Taking antibiotics can cut cancer patients life expectancy in half

Oh boy – more news about the dark side of antibiotics: A new UK study found that patients undergoing cancer treatment survived for only half as long if they were also taking an antibiotic. And taking more than one antibiotic shortened survival time even more.

Researchers looked at 303 cancer patients undergoing immunotherapy and found that those who were taking an antibiotic survived for an average of 317 days, while those who had not taken antibiotics survived for 651. And those who had used antibiotics over a longer period or been given multiple antibiotics had an even lower survival span of just 193 days.

Immunotherapy uses drugs, “biologics,” to stimulate your body’s immune system, especially T cells, to fight cancer. And the greater the number and diversity of bacteria in the gut, the more T cells there are available to take on the disease. But a course of antibiotics can suppress bacteria levels for weeks thus wiping out gut bacteria essential for fighting cancer.

Antibiotics are given to people undergoing traditional chemotherapy because the treatment weakens the body, making it more vulnerable to bacterial infection.

Co-author of the yet-to-be-published study, Dr. Nadina Tinsley, told The Telegraph that using antibiotics while undergoing immunotherapy is “quite a big problem.” And she has a message for GPs who think, Oh my goodness it’s a cancer patient, they need antibiotics:

… the challenge is striking the right balance and making sure that we identify those patients that are at risk of having a serious infection, without giving antibiotics for less justified indications and maybe overusing antibiotics … What we’re saying is think really carefully about it.

The research was presented last week at the American Society of Clinical Oncology in Chicago, the world’s largest annual cancer conference.

Further reporting on how antibiotics adversely affect our gut microbiome can be found here, here, and here.

 

‘Nuf Said:

Which waitress do you prefer?

Waitress #1: Hi, would you like a cup of coffee?

Waitress #2: Hello sir/ma’am, would you like a beaker of steam-extracted Coffea arabica?

As the humorous video below reminds us, if it’s important for a waitress to communicate effectively then certainly  doctors should too.

The leaders in science and medicine understand this and they’re trying to get the message out.

That’s why, for example, the video was posted on Jennifer Doudna’s Twitter page. Dr. Doudna teaches at Berkeley and is the co-discoverer of the gene editing technology called CRISPR that has – oy vey – the power to control evolution and thus considered by many the most important invention of this century.

So, too, the prestigious National Academy of Medicine, who just called for the greater participation of patients in their own care, to which infectious disease expert Brad Spellberg, MD, tweeted, Yes! Need to move away from paternalistic medicine!

And Stuart Levy, MD, a pioneer in the field of antibiotic resistance told a live audience at the Harvard School of Public Health, “If I had $800,000 to spend on fighting infectious disease, he said, I’d spend $700,000 of it on educating the community: They need to be a partner in using antibiotics properly.”

But if partners don’t speak the same language, confusion reigns. Hence the World Health Organization report telling us that 3/4 of us think that antibiotic resistance happens when the body becomes resistant to antibiotics (it’s the bug that becomes resistant to the drug). And nearly 2/3 of us believe antibiotics can be used to treat colds and flu, despite the fact that antibiotics have no impact on viruses.

As the other half of the partnership, patients have a role to play too. It can be as simple as asking your doctor which waitress they would prefer.

Moving away from paternalistic medicine

In a series of tweets yesterday the prestigious National Academy of Medicine called for the greater participation of patients in their own care, to which infectious disease expert Brad Spellberg, MD, tweeted, Yes! Need to move away from paternalistic medicine!

In fact, Dr. Spellberg, who is the CMO at the Los Angeles County-University of Southern California Medical Center, has a specific instance in mind where docs & patients need to work together more: to customize the duration of antibiotic therapy. Spellberg says it’s a myth – an urban legend – that patients must complete every dose of antibiotics prescribed, even after they feel better. He explains:

Every randomized clinical trial that has ever compared short-course therapy with longer-course therapy … has found that shorter-course therapies are just as effective … This myth needs to be replaced by a new antibiotic mantra: ‘Shorter is better!’ Patients should be told that if they feel substantially better, with resolution of symptoms of infection, they should call the clinician to determine whether antibiotics can be stopped early. Clinicians should be receptive to this concept, and not fear customizing the duration of therapy.

Aiding & Abetting Disease

 

We’ve got to stop focusing solely on the bugs. Decisions we make individually and collectively; for example, through legislation, strongly shape the risk of disease.

