Relevant story: As a kid, one of my friends would frequently get strep throat. So his mom would give him amoxicillin until he appeared better... and then save the rest of the bottle for the next time he'd (invariably) get strep throat.
This was precisely addressed by Sir Alexander Fleming's 1945 Nobel Prize speech:
“But I would like to sound one note of warning. Penicillin is to all intents and purposes non-poisonous so there is no need to worry about giving an overdose and poisoning the patient. There may be a danger, though, in underdosage. It is not difficult to make microbes resistant to penicillin in the laboratory by exposing them to concentrations not sufficient to kill them, and the same thing has occasionally happened in the body.
The time may come when penicillin can be bought by anyone in the shops. Then there is the danger that the ignorant man may easily underdose himself and by exposing his microbes to non-lethal quantities of the drug make them resistant. Here is a hypothetical illustration. Mr. X. has a sore throat. He buys some penicillin and gives himself, not enough to kill the streptococci but enough to educate them to resist penicillin. He then infects his wife. Mrs. X gets pneumonia and is treated with penicillin. As the streptococci are now resistant to penicillin the treatment fails. Mrs. X dies. Who is primarily responsible for Mrs. X’s death? Why Mr. X whose negligent use of penicillin changed the nature of the microbe. Moral: If you use penicillin, use enough.”
Every time I've filled a script for antibiotics, they have been accompanied by very prominent written warnings that you must complete the full prescribed course. Often reiterated verbally by the pharmacist.
But has the warning ever said why you should complete the course? I always assumed (until recently) this was to prevent reinfection, not resistance.
Stern warnings with no information about possible consequences is heavily lambasted in movies, yet we repeat this behavior with medicine and expect different results.
If you tell someone not to do something and don't tell them why not, and the consequences aren't otherwise clear, expect them to do what you said not to do.
Was going to say the same thing. My doctors have always told me to finish the prescription, but never once why.
My mother was a nurse so she always reminded me of the critical missing reason why, and I've always dutifully finished all antibiotics prescriptions as a result.
But that was a simple thing the doctors writing the prescription should have been doing themselves, and an apparent systemic failure of the medical profession to account for messy human psychology in a critical procedure.
It astonishes me that people would be prepared to acquiesce to authority when a doctor tells them to ingest these drugs that they really know very little about, but draw the line at accepting the advice about taking the whole course of drugs.
Most doctors dont have the types of antibiotics memorized by heart either unless they work in a specialty or ER. There are cell wall destroyers, folic acid synthesis interruptors, protein synthesis disruptors, etc. [1]
Gone are the days where a doctor should be taken at his judgment 100% as if medicine is a black box enigma. The average HNer would be wise to google about their conditions and drugs they consume. A doctor can only remember so much - they are primarily valuable for their experience in hueristic diagnosis -- not for knowing everything medical and everything pharmacutical. It is wise to relinquish some responsibility to a professional but not all.
Most of medicine aside from surgical methods can be understood by a mildly intelligent person who cares enough, because of wikipedia and google, everything except actual experience is very accessible.
I dont see how your astonishment is anything other than misinformed hyperbole.
People will take all kinds of advice when they're trying to feel better but once they feel good, they want to get back to partying ASAP and the doctor says no drinking while taking antibiotics.
TL;DR - In the early days of penicillin, it was used to treat various STDs. Doctors strongly advised their patients that alcohol was not to be consumed while taking the anti-biotics, not because there was a chemical interaction between the medicine and the infection, but to lower the odds of the patient getting wheeled one night and re-infecting themselves.
I think another factor is just intuition: taking medicine when you feel ill makes sense, but continuing to take the medication for several days after you feel completely recovered seems intuitively wrong to a lot of people.
Yep, you're intelligent enough to make the correct assumption. Unfortunately, I presume many others are not and could really use a little extra education by the pharmacist dispensing meds -- so they also understand the why.
Not the ones that I've encountered... they used the same dose at the same intervals for the whole period of time... maybe to keep a lethal level in your system the whole time.
I definitely remember receiving blister packs, decorated with directions and pill groupings that started with 2 pills, at high intervals like every 6 hours, then tapered to 2 pills every 12 hours toward the end of the first week, then 1 pill every 12 hours for the remainder of the pack, and included strict instructions to use the whole thing.
I got strep throat a few times as a kid. I don't have perfect recall about the details of what I had to take and when or why, though. But I do remember having to vary dosage.
Exactly this. If it's so vital that we finish the dose, why don't you make a bigger deal out of it? I feel that doctors simply don't care enough. Is there any other explanation?
This is actually typical bad parenting or poor management. Whilst orders without explanation work in the army through absolute discipline, it doesn't work very well with people who haven't been conditioned to it.
Given an instruction when you don't understand the "why" is highly ineffective. As seen by your experience with your doctor.
There is also a further problem in that antibiotics treat not just you, but prevent infection in the wider population. People in general find it hard to think about the wider impact, which is something we see every day with regards to the world wide population's regards to the impact of their own pollution. It's why we recycle but then drive SUVs.
I just got a course of antibiotics, so I asked why should I finish it (because it said so on the package)? The answer from the lady of the medical staff: otherwise the inflammation would come back.
But they don't explain why, and warnings are overdone due to litigation fears, so people will often use their own judgment, and without understanding the concept behind why, they may choose unwisely.
"Take all of the prescribed medication" : "They're just greedy and want to make me buy more"
vs.
