Category: Antibiotic Resistance

Please Sir, I Want Some More …. Antibiotics: The over-prescription problem and a lesson from history

In the Charles Dickens classic Oliver Twist, we’re familiar with  the scene where the trembling waif of a boy famously asks, Please sir, I want some more, referring to a bowl of gruel. The sight of the vulnerable child not only evokes audience sympathy, but also the sympathy, and, ultimately, acquiescence to the request, by the mean-spirited men of the workhouse whose job it was to oversee child labor in Old England.

Modern day physicians are hardly the functional equivalent of the overlords of 19th century child labor; to the contrary, we can assume they only want the best for a sick boy or girl. But that wholesome desire, oddly enough, is where the modern and developing problem of antibiotic resistance often begins.

It goes something like this. The child accompanied by a parent comes to the doctor’s office with some combination of a runny nose, a sore throat, a cough, or chest congestion (not to mention signs of the ubiquitous middle-ear infection). The child may have a cold or the flu or is perhaps developing pneumonia and has been off school for several days. The problem seems to be getting worse and the family wants something – anything – to be done, which typically means they want to leave the doctor’s office with a prescription.

The doctor, feeling the pressure and wanting to do something, prescribes the modern day cure-all, the antibiotic. The doctor feels validated, she did in fact do “something;” if nothing else the placebo effect may actually do some good. And besides, she may think, what’s the harm? If the antibiotic doesn’t work these kinds of symptoms typically run their course in a week anyway. The child is happy because he knows he’ll get better because the doctor gave him medicine. And the father is happy knowing that he was able to do something for his child, confident in the knowledge that the doctor wouldn’t have taken this course of action if it wasn’t going to work.

We are left, however, with one tiny problem – antibiotics don’t cure viral infections and that is what the common cold, the flu, a lot of pneumonia’s and ear infections usually are. Nevertheless, variations of this scene are played out in doctor’s offices across the land at an alarming rate. According to a report this April in the New England Journal of Medicine, 250 million courses of antibiotics were prescribed in the U.S. in 2010 for a population just shy of 309 million. That translates to a whopping 833 antibiotic prescriptions for every 1,000 people. Jim Hutchinson, medical director for the antimicrobial stewardship program of the Vancouver Island Health Authority, commenting on Canadian physician behavior, told the Ottawa Citizen this past June that “doctors weren’t aware of the long-term effects of antibiotics … so they prescribed what they thought was a harmless cure-all rather indiscriminately.”

Hutchinson’s inference is clear: this is not a harmless practice. When antibiotics are prescribed when they shouldn’t be they wipe out healthy bacteria that are susceptible to it. What’s left is the drug resistant mutant strains that flourish because they no longer have to compete with the now defunct healthy bacteria. These strains are then passed between people and are thus able to rip through communities in countries throughout the world. The upshot is the global health problem of antibiotic resistance described earlier this year as an “apocalyptic threat” by Britain’s chief medical officer, Sally Davies, echoing similar concerns expressed by the World Health Organization, and the Centers for Disease Control and Prevention in the U.S.

It’s crucial to understand that this global problem begins very near home, at the local doctor’s office, where a sick child, a caring parent, and a well-meaning doctor all too often unwittingly conspire to do the wrong thing – misuse an antibiotic.

We have a hard time imagining the scene in the doctor’s office as anything but wholesome. But there might be another way to look at it. What if antibiotics were available to the overseers of the 19th century workhouse and they had laced young Oliver’s bowl of food with them? And as a result of this common practice tens of thousands of English people, including children, died each year because they had contracted a bacterial-caused infectious disease no longer susceptible to an antibiotic.

In hindsight, it’s pretty obvious how we would view such a practice.  And it raises an important question for us today: how is that practice any different, morally or practically, than what’s being played out on a daily basis in doctor’s offices today?

MRSA’s Image Problem is Killing Us

MRSA is a worldwide problem. In the U.S. alone at least 19,000 people die every year because of it. 100,000 more become infected with a disfiguring, disabling, life-altering MRSA-caused disease. And studies in the U.S. and Canada show the problem increased 17-fold over an 11 year period beginning in 1995. Yet neither government nor the public seems concerned. Why is that?

Daniel Kahneman is a 77 year old Israeli psychologist. He won the Nobel Prize in Economics in 2002 for explaining the wayward thinking that is behind poor economic decision making. He was presented with the American Psychological

an Israeli-American psychologist and winner of the 2002 Nobel Memorial Prize in Economic Sciences.

Association’s Award for Outstanding Lifetime Contributions to Psychology in 2007. And his life’s work was turned into his 2011 New York Times best-selling book Thinking, Fast and Slow.

