annual body count will rise, needlessly:

IDSA Statement on Exec. Order on Travel to U.S

Infectious diseases do not respect national borders, and success in fighting them requires a global response. Broad international collaboration is critical to our ability to identify, track and respond to emerging infectious diseases.

As a medical society representing over 10,000 infectious diseases physicians and scientists from 100 countries over 6 continents, the Infectious Diseases Society of America (IDSA) joins many other medical and scientific societies in expressing deep concern about the impact of the recent executive order restricting the entrance of certain foreign nationals to the United States. Advances in medicine come as a result of international collaboration and the free exchange of scientific ideas and discoveries. Travel and attendance at international conferences, including those held in the U.S., is essential to such collaboration.

The executive order may also negatively affect our nation’s medical and scientific workforce. Over the past decade, about one third of physicians entering the ID specialty have come from countries other than the U.S., including those impacted by the executive order. These ID physicians contribute to America’s robust ID patient care, public health efforts, and biomedical research and innovation. … Limiting the capabilities of physicians and scientists to collaborate around the world threatens the very national security the administration is committed to protecting.

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