"Take all or you'll breed antibiotic-resistant bacteria that cannot be treated and you will die and kill the human race" : "I better follow this prescription"
If you're the sort to believe it's just a conspiracy to make you buy unnecessary quantities of drugs, then why wouldn't you also presume that the story about antibiotic-resistant bacteria is also part of the conspiracy?
Because the scale isn't binary here - you don't have only a) people who blindly trust doctors, and b) people who are conspiracy nuts.
Both of them are wrong, btw. Pharma companies are greedy and they do everything they can to make you spend more. Doctors are influenced by them, often very subtly. That is a fact, not a conspiracy. But the fact also is, that doctors save lives and most have noble intentions (despite the meat grinder medical career is). One needs to learn what information belongs more to "greedy companies" category, and what belongs to "life saving science" category. It's no surprise people get confused about this - and that's why you absolutely need to explain to them why they need to finish antibiotics treatments.
"they have been accompanied by very prominent written warnings that you must complete the full prescribed course"
I'm ashamed to admit that the big part of my adult life I didn't know the reason behind that, and always assumed that to be of a kind "you must eat your whole meal" constantly told by grandma. I'm sure I'm not the only one..
Oh my god the number of arguments I've had with family and friends, even my girlfriend over this. Why do people think they can stop antibiotics when they "start getting better"?!? It's not a virus ffs
Probably because they have no clue how they work, and they don't have a good mental model of diseases and bacteria. Aka. they don't understand the "why". A bit of explaining would definitely help.
I agree with the observation that telling people to do something without explaining why is stupid and will only lead to disappointment.
yeahhhh I thought it was just because although you feel better you could still be in part of the infection cycle, not because the remaining germs were probably now resistant.
For a long time since 1945, many humans have believed a supernatural being created the human race thousands of years ago.
Understanding the process that leads to antibacterial resistance requires understanding evolution. So it's no surprise that much of the world fails to understand it.
In a bizarre conversation with a coworker once, they insisted (and of course they knew because their parents are doctors) that bacteria don't become resistant to anti-biotics, people's bodies do.
Turned out this was a major point of the anti-evolution stance at his church. I've since encountered the same viewpoint from a number of other people, all going to primarily small, ostensibly non-denominational, churches.
I am happy to base my work on the currently best working scientific models.
My faith is also based on "best practices": what worked well for my parents, grandparents and me and which also happened to help create the western culture we enjoy today.
"Render therefore to Caesar the things which are Caesar's; and to God the things that are God's."
> But you have no evidence that your ancestor's faith worked well.
I am, to a certain degree, that evidence. (Edit: this holds true to some degree even if you look at it from a purely techical POV which makes me smile : )
> Probably the opposite, if you look at any conflicts they were involved in, or what social advances were blocked.
This is meaningless unless you also take into account the advances brought forward because of it.
And, FWIW, you have to cast your net wide and far to find anything real horrific.
This is not to say we are better people than other, but trying to say our faith made us worse than the alternative (warrior tribes as they existed some hundred years ago) seems very wrong.
The point of Creationism (the non-laughable variety, at least) is that some transcendental being designed this Universe with all its fundamental laws and specific constants, including Evolution, with the express intent to have us here, now, in the exact shape we are.
It is not something that can be easily refuted, BTW, nor proven. Which is why it's a matter belonging to faith and not science, for now.
> The point of Creationism (the non-laughable variety, at least)
This is a strawman, as it's quite explicitly not what's being discussed in the parent comment, which specified "created....thousands of years ago" (I assume that kind of creationism is what you're referring to as "laughable").
Yeah, complaining about religious scientists often seems to be an exercise in selectively applying high standards.
There are a lot of atheist scientists that are perfect bayesian reasoners while doing research, but when they step out of the lab they suddenly get as irrational as the rest of the general population. People are way too good at compartmentalizing beliefs.
that's because it doesn't seem to be a technical hurdle, it seems like it's a social issue. We, as a species, haven't proven terribly adept at handling those yet.
It's actually really easy to handle the problem, you have a few sets of anti-biotics and you rotate through sets every 5 years.
Furthermore in Hospitals you make people wash their hands (as in you post security gaurds at the hand washing stations and none shall pass a station without washing) and you have separate wards for those with MRSA and those without MRSA.
If you need an antibiotic that is not in rotation, you are hospitalized while everyone makes sure you take your full course.
Doing these things eliminates about 90% of the problem.
There are other problems. There are doctors that give antibiotics for obviously viral infections, just to give the patients some assurance.
There are third world countries that don't care and will not follow any of those rules. Also foreign prison systems, particularly in Russia, which breed TB.
Then there are people that are prescribed low doses of antibiotics for things like acne. I imagine that's a huge risk more than all the other things, taking it every single day.
And, as others have mentioned, agriculture uses about 50% of the world's supply of antibiotics IIRC, and that's not really safe.
That was precisely my point. What to do isn't the problem, as you pointed out so succinctly, it's really easy to solve this problem technically. What's the issue here? People and businesses they own aren't following the "optimal" plan, thus it is more of a social issue in getting everybody on the same page.
> We have collectively decided that the cost/benefit is not worth it.
I don't think the decision has been conscious.
More importantly the costs and benefits haven't been amortised over the life (and impact) of those decisions. Or, if you will, it hasn't been worth it yet. Unfortunately at the point where we can properly assess the enormous cost of these decisions, the opportunity will be long gone.
It is absolutely conscious. Mainly conscious by politicians and lobbyists, who are high powered but generally fail a science literacy test.