Our problem, says Kahneman, is that we “think” too emotionally and quickly and as a result we get important things wrong: often times it is the fear factor at work. That explains why we are afraid of certain kinds of well publicized but low probability risk but indifferent to more objectively dangerous but less probable ones. Murder, accidents, and terrorism get headlines. Diabetes and asthma don’t. So you are more likely to be afraid of the first 3 despite them being far less likely to affect you. Studies show that people judge deaths by accidents to be more than 300 times more likely than deaths by diabetes, but the true ratio is 1:4. And while death by disease is 18 times more likely than accidental death people judge the two as being about equally likely.

Kahneman calls this the “availability heuristic.” It means that we assess the relative importance of issues by the ease with which we can think of examples of them. Therefore the more dramatic an event, the more vivid the imagery associated with it, the more it’s attached to celebrity, and the more it’s replayed in the media, the easier we can retrieve examples from our memory. The most recent example of this is Asiana Flight 214 that crash-landed in San Francisco this past Saturday morning killing 2 and seriously injuring dozens more. Such a remarkable event, easily retrieved from the memory bin, is what causes us to grossly exaggerate the frequency and dangerousness of events – like travelling by air.  Importantly, it’s not just the public that falls prey to this kind of  thinking, our government decision makers do too, and perhaps no more so than in the context of terrorism.

We are more likely to drown in a bathtub than we are to die from a terrorist attack. However, since 9/11, life in the United States has been turned upside down, including the way in which the federal government allocates funds in an effort to deal with this perceived risk. There was a shift of tens of millions of dollars of federal research money since 2001 away from pathogens that cause major public health problems to obscure germs that the government fears might be used in a bioterrorist attack. So much so that according to a 2005 report in the New York Times,  758 scientists including 2 Nobel Prize winners petitioned the U.S. Government’s National Institutes of Health  saying grants for research that cause anthrax and 5 other diseases that are rare or non-existent in the U.S. have increased 15-fold since 2001. Over the same period grants to study bacteria not associated with bioterrorism including those associated with tuberculosis and syphilis have decreased 27 per cent. One of the petitioners, Sidney Altman, a scientist at Yale, who won the Nobel Prize in chemistry in 1989, said that while a risk of bioterrorist attack existed he considered it “a very minor factor” among all the risks faced by the nation.

Communities like MRSASurvivors need our support to change the MRSA image problem

So given all of this, what chance does MRSA and its cousin pathogens have of capturing public imagination and government health care dollars? On the face of it not a lot, however, there is an important precedent in the history of infectious disease that suggests otherwise.

In 1981 another then unknown disease was making its way into the United States: HIV/AIDS. The Centers for Disease Control dubiously labelled it the “4H disease” because it affected Haitians, homosexuals, heroin users, and hemophiliacs. The stigma resulted in horrific behavior towards a suspected carrier: they’d be subject to compulsory testing, mandatory quarantines, and violence. If you had it you were scared to tell anyone, health care workers quit their jobs rather than risk infection while treating someone who had it, and government treatment programs and research dollars were virtually non-existent. The word AIDS became a code word for any shameful malady. And if you got it, you died. Yet today, HIV/AIDS is no longer a death sentence. People have it and lead full lives. There is much more public understanding and acceptance, and there’s government support for programming and research.

There are several reasons for the turn-around but one event in particular drew the attention of University of Central Florida social scientist Philip Pollock: In 1991 Magic Johnson told the world he was HIV-positive. What had been stigmatized as largely a “gay disease” now had a very different face. Pollock wanted to know if Magic Johnson’s public acknowledgement mattered. This fit nicely into Pollock’s interest in how you go about changing the public’s perception of issues. What he found was that immediately after the announcement and again 10 months later the public “constructed” their view of AIDS more positively, and that included a 15-point increase in support of AIDS spending. Pollock says that intense, public, value-laden communications, or “critical moments,” are of key importance in changing public awareness and opinion of issues.

This is exactly what Kahneman is saying. The flip side of dramatic personal testimony constantly played out in the media is marshalling statistics about obscure-sounding Latin-named pathogens. No matter how strong the numbers are the public and our representatives in government can’t “hear” them: that’s just human nature, says Kahneman. As he puts it, “the world in our heads is not a precise replica of reality.” In other words, it’s not just the pathogens that we have to confront it’s also the flawed way in which we think about them.

It’s only a matter of life and death.

The Rise of Superbugs: How Far Have we Come?

In 1969, U.S. Surgeon General William Stewart reported to congress that it was “time to close the book on infectious diseases”. The advent of penicillin and methicillin in the 1940‘s and 50‘s changed the face of medical history and how bacterial infections were treated. The discovery and commercialization of antibiotics saved countless lives back then, but how effective are antimicrobial agents today?

