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.

Idsa 2

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.

What is Antibiotic Resistance?

Here’s a great 3-minute video by Ohio State’s Debbie Goff explaining the resistance problem. Keep in mind there’s 3 main actors here: the bug, the drug, and you. And it’s the bug, e.g. MRSA, that becomes resistant to the antibiotic drug, e.g. methicillin, leaving you with a harder to treat, or untreatable, bug-driven infection.

We explored this issue in greater detail with Debbie Goff yesterday. You can access that here.

 

About all those resistant infections … We’re not doing anything wrong, are we?

Please think carefully about the brief and exceptional talk by Debbie Goff, an infectious disease clinical pharmacist of 30 years standing, and ask yourself a question: Because of how we misuse antibiotics, are we essentially engaging in a form of collective self-harm?

Before you write off the question as hyperbole, consider, first, the vast amount of harm caused by “superbugs,” i.e. bacteria that antibiotics have little or no effect on. To really come to grips with how much damage is being done, a thought experiment helps: Visualize the packed crowd in a large American football stadium, say from the Super Bowl. Now think of seven such stadiums, all jam-packed – say, the Patriots home field, the Packers, the Giants, and so on – and finally, imagine all those people dying … every football season, from an infection.

guiltThat’s the death toll every year, worldwide. Add to that the people who become seriously infected but recover, and the total harm is orders of magnitude greater.

There are no safe harbors. For example, in a U.S. hospital (you’re safe there, right?), you have a 1 in 7 chance of catching a superbug; in a nursing home, the risk goes up to 1 in 4. All-told in the U.S., over 2 million serious resistant infections happen annually – i.e. multiple hospitalizations, stays in the ICU, surgeries, amputations (and years of anxiety by patient & family over possible re-occurrence) – plus over 23,000 deaths, around half due to MRSA alone.

And consider, second, and most importantly, how much all this carnage is driven by what we do (vs. what the bug does), and by how we think. This is the thrust of Debbie Goff’s talk: It’s not just about the bug, it’s about us too, and probably more so. The threshold issue is how we (mis)understand antibiotics: unlike every other therapeutic, they’re a “societal drug,” which means the more we use them the less effective they become – for everyone – because bugs adapt to drugs by evolving resistant strains, as quick as overnight. The logical import is therefore crystal clear: conserve antibiotics as best we can by using them properly & only when we must.

But logic is not our strong suite. Instead, we humans drive resistance to antibiotics (in a sense, we manufacture it) through a worldwide network of misuse. For example, by health care providers handing out scripts like Halloween candy – “just-in-case” as Goff correctly puts it – and by us, as patients, demanding them just like, well, kids at Halloween. Hint: “Hey Doc, I need a Z-pak,” is not the way to go about it. With the upshot that we’ve developed a dangerous one-third rule of abuse: 33% of antibiotics prescribed in hospitals have errors – wrong drug, duration, or dose; and 30% of antibiotics prescribed at the doctor’s office are unnecessary, typically because your illness is viral – a cold or the flu – not bacterial.

The practice of medicine is, ultimately, very personal. Debbie Goff begins by introducing us to a 35-year old mother of two, fresh from a successful surgery, who is prescribed – unnecessarily – a 10-day course of antibiotics, “just-in-case” she develops an infection. Keep in mind that what unfolds next didn’t have to. And that’s the whole point: we’re doing this to ourselves. Another name for that is self-harm.

 

“Catch”: A new film about a world without antibiotics

Looks like there’s a must-see short film out there about what antibiotic resistance has in store for us. Britain’s leading medical journal, The Lancet, had this to say about in today’s online edition:

It is an ordinary enough scene—a young father playing with his daughter. But it is also a chilling one, set in a dystopian near future in which all antibiotics have failed. A lethal pandemic has gripped the country; Tom’s wife and young son have succumbed to the infection and been taken away by the authorities, and it is unclear whether they are still alive. Tom and 8-year-old Amy are being kept housebound under strict quarantine. Amy is now sick, and Tom has an impossible decision to make. Does he give her up to the same authorities that have “taken mummy and Ben away”, or risk his own life? This is the scenario in CATCH, a 16-minute film from first-time directors Paul Cooke and Dominic Rees-Roberts that presents the crucial issue of antibiotic resistance as a story that might so easily be part of our children’s future.

The Lancet is not in the habit of reviewing films, so there must be something to it. Have a peek:

The Idea Behind CATCH from BorderPoint Films on Vimeo.

MRSA’s “Moon Shot”

This past Sunday, using the same launch pad that sent Neil Armstrong and Buzz Aldrin to the moon in the summer of ’69, NASA launched MRSA (below) to the International Space Station in order to conduct a novel experiment, as we explained last week.

The day before the launch, the lead scientist of the MRSA mission, Harvard’s Anita Goel, MD, PhD, in an interview with the CBC, told us why she selected MRSA, what she hopes the experiment will accomplish, and how she’s feeling on launch eve.