And our population, we, are the ones electing them.
Reminds me of the climate change warning made by one of the researchers from ExxonMobil back in 1981.
When I see something like this I start to question our governing system. Its way to slow and sluggish to react to these kind of events that requires immediate attention.
The problem is the signal to noise ratio. Every day you have catastrophic predictions from asteroids, super volcanoes, big earthquakes, new ice age, peak oil, loss of ozone layer, loss of biodiversity, solar storms, ... All with dire consequences.
Each of these events would cost a few (hundreds of?) billions to address or mitigate. It requires a super human intelligence to separate the chaff from the wheat. And this is hard to know what is scaremongering, and what is really dangerous.
> And this is hard to know what is scaremongering, and what is really dangerous.
Indeed. Also there are increasing evidence that many scientific studies aren't reproducable.
We need a better System to identify 'useful signals' among noises. But in our current socio-economic structure, this topic never comes up as the most important issue. Abraham Lincoln founded National Science Foundation that laid out a solid ground work for this movement, but nobody(correct me if I am wrong) picked it up where he left of and pushed Scientific inquiry as one of our top agenda.
Reasons for agricultural antibiotic use are twofold.
On the one had it is as you said, as a preventative measure to head off infection (which is obviously very bad), but it's worse than that - industrial farmers use antibiotics so they don't have to inspect and treat each animal. Just dump antibiotics into their food and if they are injured somewhere along the way it will hopefully heal on its own. Inspecting and treating each animal individually would be a lot more expensive.
The other reason antibiotics are given to livestock is to cause weight gain. If the antibiotics cost less than the value of the extra meat produced, then you make more money.
It's a fucked up practice that we'll be all pay for in a few decades.
Note the wiki page is an ok source, but is in need of some attention from someone outside the industry.
How about a startup that uses image recognition from video feeds to identify and track individual anmials, and then tags those to be medicated once symptoms pop up? Or will the continuing dosage of antibiotics in the food prevent symptoms from appearing at all?
I see some great opportunities in technology for streamlining processes behind fair and high-quality agricultural products.
Even if they are sick, we shouldn't medicate them. Sick animals should be a loss ("too bad, you should've not let them get infected") because every other option creates resistant microbes that lead to human misery and death. Of course, even that wouldn't be a total loss; you can still turn the animals into pet food.
If we were serious about humanity's future, antibiotics would only be given in hospitals and all of your bodily waste would be incinerated until it no longer tests positive for antibiotics. You'd leave the hospital with a shaved head too, since hair may come to contain the antibiotics as it grows.
The real issue is that continuous low dosing of antibiotics increases weight gain, for not entirely known reasons, even when given to animals that don't otherwise appear sick.
This is a case where government just needs to step in and ban the practice.
This sounds like an "Internet of things" opportunity: an implant that monitors an animal's temperature, antibody levels etc. Then they could target only the animals with telltale symptoms.
The implants would likely be pretty cheap -- a one time purchase of an RFID sensor encased in glass or similar non-immunogenic coating. RFID tags are on the order of a few cents. Probably this type of sophisticated sensor is going to be more like a few dollars in quantity.
The reader and the software are going to be a few hundred dollars or maybe a couple thousand. But it's a one time investment, plus ongoing implants as the herd changes over time.
I suspect the main selling point is going to be the one-time capital investment aspects and the fact that antibiotics are being painted as an undesirable additive in meat and dairy. When the general public starts to dislike a substance, suppliers scramble to distinguish their products, e.g. "No added growth hormones" and the like.
So you're saying the correct answer is a massive tax on all antibiotics not dispensed in response to a human doctor's prescription for a patient that is seen?
Both those points are valid, however possibly there is a market for people who would pay more for meat that they know hasn't been pumped with antibiotics?
Maybe the startup could manage to do it for a cost that's less than organic meat?
Example: almost all turkey meat that's so in fashion today comes from farmers that use antibiotics as preventative measure. I personally source meat from small family run farms that adhere to biological agriculture principles, (there only ill animals get antibiotics and those aren't butchered and sold later as meat).
<rant>
You won't believe how prevalent this is in India. You can hardly count people who'll take the full course of antibiotics. The general rhetoric is 'oh I'm fine' or the doctor is an ass, he always prescribes more than required. Not one person, even the so called educated class adheres to what the physician says, they all somehow think they know better and in the process, endanger every one else's life.
</rant>
Primary care doc here. I agree that strep is "severe" as in "makes you uncomfortable with a fever, sore throat, enlarged tonsils, etc" but the infection generally resolves without antibiotics, if given proper time. The main rationale for treating strep pharyngitis (aside from appeasing patients) is prevention of rheumatic fever, a rare but devastating heart condition that occurs as a sequelae of untreated strep throat. Given the rareness of RF in the developed world, there are those in the infectious disease and primary care communities who think it is an excellent example of antibiotic overuse.
I had untreated strep when I was a kid, because the strep screen came back negative. Turns out it was group C, which didn't show up on the strep screen, but also didn't resolve itself. Some months later it got much worse. Somebody finally did a culture, figured it out, and gave me antibiotics (which cleared it up). Fast forward to age 29, when I had to have open heart surgery to get a mechanical mitral valve, for which I have to be on warfarin for the rest of my life (which comes packaged with increased risk of stroke and hemorrhage for the rest of my life) along with a beta blocker ('bystolic', aka nebivolol) because something happened to mess up my heart rate regulation during the surgery. I'd call strep pretty serious.