In a recent publication of a study from the journal Infection Control and Hospital Epidemiology, it was reported that one in twelve adults in Canadian institutions are either colonized or infected with a superbug. Superbugs are strains of bacteria that have become resistant to one or more antibiotics, making them difficult to eliminate and contain. There is an important difference between being colonized with a superbug and being infected by one of these pathogens. Being a host to superbugs may not result in disease if the patient’s immune system is functioning correctly, but if the patient is immunocompromised, they may be at increased risk. As an example of what can happen if one is susceptible to disease and acquires a superbug, the mortality rate for those with MRSA as well as pneumonia is between 20-40% (1).

The utilization of antibiotics has increased dramatically over the past fifty years in both humans and animals. In 1954, 2 million pounds of antibiotics were produced in the United States (2) while in 2011, 29.9 million pounds of antibiotics were consumed in the U.S.(3) The rise of antibiotic consumption is due to their powerful medicinal effects but also their effectiveness as growth promoters. In fact, around 80% of all antibiotic consumption in the United States is from the agricultural industry (4). This increased usage of antimicrobials in human and animal populations has led to the rise of drug resistant bacterial strains such as MRSA (methicillin resistant Staphylococcus Aureus), VRE (vancomycin resistant Enterococci), and Clostridium difficile (C diff).

The conventional methods of treating and mitigating the spread of superbugs are to reduce unnecessary prescription of antibiotics and to enforce high standards of infection control in hospitals. Technology can also play a significant role with the use of aPDT (antimicrobial photodynamic therapy) to eliminate pathogenic bacteria. Vancouver General Hospital implemented a year long program using the MRSAidTM nasal photodisinfection system. MRSAidTM applies photodisinfection technology to decolonize harmful bacteria in the nose prior to surgery (the nose is where most MRSA reside). This process is entirely non-antibiotic, eliminates the need for patient compliance, and does not result in increased microbial resistance. In addition to reducing surgical site infections, the program was so successful that it freed up an additional 553 patient bed days, enabled 138 additional surgeries to be performed, and saved the hospital $1.9 million in costs.

This advent of nasal photodisinfection technology means that health care practitioners now have a three-fold armamentarium available to decrease the incidence of bacterial resistance while maintaining a high standard of patient care. The judicious use of antibiotics, consistent infection control procedures (such as hand hygiene compliance), and the implementation of advanced non-antibiotic technology such as nasal photodisinfection are all important tools.

With the assistance of new technology and optimal infection control practices, we are moving one step closer to what Surgeon General William Stewart declared in 1969, and perhaps may one day close the book on infectious diseases forever.

(1) http://www.cbc.ca/m/touch/canada/story/2013/05/13/antibiotic-resistant-superbug-hospital-canada.html
(2) “The Killer Within”, Michael Shanyerson and Mark Plotkin, pg. 14
(3) http://www.cbc.ca/m/touch/canada/story/2013/05/13/antibiotic-resistant-superbug-hospital-canada.html
(4) http://www.motherjones.com/tom-philpott/2013/02/meat-industry-still-gorging-antibiotics

Antibiotic Usage needs to be Studied for Long Term Harm

Apart from the creation of superbugs, overuse of antibiotics has negative consequences including killing many of our beneficial bacteria.  In the grand scheme of things, little is known about the bacteria we live with, and how they individually as a species, and collectively in combinations forming biofilms, get affected by various exposures to our antibiotics.  Insufficient research is being conducted to help us find the answers.

Some research has suggested that antibiotic use may play a role in conditions that lead to obesity, Type 1 Diabetes, inflammatory bowel disease, allergies and even asthma, a common chronic airway disorder. Patient populations suffering from all of these chronic diseases appear to be increasing in prevalence, but very little is being done to understand if anything in contributing to all of these conditions as a group instead of just individually.

In agriculture, antibiotics have been used as “growth promoters” enabling farmers to increase their livestock yield, as their animals can gain more weight with less food. The influence of these antibiotics on the livestock we eat is likely to have some impact on our own bodies but this field has not yet been adequately investigated primarily due to lack of financial motivation. In Europe, where usage of antibiotics in livestock as growth promoters has been banned, it was determined that the same dollars spent on extra food resulted in the same growth as yielded by the additional antibiotics.

Given that antibiotics are a critical part of our medicinal arsenal, it is not likely that antibiotics will be replaced any time soon. However, it is important to start asking the questions and dedicate more resources to learning more about how the antibiotics we use directly and indirectly are truly affecting us. Once we learn more about this impact, then we can start to make progress in influencing the development of new alternatives and better approaches to antibiotic usage.