 

 

On MRSA: “MRSA … stands for methicillin-resistant staphylococcus aureus, a superbug, that’s a hospital-acquired infection that’s rampant in hospitals across North America and the world actually. And this bug rapidly mutates to become drug-resistant to current antibiotics which means it can easily spin out of control.”

On the experiment: “If we can use microgravity in space as an incubator to fast forward what these mutations of this superbug MRSA will look like in the future, we can build better drugs on Earth well before these mutant strains actually come, or emerge on the ground.”

Goel explained that the experiment is still proof of concept: namely, will the microgravity environment actually fast forward the growth rate of MRSA? And if so, how does it do that?

And how is she feeling one day before the big event? “It feels a little bit like what it might have been to be there on the first space launch when we had the first man mission to the moon … it feels like a moon shot.”

Planes, Trains, and Automobiles

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Below is the second of three installments of NPR’s entertaining and informative animated series about our relationship to germs.

While you’re watching it, reflect on the significance of (then) Center for Disease Control Director Tom Frieden’s warning that “A disease outbreak anywhere is a risk everywhere …. We are all connected by the air we breathe, the water we drink and the food we eat, and the next outbreak may be just a plane ride away.”

Do you agree?

The video offers some supporting evidence from history: “When people figured out how to sail around the world new germs came with them. The results weren’t pretty. In the centuries after Columbus’s voyage across the Atlantic some estimates say 90% of the entire Native population of the America’s died, mostly from diseases the Europeans brought with them.”

I hope you like the 3 minute film and if you do pass it on. The final installment should air in 2 weeks.

 

The Choice

Choice 1

 

Do you know anyone who would take medicine away from a sick child?

Take a close look at the powerful opinion piece in today’s Times by Baylor College of Medicine physician Peter Hotez. He warns that because of the new U.S. administration’s view of science, 2017 is “looking as if” we will “see a reversal of several decades in steady public health gains,” and “[t]he first blow will be measles outbreaks in America … one of the most contagious and most lethal of all human diseases.” (My emphasis.)

Hotez’s point is that sickness and health is about more than just bugs and disease, it’s also about how we choose to fight disease. We can come at disease with all we’ve got, i.e. rely on the best available science or, as Hotez argues we’re beginning to do, rely on “pseudoscience” and “myth.” And that if we opt for this junk science approach then understand that the consequence will be lethal and personal: more of us – children and the elderly, especially, because of their weaker immune systems – will get sick, suffer, and die, inevitably.

And if that is the case then let’s be completely honest: the analogy drawn in the first sentence above isn’t quite right. It should read, instead:

Do you know anyone who would take medicine away from sick children across the country?

 

The Good Host

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For germs to thrive they need help – ours. We’re what biologists call ‘hosts’: “the larger participant in a relationship … often providing a home and food source ….”

A new 3-part series on NPR examines our relationship with germs. Part 1 began with man’s early encounters with microbes and concluded with this observation:

 

Luckily, humans were so few and far between back then that this virus [or bacterium] can’t find any more humans to infect. That first mutant virus [or bacterium] doesn’t get very far. But after many thousands of years something big starts to change: humans discovered agriculture. This means we started to settle down …. We started having large families, more neighbors; there’s more food.

 

Part 2 of the NPR series will be aired Thursday. If you watch it, keep in mind that in the ensuing decades the U.N. estimates that:

(1) The world population will increase by 2.3 billion people by 2050, reaching almost 10 billion in all.

(2) We will have a lot more close neighbors: In 2014 there were 28 “mega-cities,” defined as having 10 million inhabitants or more; by 2030 the world is projected to have 41 mega-cities.

(3) The number of persons aged 60 or above – people with weaker immune systems – is expected to more than double by 2050.

In other words, there will be a lot more good hosts out there, all ready – willing or not – and able, to provide food and shelter to the germs mentioned in the broadcast as well as to these guys.

Here’s the series opener. It runs less than 3 minutes:

 

Back to Basics: The Bug, the Drug, and You

Before you tackle a problem, you need to understand it. But a 2015 World Health Organization survey confirms something we’ve suspected all along – there’s still way too much confusion out there about what antibiotic resistance actually is. For example, the WHO survey found that “76% [of respondents] think that the statement ‘Antibiotic resistance occurs when your body becomes resistant to antibiotics and they no longer work as well’ is also true, when this is in fact a false statement.”

This two-minute video from Stat News – which they run with most of their antibiotic resistance stories – addresses the above misunderstanding. As they teach you in first year law school, when you approach a problem, always identify who the “actors” are – in this case, the bug, the drug, and you – and what their relationship is to each other. So if you’re in the majority and don’t understand why the above statement from WHO is false, this video should help you. (A larger video can be found in the body of this article.)

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