I'm very sorry to hear about your medical situation. I agree that RF and RHD are very serious ... my comment was only to say that treatment of a (frequently) self-resolving condition with 10 days of strong antibiotics has been an ongoing topic of debate due to the likely contribution to antibiotic resistance among other concerns. Here's a representative editorial from a few years ago:
Your condition is the reason that I find myself prescribing courses of amox even when chances of chronic strep colonization are much more likely than true acute infection. It's a real diagnostic quandary.
The key words there are appeared better, meaning that the mother halted the treatment once the child was no longer symptomatic. Assuming that the author of the parent comment is from the US or EU then the amoxicillin would have been prescribed. If the course of treatment was carried out then there would not have been any amoxicillin left over.
I think his point was that the boy's mom wasn't careful to ensure all the bacteria had actually been killed. The boy probably kept getting strep because some bacteria had survived and thus the bacteria could have become resistant to the antibiotic.
I used to work with a guy who bought veterinary antibiotics, cut them in half until they were a human dose, and took them whenever he felt a sniffle, and stopped when he felt better.
And he completely understood the concept of antibiotic resistance. He just gave a sheepish grin when I confronted him like "Aw, shucks, ain't I a scamp". He was a really nice guy, except for this case where he was a sociopathic asshole.
Ah, The Futility Illusion "If I don't do it, somebody else will."
It is a famous and time-honored rationalization that sidesteps doing the right thing because the wrong thing is certain to occur anyway. The logic is faulty and self-serving, of course. Sometimes someone else won't do it. The soldiers asked to fire on their own people when the Iron Curtain governments were crumbling all refused, one after another. Sometimes someone else does it, but the impact of the refusal leads to a good result anyway. When Elliot Richardson was ordered by Richard Nixon to fire Watergate Special Prosecutor Archibald Cox, he refused and resigned. Cox ended up being fired anyway, but Richardson's protest helped turn public opinion against the White House. Even if neither of these are the final result, the individual's determination to do right is always desirable in itself. The Futility Illusion is just a sad alternative to courage.
I thought this would be some people's reactions because they don't want to address the science. It could very well be possible that we are under prescribing antibiotics to the point where they can stay in the population long enough to develop immunities. Everyone seems to think this a crazy idea, but can't produce a shred of evidence to refute it.
Do you have any scientific evidence to back up your theory? Or, said another way, where is this science you speak of documented and tested?
As far as evidence against your theory, evolution (e.g. bacteria becoming resistant to antibiotics) is the result of mutation and selective pressure. If antibiotics are never used, then there is no selective pressure. Significant percentages of a bacterial species do not just decide to become immune to some antibiotic that doesn't exist or is never used.
When the selective pressure of an antibiotic is present, however, those mutations that provide immunity to the antibiotic are selected (as the others die) and become a larger percentage of the total population of the species.
This is also why you take the full dosage of an antibiotic. Otherwise, you leave the most resistant alive (those more vulnerable to the antibiotic die first, in theory).
Also why farms are considered to be the leading cause of antibiotic resistance. By constantly administering antibiotics when they are not needed, you are providing a constant selective pressure, forcing adaptation to occur.
The science tells us another thing, too: because the mutations that provide the antibiotic resistance tend to reduce fitness in other ways (there's always a tradeoff), in the absence of the antibiotic in the environment the non-resistant strains will tend to become dominant again.
Bacteria survive outside of the human body. Without an immune system to clean up the stragglers antibiotics 100% of the time fail to kill off the entire population.
Bleach is vastly more effective at sterilization than any known antibiotic. Their only advantage is inside an organism by nocking things back immune systems can win. However, for example in imunocompromized people they have minimal effect.
It's well known that bacteria live and reproduce outside the human body. Many strains, like listeria or salmonella, can live in food, outside of any human or animal host. Cholera lives in sewage. Also, animals are reservoirs for a large number of bacterial species. Unless we're going to dose all humans, all animals, and the environment as well, then we're not going to succeed.
Further, 80% or so of most antibiotics get excreted right out of the body in urine within a matter of hours. This means that the environment is going to get dosed with a low level of antibiotics, just the perfect environment for breeding immunity.
Finally, bacteria can exchange plasmids inter-species, so if some innocuous bacterium in the environment develops immunity, it can transfer that to a virulent species at a later time.
Your paragraphs 3 and 4 and excellent points I hadn't considered.
I think however it's not enough to conclude that consciously avoiding using antibiotics provides a net gain.
It, in my mind, becomes a bit of an economics question if you consider the trade-offs. Not dosing cattle could to food poisoning which could lead to higher human consumption of antibiotics.
I also have a fear of this becoming a panic, much like the anti-vaccine panic which leads people away from getting proper medical treatment.
To be fair, I have a huge amount of what everyone perceives as crazy ideas that no one will ever be able to produce a shred of evidence to refute. That qualification does very little to forward your argument.
The pattern described by the OP can reasonably be described as under prescribing the antibiotics. Rather than following the recommended schedule which may last longer than the person feels sick, the mother was only giving enough to treat the immediate symptoms. The prescription is to give more!
The thing about antibiotics is that you should run the full course. It reduces the chance of resistant strains developing. So this person's problem was saving the rest of the bottle instead of continuing to give it.