Antibiotic Awareness Week: Stepping up to the Challenge of Antibiotic Resistance

Imagine a world where antibiotics are no longer effective and where even the simplest of illnesses, such as strep throat or a urinary tract infection, can lead to permanent disability, or even death.  Now imagine the effect this may have on your family or loved ones—watching an elderly parent die from pneumonia, or a child losing a limb from an antibiotic resistant infection.  Whether we like it or not, our lives have become intimately connected with the fate of antibiotics.  Chances are we’ve all been treated at some point or other—for childhood illnesses, such as ear infections or strep—or even for something as small as a complicated scrape.  Chances are we’ve also taken antibiotics for granted.  Unfortunately, antibiotic resistance is quickly catching up to even the strongest antibiotics in our arsenal—potentially limiting their future use and effectiveness.

This is the primary focus of Antibiotic Awareness Week (Nov. 12 – 18): a campaign meant to educate various groups on the dangers of antibiotic resistance and warn of inappropriate use.  Sponsored by antibioticawareness.ca, and backed by an international coalition of healthcare and disease control organizations, the event features international meetings, webinars for health professionals, fact sheets, and downloadable awareness posters. Read More

The Human Microbiome Project: When Bad Bacteria Turns Good

When we think of antibiotic misuse, we often think of how it contributes to big name superbugs such as C. diff and MRSA. But what often goes overlooked is how antibiotic misuse affects the many microbes that are beneficial to our health. While the Human Microbiome Project is a step in the right direction towards learning more about combating horrible diseases like C. diff, it is also a huge advancement in terms of understanding which microbes truly benefit us—and which ones we may have been too quick to label as hazardous to our health.

Take for example the germ H. pylori. During the 1980s, it was discovered that H. pylori was a causative agent for peptic ulcers. While this major discovery resulted in the treatment of such individuals by aiming to eradicate H. pylori microbes from the stomach, researchers are now discovering possible adverse implications of this.

Before I begin discussing how the Human Microbiome Project has already impacted our knowledge of H. pylori, I want to make it clear that I am not by any means suggesting that this particular microbe is not hazardous to our health. In other words, I’m not suggesting you go and ingest H. pylori as Barry Marshall did in order to validate his theory about H. pylori and peptic ulcers. Read More

Foreign Superbugs Invade The U.S

Two new cases of what is being deemed an emerging “superbug” have been confirmed by the Centers for Disease Control and Prevention. Both cases occurred in my home state of Rhode Island, and bring light to an emerging threat that people need to be made more aware of.

This new threat, known as carbapenem-resistant Enterobacteriaceae (CRE), describes a family of germs that are highly resistant to many antibiotic treatments. CRE can be found in the normal gut flora of humans, where such bacteria can survive without causing any clinical problems in healthy individuals. For those with compromised immune systems however, CRE can wreak havoc through mechanisms of destruction similar to that of C. diff and other opportunistic pathogens.

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Over 100 Million Doses Of Antibiotics Are Administered Every Year

More than 80 years ago, Alexander Fleming, a bacteriologist, theorized that antibacterial would be found in his own nasal mucus.  During his experiment, a spore of a variant called Penicillium notatum accidentally contaminated his culture plate of Staphylococcus bacteria. This mold released a substance that inhibited the growth of the bacteria, leading to the breakthrough discovery of penicillin which triggered the beginning of a worldwide medical revolution.

Antibiotics, such as penicillin, have greatly reduced illness and death from infections. Today, 130 million doses of antibiotics are administered every year, and up to half of these have been deemed as unnecessary.  One of the main reasons for this occurs when antibiotics are prescribed for viral rather than bacterial infections. As a result, bacterium such as MRSA (Methicillin-resistant Staphylococcus aureus) have “learned” to develop resistance against common antibiotics and have begun to cause severe infections that are expensive to

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The Rise of Superbugs- MRSA In The News

Welcome to a world where drugs don’t work – MSNBC March 31st, 2011

When Alexander Fleming discovered in 1928 the first antibiotic, penicillin, we believed that we had the tools necessary to beat bacteria. We understood that bacteria could develop resistance to antibiotics, but were quick to assume that scientists were always one step ahead of the game. Today, this is no longer the case. As this MSNBC article points out, antibiotic resistant superbugs have become a global problem, and we may be heading towards a pre-antibiotic era of medication where we will be unable to treat simple infections.

How did we get to this point? For many years now, we have been living in an era of antibiotic dependence. Considered “wonder drugs,” antibiotics are too often prescribed inappropriately by doctors, or are being used far more widely than for the treatment of sick patients. According to the US FDA, 29 million pounds of antibiotics are given to food-producing animals every year, accounting for ~ 80% of all antibiotics sold in the US. The more that people are exposed to these antibiotics, the higher the likelihood of them developing resistance and rendering these medications ineffective. Read More

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