The end of antibiotics?

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There’s been a big hubbub this past week about antibiotics. After Lancet Infectious Diseases reported the spread of a new drug-resistant superbug spreading from south Asia, news agencies around the world reported “panic” and “fear and loathing” over the  germs’ possible consequences. Some experts claimed the news was overblown –that the new bug was no worse than many others — even as other experts, meanwhile, opined that antibiotics could soon be obsolete altogether.

Writing last week in the British newspaper the Guardian, for example, editor and columnist Sarah Boseley asserted:

The era of antibiotics is coming to a close. In just a couple of generations, what once appeared to be miracle medicines have been beaten into ineffectiveness by the bacteria they were designed to knock out. Once, scientists hailed the end of infectious diseases. Now, the post-antibiotic apocalypse is within sight.

So who, then, is correct? Is the era of antibiotics really coming to a close, or are the fears over-hyped?

The truth is that either one of these groups of experts could be right. Quite simply, the effectiveness of antibiotics depends on how we choose to use antibiotics — how well we manage drug use in clinical practice and outside of it, and how well we prevent the spread of antibiotic-resistant bacteria without drugs.

Antibiotic resistance is not complicated. In fact, it’s one of the simplest demonstrations we have of evolution at work. If you get a bacterial infection, you can take an antibiotic to treat it. But there may be some minor genetic variation among the bacteria that are causing your illness, and some of those genetic differences may happen to make one particular bacterium more or less susceptible to the drug than other bacteria are. When you take your pills then, the most susceptible bacteria die off first — they’re the ones killed most easily by the drug — thus leaving behind the more robust bacteria. The more robust bacteria then reproduce, so that the next generation of the infecting bacteria is more likely to carry the genetic trait that confers resistance. If this process is allowed to go on for several generations — just as evolutionary theory would predict — the bacteria can become entirely resistant to the antibiotic.

All that this means is that overuse of antibiotics will lead to drug resistance. There is some dismal irony in the fact that British papers are (on the whole) wailing about the end of an era while the U.S. papers are (also on the whole) more sober, since it’s the U.S. that has much greater non-therapeutic use of antibiotics. Some 70% of American antibiotics — tens of millions of pounds of drugs each year — is used in animal feed, according to the Union of Concerned Scientists. Those drugs help to plump up animals for slaughter, since nasty infections might otherwise sap animals’ energy for growth. The European Union banned routine use of antibiotics in animal feed years ago because of evidence about its drug-resistance consequences for humans. Now the U.S. Food and Drug Administration is recommending the same for the U.S. as well, for the same reason. But for now the practice continues.

Antibiotic use is half of the drug-resistance equation, however. The other half is controlling the bacteria that have already developed resistance. There’s no doubt that bacteria like MRSA — methicillin-resistant Staphylococcus aureus — can wreak havoc on a healthcare facility. Immune to a wide range of all but the most powerful (and expensive) antibiotics, MRSA infections are extremely hard to treat in patients. And yet the rate of new infections is falling in the U.S. This success was not brought about by more impressive drugs or new medical technology. Instead, it’s due mostly to the disciplined, but frankly boring work of basic infection control: promoting hand-washing among medical staff, diagnosing new MRSA infections quickly, and then isolating infected patients so that they do not come in contact with other susceptible patients. This kind of basic infection control is a field where Americans, despite their fragmented healthcare administration, may actually have greater chance for success than, for example, the British. Say what you will about the inefficiencies of “over-capacity” in U.S. medical care. As an expert at the European Antimicrobial Resistance Surveillance System once pointed out to me, to isolate infectious patients effectively, a hospital needs an empty bed in a private room. That’s common in some hospitals in some parts of the world, but not in others.

Lastly, you too can make a difference in the fight against antibiotic resistance. First, don’t take antibiotics when you don’t need them. Many patients will request pills — any pills — when they’re feeling sick. But antibiotics won’t help against non-bacterial infections like cold or flu (both caused by viruses), so unless you’re immune-suppressed or otherwise at genuine risk for, say, an opportunistic bacterial pneumonia infection, please don’t bug your doctor for pills when you have (or your child has) a cold.

Also be sure to follow doctors’ orders. When you do have a bacterial infection, your MD will usually advise you to take all of the antibiotic medication you’ve been prescribed, even if you feel better after just a few days. This is to make sure you kill off as much of the bacteria as possible the first time around. If you kill off just some fraction of the bacteria (enough to make you feel better, for example, with your natural immunity fighting the infection comfortably), you may still be able to spread the surviving bacteria, which are more robust than usual. This kind of practice can lead to a slow build-up of antibiotic resistance within a community. Use wisely — because nobody wants to see the end of antibiotics.