And from that story, it talked about Colistin (the drug this patient's E. coli is resistant to):
"Some of the antibiotics farmers use are those that doctors hold in reserve for the most difficult cases. Colistin is not much used in people because it can damage their kidneys, but it is a vital last line of defence against Acinetobacter, Pseudomonas aeruginosa, Klebsiella and Enterobacter, two of which are specifically mentioned on the CDC watch list. Last year bacteria with plasmids bearing colistin-resistant genes were discovered, to general horror, in hospital patients in China. Agricultural use of colistin is thought to be the culprit."
Considering the same article says that "In America 70% of [antibiotics] sold end up in beasts and fowl" it seems that an easy thing to do would be to stop giving antibiotics to animals
It would be easy, if the agricultural industry was concerned about antibiotic resistance. Unfortunately, like most markets, externalities like that are hard to price in. If Farmer Bob takes the high road and stops using so many antibiotics, he'll lose some stock and get outcompeted by Farmer Bill. If the turkey farmers band together heroically and agree to reduce their use of antibiotics, uninformed consumers will choose chicken instead. And there's not enough governmental desire for them to regulate it - and local government would be outcompeted by imported goods that use antibiotics.
It sounds like an excellent case for legislation to outright ban the use of human-safe antibiotics on animals.
Working antibiotics are among humanity's most precious and most limited natural resources. In a century they'll be gone, with devastating impact on routine medical care. We're living in the one glorious sliver of humanity's history that we have access to antibiotics, and we're squandering them to make meat a few cents/pound cheaper. It's criminally irresponsible toward future generations.
Exactly. Agricultural antibiotics are often very different from the ones humans take. Yes, they might be in the same class as human antibiotics (which would explain resistance) but some aren't.
Yes, but although the arstechnica article points out a lot of problems with the original article's claims about this specific bacteria and points out the fear mongering about this specific case, even the ars article admits that the overlying problem of antibiotic resistance is still a bigger issue:
"For now, the case serves mostly to highlight the ongoing crisis of rising antibiotic resistance and furthers the need for better stewardship of old antibiotics and development of new ones."
Agreed, but the level of research in novel antibiotics is really quite limited, mostly due to a lack of return on investment.
This actually means there is almost certainly a lot of unexplored potential, but getting drug makers interested is quite difficult (though in the last 5 years the field has been 10x more popular).
Most antibiotics on the market are just penicillin variants (well, β-lactam variants), mostly because that was one of the first things to blow onto a petri dish, was non-toxic, easy to manufacture, small molecular weight, and it happened to work quite broadly. Most bacteria share β-lactamase encoding plasmids with each other, so resistance is conferred within years (I think the original penicillin made it 4 years). Honestly we have done very little outside of this space.
β-lactamase inhibitors (basically blocking the method of resistance with a separate drug) have a lot of potential, as do many other combination therapy techniques. There are also many other non-β-lactam templates we could play around with.
With modern sequencing, you can actually identify the exact resistance mechanism of each strain you encounter. If we move to rapid diagnostic sequencing, we can tailor the treatment to avoid any existing resistance for the specific infection.
Look, this is scary and a big problem, but can we please stop talking about the "end of the road" for antibiotics?
The worry here isn't that antibiotics will suddenly become useless and whenever anyone gets a bacterial infection they'll have no hope. The worry is that there will be a number of prevalent bacterial illnesses which can't be treated with antibiotics.
Currently antibiotics work for an overwhelming majority of bacterial illnesses, that's not going to change overnight. What will change is the idea that bacterial illnesses are trifles because they can be cured every time by antibiotics. A few diseases will emerge, more and more over time, that have much worse consequences than we are used to thinking about right now, but the rest will be the same.
I don't mean to underplay the threat, but if we keep pushing this rhetoric, people will discredit the threat when it turns out that 50 years later we're still using antibiotics for most illnesses that people actually get (because antibiotic-resistant strains are effectively quarantined). People will compare it with the "we're going to run out of oil" scare.
We shouldn't forget that antibiotic resistant bacteria become that way by giving up a metabolic pathway. Calling them 'superbugs' is actually misleading, because the resistant bacteria are usually less efficient.
If you remove the exposure to the antibiotic, they will revert back to the wild strain pretty quickly.
If we just stopped using antibiotics in agriculture, especially to promote growth, this could actually be possible.
You raise a really good point. Antibiotic resistance doesn't always go up. For example, the rates of MDR gonorrhea have dropped substantially.[1] There are other examples as well.
Is it a problem that needs to be addressed? Yes. Is it the end of the world? Unlikely.
Bacterial pneumonia, bacterial meningitis and bacterial septicemia all carry a substantial risk of death even in affluent countries with good healthcare systems.
surgery becomes more risky with these antibiotic resistant bacteria circulating in hospitals. so any medical condition that might be improved or even cured by surgery becomes more difficult to handle. surgery may not be such an easy choice to make.
Surgery is never an easy choice, but infection is always something to worry about. I had jaw surgery last year which was supposed to be an outpatient procedure, but there was a complication and I had to spend the night. My main thought was "oh no, I am probably going to get some weird infection". And indeed I did! A hole opened up between my mouth and nose and it got infected. Augmentin did nothing, but the doctor did a test where they grow a culture and test every antibiotic against it, then prescribe the one that killed it. That cleared up the infection immediately and I am now in perfect health with no unnecessary holes ;)
It is really weird how we concentrate all sick people in one place, and then act surprised when they start growing weird diseases.
> It is really weird how we concentrate all sick people in one place, and then act surprised when they start growing weird diseases.