Exhibit A: Next week members of the House Energy and Commerce committee will vote to amend the Animal Drug User Fee Act (ADUFA) in a way that will greatly expand the use of antibiotic drugs in cattle, pigs, and poultry. That step, says the National Resources Defense Council, a U.S.-based environmental legal group, would be “rash, unforgivable, and will hasten the spread of antibiotic resistance.”

How increased use of antibiotics hastens the spread of resistant infections was explained by infectious disease expert, Brad Spelberg, MD, to an international audience via webinar this past February. Referring to our overuse of the drugs as an “ecological tidal wave of antibiotics,” he said:

But boy I’ll tell ya, we sure do our damnedest to educate them [bugs] to be resistant.

The amount of antibiotics that we put into the environment every year in this country is absolutely staggering: 21,000 tons every year in just the United States. And the rate of use in agriculture is not going down it is going up. It is continuing to increase despite our clarion calls that we have a resistance crisis. We truly have a problem, Washington.

Yet Washington’s response, according to the NRDC analysis, is to pour more antibiotics into the environment and do so with improper motive: “The Food and Drug Administration loves ADUFA because it requires pharmaceutical companies to pay tens of millions of dollars in fees that pay salaries and maintain FDA budgets. Pharmaceutical companies love ADUFA because it has greatly reduced the time needed for FDA to approve new animal drugs, meaning increased product sales and profits.”

In essence, the NRDC says the proposed amendments accomplish this by reducing the regulatory reach of the FDA over the use of antibiotics:

Since 1962, FDA’s primary job has been to make sure that human and animal drugs are both safe and effective. In 2004, Congress allowed “conditional approvals” which allowed companies to sell certain new animal drugs without submitting all the data showing that those products are effective. Congress intentionally limited these conditional approvals to minor animal species (like goats and rabbits) or to minor uses in major species (intended for small numbers of dogs, cats, pigs, cattle, turkeys, or chickens). They rationalized that because the markets for these products were so small, pharmaceutical companies needed lower costs to bother making them.

The problem is that now these same companies want Congress to expand conditional approvals to major uses in major animal species like cattle, pigs and poultry. These markets are enormous. If this provision passes, companies won’t have to submit all the data needed to approve drugs (including antibiotics) used in tens of millions of animals. [Emphasis in original.]

This ploy is dangerous to public health. It is laser focused on increasing the use and sales of drugs, including animal antibiotics. And that increase will speed up the development and spread of superbugs.

As bugs evolve so must our notions of what drives disease. A growing literature says “profit-driven diseases” are giving rise to pandemics. And thus we have, for example, a special report in next month’s Scientific American that shifts the focus from the bugs to us. They say that resurgent outbreaks of infectious diseases in the U.S. are sickening thousands, and the causes are societal, countering the “conventional wisdom that says that infections are caused solely by germs.”

 

 

 

 

How fast can bugs develop resistance?

Bugs can develop resistance to antibiotics during treatment and probably because of that treatment. As infectious disease specialist, Brad Spellberg, MD, told Frontline:

I have watched some of these pathogens develop new resistance in the middle of a course of therapy.

Just within days?

Within days.

That means that that antibiotic has basically stopped working while you’re treating the patient.

The way you know that the resistance has emerged in the middle of a course of therapy is the patient is very sick. You start the antibiotic; they get better. On day three or four, all of a sudden they get sick again, and back comes the same bacteria that you thought you eradicated. And now when you sent it to the lab, instead of “S” for “susceptible,” it says “R” for “resistance.”

So what do you do, switch to another and another?

If you have another, you switch to another.

But sometimes you don’t have another. Here’s Dr. Spellberg explaining what that’s like:

Good things happen when judges and doctors are rested and well fed

When we’re tired we take the easy way out. Psychologists call this “decision fatigue,” the idea that the quality of our decisions deteriorate over time as our brains get tired. No surprise there. The interesting bit, however, is that it applies not just to you and me, but also to judges and doctors acing in their professional capacity.

For example, a well-reported study of judicial decision making found that as court sessions wore on judges were far more likely to deny parole. The reason? Denying parole is what’s normally done. Thus as each case comes before the court, denying an application for release is the safe, easy option. To buck that trend and grant parole takes intellectual energy. Therefore, the study found, if you want out of jail your chances are “greater at the very beginning of the work day or after a food break than later in the sequence of cases.”