I don't think anyone finds it that surprising really. But healthcare is expensive and centralising in-patient care is the only practical and affordable system that we have come up with so far! Key things are to maximise hygiene and minimise length of stay :)
Yeah, studies show that many healthcare professionals don't wash their hands like they are supposed to. My guess is this is the primary vector for spreading disease in hospitals. I know it's kind of annoying to scrub your hands for 30 seconds multiple times per day, but it really is such a simple fix.
On a similar note, I have never once seen someone in my office wash their hands for more than 5 seconds. Also, on several occasions I've seen someone poop and simply run water over their hands for half a second. It boggles my mind.
> It is really weird how we concentrate all sick people in one place, and then act surprised when they start growing weird diseases.
Ideally there are separate hospital buildings for patients with diseases, broken bones, new born babies, etc - often older hospitals that evolved over many decades are like that. Contrary to that are these centralized mega-structure hospital building from the 1960s to 1980s. Often the same small number of operating rooms (often centralized in one location, next to each other) are used for all kind of treatments.
The article doesn't touch on it, but the obvious followup question from the laymen is why can't we develop new antibiotics? I was curious and according to Wikipedia we haven't developed a new class of antibiotics in 30+ years. Can someone with knowledge on the subject explain why we seemingly can't discover/develop new forms of antibiotics to combat these resistant bugs?
1. It's hard. You need to find a molecule that has a mechanism of action against bacteria, but only bacteria. Any cellular function you share with human cells is right out (this is why anti-fungals are double-plus hard mode). We got away with this by glueing new functional groups onto things to evade resistance, but inventing a new target never before seen in nature is...tricky. Most of the easy stuff got developed by the bacteria first - they've been working on this problem longer than we have.
2. It's very expensive. Fidaxomicin (aka Difficid) cost $175 million to develop, and it's on the cheaper side. While it might still be profitable, that's a steep up-front cost. One does not casually embark on developing a new antibiotic.
From what I have read, the problem is that antibiotic development is not profitable. If a new antibiotic gets developed then it will be out on the shelf as a last-resort antibiotic, preventing the developing company from extracting a lot of revenue. And it is more profitable to develop drugs for chronic diseases. So pharmaceutic companies don't bother with antibiotics.
...displaying a great example of why the free market is not the best way to handle healthcare and medical research. The availability of treatment has everything to do with profit, and little to do with need.
Given the heavy involvement of the state in funding and directing care and research, I don't think anyone would describe healthcare and medical research as a free market.
Yeah but that's more because of lobbying and politics than logical, economic approaches to problems. It's not like when I go to the doctor everyone's incentives are aligned. The insurance company is still actively working against me, just now it's really complicated how they do it due to regulation so only they can play the game and I just have to take their decision until it's worth getting lawyers involved.
It's more profitable to develop drugs for chronic diseases because there are a lot more people with chronic diseases than there are people with infections only treatable by antibiotics of last resort, hence there is a lot more need for drugs that treat chronic diseases than there is need for last-resort antibiotics.
For the same reason we cannot close one bug per developer per day.
At first you can do it, then, all the easy ones get solved. The ones that remain all have a number of troubles: they are hard to reproduce, or the last person to touch that module quit last September, or that's a known issues with the architecture that has been put off for the last 2 releases, etc, etc.
No, it's nothing like rat poison because bacteria cellular pathways are a more different than eurakayotic cellular pathways. This is why most antibiotics work against many bacteria just as rat poison works on most mammals.
AFAIK, the main issue is that we don't know how to cultivate very many kinds of bacteria (relative to the number of species there are.) Since antibiotics are a by-product of bacteria, the number of antibiotics we can effectively produce are limited to the antibiotics produced by species of bacteria that we can effectively cultivate.
This is a tricky thing. "Not being profitable enough" isn't always a petty reasoning. With today's technology and science levels, you can do almost anything you can imagine - if you can get enough minds, hands and resources into the project, which is equivalent to throwing enough money at it. Technological advance today is really less about discovering new things and more about making everything easier and cheaper - so that projects that were previously too expensive become cheap enough to tackle.
That's vaccines and there are regulatory issues in the US with them, antibiotics are perfectly profitable.
Also, only in the US does profitability seem to affect making basic medicines. Bacterial resistance is a global issue, not just one like vaccines that is largely a US issue.
Antibiotics aren't generally that profitable in the US. The first reason is antibiotic stewardship: make a really great antibiotic and nobody wants to use it unless they have to. The other reason is that the way antibiotics are reimbursed in the hospital setting prevents charging a price that makes it all that profitable.
> Health officials said the case in Pennsylvania, by itself, is not cause for panic. The strain found in the woman is treatable with some other antibiotics.
Thanks for completely ignoring that advice with a headline and three paragraphs of misleading information designed specifically to cause panic.
1. Stricter regulation of antibiotics, particularly in farming.
2. Better government funding of antibiotic discovery.
3. Stricter regulation of antibiotic use. No solo-drugs, all antibiotics used in stacks of 3 or more. Better monitoring of complete antibiotic use cycles.
Biologic resistance can be managed, HIV is more than enough evidence of it working. We have to get serious about it, the age of reckless antibiotic use needs to end, now.
I'm going to go out on a limb here, and say antibiotics overuse in third world countries is a big part of the problem, and the hardest one to fix.
This is purely from anecdotes, but I've heard from several friends who were exchange students from Pakistan/China/India that we have such a ridiculous system here, that back home they can just buy random antibiotics from the pharmacy whenever they catch a cold.
Biggest problem is animal agriculture. The use of extremely aggressive antibiotics increases muscle growth, improves health and eventually leads to larger profit.
150 billion land animals raised yearly are a big evolutionary pool of bacteria. To become resistant to antibiotics takes much less time when you run the experiment in parallel 150 billion times per year, than a couple hundred million in humans.
One strain, isolated in one of the 150 billion animals can become resistant and spread around the farm. If it goes unnoticed it can quickly spread over the country.
That's definitely been my experience. A few years ago, I went to a pharmacy in Thailand with what was clearly a common cold. Instead of handing me the Sudafed I wanted, the pharmacist recommended I take a weeks supply of low-dose amoxicillin. Not only would this do absolutely nothing for my viral cold, it would have increased the risk of creating amox-resistant bacteria in body. Truly concerning to imagine how often this scenario repeats itself every day all over the world ...
Exactly, I was in China and had a fairly bad sore throat. I didn't really think it was bacterial, and it ended up being just a cold. I went to a doctor (roll up door in a street). He shined a light in my mouth and decided that I should take vitamin C and some antibiotics. I paid about 2 USD for the whole experience, pills included.
In Latin America too. And worse yet almost everyone grows up thinking you treat a cold with antibiotics. Doctors prescribe antibiotics, knowing full well it does no good, but they have to justify their fee. I tried in vain many a time to convince a person that antibiotics are pointless against a virus, and the common cold is a virus, ergo don't buy antibiotics. But the behavior was too ingrained to sway anyone.
Not my experience in Brazil. Can't buy antibiotics at pharmacies without prescription. Most doctors will not prescribe them for viral infections, even though they will prescribe something, as it is expected by the population.
Maybe you'll find doctors that will prescribe antibiotics for anything, but the amount of required paperwork seems to be eliminating the practice successfully.
Brazil is somewhat more... I want to say civilized but that seems overly mean. It's more modern in many respects than the rest of south and central america.
but I see that this story with the alarmist headline got more traction on the main page of HN. That's unfortunate for understanding the underlying issues.
Wonder if we'll see a resurgence of phage therapy due to this.
Phage therapy is using viruses which will infect and attack the bacteria. Viruses can mutate and adapt just as well as bacteria (while say antibiotics are static in a way). So they can keep up with the mutations.
Phage therapy is super interesting, but there are a lot of technical problems. If I ever leave software engineering, it'll be to go back to mucking around with phage.
Immune clearance: The immune system really enjoys soaking up phage. Blood titers drop stupidly fast. Maybe we could flood the colon with a phage-bearing solution to handle GI infections, but in general I'm really skeptical. There was a paper ~8 years ago describing serial passages in rabbits to enrich for immunocompatible phage. Don't know if further work has been done here.
Specificity: Phage really, really like their hosts. I had a strain of Phi X174 in lab that would simply never infect wild type E coli. To deploy phage effectively, you need to culture whatever it is that you're after. Next you'd want to infect the pathogen in culture and pass your phage for O(many) generations. A lot of human pathogens are just miserable to grow.
Efficacy: Antibiotics are just better at killing bacteria (resistance aside.)
Regulatory: You'd need to convince the FDA to approve a viral cocktail that is potentially going to kill the patient through anaphylaxis.
Indeed, the name of one of the major hospital-acquired human pathogens, Clostridium difficile, literally means "Clostridium pain in my ass to culture".
I once tried to grow magnetotactic bacteria. For the growth media, you had to prepare a witch's brew of unusual chemicals which sent me on a goose hunt around a few friendly chem labs. The protocol called for making a couple of litres; smaller quantities would just exacerbate measurement errors. After cooking it up, you were supposed to add 2mL to the growth media and incubate the whole mess for four weeks.
Needless to say, I could never get them to grow.
Edit: I found the protocol!
NTA 1.5g
MgSO4 3.0g
MnSO4 0.5g
NaCl 1.5g
FeSO4 0.1g
CaCl2 0.1g
CoSO4 0.1g
ZnSO4 0.1g
CuSO4 0.025g
AlK(SO4)2 0.01g
H3BO3 0.01g
Na2MoO4 0.4g
NiCl2 0.01g
Phew. Did I mention: it was an anaerobe? Flushing an exotic growth media with nitrogen is a dull way to spend a Friday afternoon.
It does seem to be undergoing a growth in interest in the research and development communities. I suspect that this might get squashed by the newfound ability to discover new classes of antibiotics pretty much as needed, however:
A start-up from Boston called Sample6 is using phages in diagnostics, currently only for food but it is start. I would be very afraid it ends up like the introduction of Mongoose to Hawaii to control rats in the 19th century.
> I would be very afraid it ends up like the introduction of Mongoose to Hawaii to control rats in the 19th century.
There's no way for them to jump domains prokaryotes to eukaryotes. It's just biologically implausible. Phage are very narrow spectrum and coevolve with their hosts. They're all over our environment and have been since just about the dawn of life.
Hypothetically, I guess you could accidentally sterilize your gut flora, but again: they aren't broad spectrum.
> Colistin is the antibiotic of last resort for particularly dangerous types of superbugs
and further down:
> Colistin is widely used in Chinese livestock ...
This is absurd. Preventive use of antibiotics on livestock works just like a giant training camp for hostile bacteria, and horizontal gene transfer will spread the necessarily created resistances to human microbes rendering them useless sooner or later.
>Health officials said the case in Pennsylvania, by itself, is not cause for panic. The strain found in the woman is treatable with some other antibiotics.