Similarly, with doctors, researchers asked the question whether decision fatigue would increase the likelihood of inappropriately prescribing antibiotics as the day wore on. And sure enough, in a study called Time of Day and the Decision to Prescribe Antibiotics, they found that inappropriate antibiotic prescribing “increased throughout the morning and afternoon clinic sessions … consistent with the hypothesis that decision fatigue progressively impairs clinicians’ ability to resist ordering inappropriate treatments.” (Chart below.)

The reason: Issuing the prescription is “again, the easy, safe, practice” because it conforms to a “perceived or explicit patient demand, a desire to do something meaningful for patients, a desire to conclude visits quickly, or an unrealistic fear of complications.”

The remedy involves doctor and patient. The physicians job, the authors suggest, is to modify their schedules, take mandatory breaks, or snack more frequently. Our job, as patients, is to stop asking for antibiotics and realize that they’ll be prescribed when appropriate.

And perhaps bring to the appointment, along with our insurance card, an apple for the doctor.

What do microbes look like? And how do they compare to various microcomponents of the human body?

Here are two helpful resources that let you into the world of the microcosmos so you can see for yourself what things look like.

The video begins by comparing the size and shapes of viruses to the much bigger bacteria, including Staphlococcus.

But the more detailed resource is this one from the University of Utah (sorry, it can’t be embedded). It takes you from a coffee bean all the way down to a carbon atom. Click on the cursor below the graphic and drag it to the right. It shows you not just the microbes, but how they compare to various well-known components of the human body. For example, you’ll see how bugs are smaller than a red blood cell or X chromosome, but larger than – in descending order – an antibody, a molecule of hemoglobin, methionine (an amino acid), glucose, and water.

The unaided eye can just make out the human egg; for anything smaller you need a magnifying glass or microscope.

So, about that rubber duck …

 

Folks over at The New England Journal of Medicine aren’t too impressed with all the media attention devoted to a recent paper in Nature about the bacteria they found inside your kid’s rubber duck.

Nor are they impressed by similar media stories reporting bacterial counts on, well, pretty much anything: the coffee maker, the kitchen sponge, TV remote control, the playground sandbox, your flight’s tray table, your doctor’s necktie, lab coat, and stethoscope, and so on …

The reason the NEJM isn’t amused is captured by the title of their story: News Flash – The World Isn’t Sterile. Indeed, if you look hard enough, they say, bacteria can be found literally everywhere. And thus:

What’s missing from all these studies, of course, is a correlation between identification of these bugs and any subsequent diseases. It’s not as if kids with rubber ducks were coming down with more infections than kids who don’t have them …

In summary, bacteria on common household, work, and travel items are ubiquitous; furthermore we lack any clinical data that this is important in any way.

In other words, all these news stories are unfair to the duck. It’s just a kid’s toy – it’s not R. Ducktococcus aureus.  

 

 

Spot the Urban Legend

“Sigh. This urban legend about taking every last dose must stop. Who is spreading this malarkey?”

That was the response yesterday of @BradSpellberg, Chief Medical Officer of the Los Angeles County-University of Southern California Medical Center, to the NBC News headline, below, concerning a countrywide outbreak of a drug-resistant bug.

 

 

The problem, of course, isn’t with the hand washing. It’s with the idea that you must take every antibiotic pill in your prescription. Dr. Spellberg is one of the leading proponents of the new thinking that “shorter is better.” He explains:

“Every randomized clinical trial that has ever compared short-course therapy with longer-course therapy … has found that shorter-course therapies are just as effective … This myth needs to be replaced by a new antibiotic mantra: ‘Shorter is better!’ Patients should be told that if they feel substantially better, with resolution of symptoms of infection, they should call the clinician to determine whether antibiotics can be stopped early. Clinicians should be receptive to this concept, and not fear customizing the duration of therapy.”

This new thinking is predicated on the understanding that antibiotics, while sometimes necessary and even lifesaving, come with serious side effects. Spellberg:

“Antibiotics are harmful. They’re not this thing that magically cures disease and has no unfortunate side effects – that’s not real. Antibiotics have lots of problems associated with them: They breed out resistance. They breed out superinfections like C. diff [an antibiotic-driven bacterial infection] and Candida [a fungal infection]. They cause side effects.”

For further information on adverse side effects associated with antibiotic use, see here and here.

 

 

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