So the last resort doesn't work, but other stuff works. It's totally reasonable to assume that if bacteria becomes resistant to more common antibiotics, that some other kind of antibiotic could do the trick.
Though I guess it would be nicer to have some sort of "proof" that the bacteria _does_ get weaker to stuff it's less exposed to.
Actually, side note but wouldn't mass feeding of antibiotics for certain kinds of bacteria let us completely wipe it out, a la smallpox?
-- Viruses can't reproduce outside their host. They have a limited lifetime in the environment before they degrade.
-- Immunity lasts a long time, even a lifetime.
-- So, if you successfully immunize everyone in the population against a virus (like smallpox), and keep doing it for a few years, then eventually that virus will die out
This is not true for bacteria. Many bacteria can live in the wild, and in fact only opportunistically infect humans. Also, antibiotics are only effective while you are taking them, and many of them have negative consequences if taken for long times in therapeutic doses (stomach upset, light sensitivity, yeast infections, just to name a few). Next, 60% to 90% of a dose of penicillin is excreted into the urine fully intact, so our sewers, which are teeming with bacteria, would also be flooded with sub-therapeutic doses of antibiotics. Finally, bacteria can exchange DNA with each other, even inter-species, so if we train the sewer germs to survive an antibiotic dose, then they can transfer that capability to other more virulent bacteria that can infect humans. This is, in fact, probably the mechanism for formation of some of these multi-drug resistant strains.
It might be time to start editing our (DNA) code to fight the bacteria. It seems like the only thing that will be fast enough to keep up with the mutations.
There already is a method, decades old: bacteriophages [1] in phage therapy [2]. Put them with bacteria that have resistance and they'll evolve along with them. It's cheap and will always be effective.
>It might be time to start editing our (DNA) code to fight the bacteria.
This will just create the same selection pressure chemotheraputics did, except now you have the additional burden of fucking with your DNA (and probably risking cancer).
There are pneumonia vaccines[1], but they mostly cover the main bacterial strains that cause it. A lot of diseases like pneumonia can be caused by multiple strains of bacteria. It's hard to vaccinate against all of them.
Time for Congress to authorize a very big monetary prize for the company that comes up with a better solution, with that solution then being licensed for free to all U.S. manufacturers (or something like that to make it politically acceptable to the xenophobic elements in the GOP).
Sorry for the redundant comments, but it's important for people to hear this. More people die from MRSA than AIDS in the US, and the FDA is structurally against adaptive therapies.
Even then, generalized, FDA-approved "Phage Kits" that don't require bespoke lab solutions for each and every patient likely won't be free as in libre.
Requiring there not be bespoke lab solutions for any patient is the problem -- it's why people are suffering and dying from MRSA now in the USA, but some can travel to poor areas of the former USSR and get cured. We can already take bacterial cultures and breed them in an automated fashion, breeding effective bacteriophages is the next step. We need to be funding R&D into doing this safely and in an automated way. It's already possible to do with 1930s technology so we should only be able to do better now.
It's a scientific and medical requirement, not a regulatory one. Using that on a mass scale, rather than for occasional one-off treatments for particularly unresponsive infections, is going to require kits, or a massive investment in laboratory capacity in the U.S.
This is the field I work in. Phage therapy is awesome, and actively being explored, but there is a reason antibiotics won out. Phages are anything but easy and general-purpose.
Wikipedia has "In the West, no therapies are currently authorized for use on humans, although phages for killing food poisoning bacteria (Listeria) are now in use"
which sounds like a regulatory issue. And a bit of an unnecessary one it seems as the treatments seem harmless to humans.
It's a regulatory issue, but it's also a clinical one. Even if it gets approved, it will still need a general purpose kit-based form, and that's a massive clinical and scientific hurdle.
Also, phage therapy killed people in the past. Mostly due to poor purification, but it's not inherently harmless.
There is a difference between treating particularly unresponsive cases of S. aureus with phage therapy and it becoming the frontline standard of care for all bacterial diseases.
Additionally, Russia has done the investment in laboratory capacity in order to do phage therapy. Introducing it into the United States would require new equipment, space and staffing in order to facilitate more widespread culturing (as there are no "broad spectrum" phages), as well as the actual preparation of phage-based therapeutics.
The UK recently promoted the same thing. However, the prizes were $1B for a new antibiotic. Not exactly super compelling when even a mediocre drug would have an NPV much larger than that.
It's already a huge problem. Post-op infection is common and hard to treat. There are new approaches in use to reduce risk. I recently needed to have surgery.
A preventative measure was a gown with ventilation ports. I was told circulating warm air over the body surface has been shown to reduce post-surgical infections. As well, in the hospital IV antibiotics were administered as a further precaution. Fortunately for me I escaped infections, but a number of people I know did not have as favorable an outcome.
As you point out, using disinfectants is not a new idea. Readily available materials other than bleach are effective and not as malodorous or irritating as bleach. Hospitals are usually pretty careful about that, there are always mishaps, chance of carelessness, infections are hardly rare.
By all means avoid surgery if that's feasible. If not avoidable, may we find an excellent hospital with great, dedicated staff and be blessed with generous insurance benefits. And of course, one can never have too much good luck.
Hospitals generally don't use bleach as a multipurpose germicide/virucide/fungicide as it is really bad at doing that, they use an specialty chemical solution that can kill things that bleach won't.
They use a great deal of bleach (Chlorox frequently has a booth at conferences I go to) along with other specialized cleaners, ozone foggers, UV radiation robots...
And that's how antibiotic resistance happens.