So, I’m on this antibiotic resistance kick these days.
Actually — this is a topic that’s been on my mind for a while. The blunt truth is that it was when I first started reading about Vancomycin, a pretty damn nasty drug, originally discovered in 1953 but largely shelved until it became a drug-of-choice as a last line of defense against largely intractable MRSA (Methycillin-resistant S. aureus infections. That started to happen in the 70s, and I guess I began to notice some press on this at the start of my professional career as a science hack, sometime in the early 80s.
It struck me then and at intervals since that I — and most of you, almost certainly — have lived entirely in this really atypical period in the history of human-microbe relations. Antibiotics first became fairly broadly available in the midst of World War II — 1943 or so. Since the fifties, diseases that routinely killed some large percentage of their victims simply ceased to be meaningful threats. My grandparents grew up in a world in which you could die from a scratch, one in which TB killed half of those (or more) who developed active disease.
Theirs was one in which the dangers of surgery included real, scary risk of dreadful illness and sometimes death from post-op infection. Mine — ours — is not.
That’s changing now, to the point where we may look back on the last half of the 20th century and two, maybe three decades of this one and see it as this almost Eden-like mirage, that brief time in the garden when humans and (pathogenic) microbes could co-exist peacefully.
If antibiotic resistance progresses in the way it’s been going — well let me turn to Maryn McKenna, the journalist who more than any other has made this story current for me, and follow the links from a post she put up last month to these words from a genuinely serious person:
“Antimicrobial resistance poses a catastrophic threat,” said [England’s chief medical officer Dame Sally] Davies. “If we don’t act now, any one of us could go into hospital in 20 years for minor surgery and die because of an ordinary infection that can’t be treated by antibiotics. And routine operations like hip replacements or organ transplants could be deadly because of the risk of infection.”
That struck a chord because I’d already been thinking about a CDC-published field report from South Africa, documenting 17 cases of what seem to be TDR-TB, tuberculosis that has evolved Total Drug Resistance — which is just as grim as it sounds. That finally prompted me to get off my ass and start reporting and writing, which has now generated a piece over at The New Yorker’s new science and tech web vertical (what we used to call a section, I suppose).
Go over there to read the whole thing, but for what I think of as the heart of the matter, there’s this:
Working against pathogenic microbes is not simple altruism. Keeping the lid on bad diseases in the age of air travel is a matter of self-interest, at least as much as it is a duty to our neighbors. And the invisible hand of the market is not currently taking care of this particular business. We are in the midst of a persistent antibiotic-development drought—only two new classes of the drugs have been identified in the last thirty years or so. Drug companies have been withdrawing from antimicrobial research for several reasons…For…perfectly rational economic reasons, the pharmaceutical industry is unlikely to keep pace with the need for a social good whose benefits don’t translate into profits that can be readily captured. That makes this a political matter: some other institutions will have to do the work.
Friends and readers here can guess at where the political theme leads…
In this context, I also was eager to have my second on-the-air/web conversation with McKenna about TB and much else this last Wednesday. I posted about that in advance (barely) of the broadcast — and now the podcast is available.
This is serious sh*t folks. We’re facing more and more resistant diseases — here’s a piece about completely resistant gonorrhea that should make the adventurous among us check the sell-by dates on their condoms — and we are devoting less and less social attention to the problem. I really don’t want to be 80, and in need of a hip replacement, and have to weigh a 1/n (where n is a small number) chance of dying from a bug against my ability to walk into senescence. Or to die coughing in my bed.
I’ll probably be beating on this drum some more, you know. It has (perhaps literally) gotten under my skin.
Cheers everyone. Happy Friday.
Images: Cristobal Rojas, La Miseria, 1866
Michaelangelo, Expulsion from Eden from The Sistine Ceiling, 1509-10
WPA poster created between 1936 and 1941.
How are bacteriophages doing these days? I heard a story on them, I think it was on SciFri, a while ago. the guest was saying that they were being heavily researched before the invention of antibacterial drugs, but the success of the drugs killed the phage research.
I heard a story recently on NPR about the drug-resistant gonorrhea and that was my first thought,too…how lucky we were to live in the brief window of time when we could control infectious diseases with antibiotics….
If it makes you feel better, given what we’re doing for climate change (jack-all), you’ve got a decent shot at dying from famine, drought, or the wars accompanying the two long before the hip replacement is necessary.
And that assumes we still have hospitals and aren’t crawling around the desert that used to be the Southwest with Dogmeat fighting off raiders.
Another Halocene Human
That’s changing now, to the point where we may look back on the last half of the 20th century and two, maybe three decades of this one and see it as this almost Eden-like mirage, that brief time in the garden when humans and microbes could co-exist peacefully.
Say what? This is such an incredibly ignorant comment, I think I can safely say so as I flunked biology in HS!!
Role of microflora in human metabolism, just for fucking starters?!
You realize the best of all possible worlds may be important in the history of letters but from a scientific point of view is a long discarded theory with no predictive value?!
I’m not really sure what we’re supposed to do about this, though. Other than remembering to finish your bottle of meds rather than kicking them the moment you can crawl out of bed, there’s not much that we can – personally – do to address how we use antibiotics.
Beyond that, you’re quickly getting into territory where generally wise health care policy bumps up against individually prudent health care decisions. “Hey, I’m sick. I should probably take pills that kill the little bastards inside me”, isn’t going to stop being a good idea at any point in the future for a single individual, even if – over the aggregate – it’s bad news for us long term.
And even further beyond that, I really do get the feeling that we’re outpacing the natural evolution of microbes. We stomp out the flu on a regular basis with what amounts to a virtually nation-wide annual vaccination campaign. We bet AIDS inside, what? 30 years? And that’s considering the 80s-era technology of our original treatments.
If a pathogen truly becomes an endemic threat, how long will it actually take us to quash it down again? :-p Not to openly dismiss the concern over resistant drugs, but I really do wonder what the cost-benefit is of changing current antibiotic policies.
I refuse to buy dish soap — or any soap — that proudly warns me that it contains antibiotics. Let alone sterilize my hands constantly any time I enter a store.
La Miseria is quite a picture.
TB that just won’t stop.
Drug resistance is scary. Evolution can be a bitch.
Tom: this from your article is, I think, not the whole story:
“While blockbuster drugs treat chronic diseases for years at a time, when antibiotics work patients take them for a little while, and then they’re done. For such perfectly rational economic reasons, the pharmaceutical industry is unlikely to keep pace with the need for a social good whose benefits don’t translate into profits that can be readily captured.”
Another reason why the market does not reward the makers of new antibiotics is that a new antibiotic, when discovered, is likely to be kept out of use as much as possible, on purpose, so that bacteria do not develop resistance to it. So of course its sales will not come close to matching its social value.
This has terrified me for a long time. The power of evolution that gave the microbes the ability to do what they do has been stopped in its tracks, but now evolution, inexorable force that it is, combined with our overuse and improper administration of antibiotics, has allowed the microbes to jump ahead of us again. The future is not pretty. Religious fundamentalists of all stripes often use the reasoning that you can’t see evolution happening to deny the reality. You can’t see it happen with organisms with a 70 year life span, but it sure can show up in organisms with a life span of a few hours or so. But we know what happens when fundamentalists are confronted with facts that disprove their worldview: the facts always lose. Here’s an evolutionary question: Is fundamentalism an adaptation to prevent humans form overpopulating the planet, by exposing us to all sorts of dangers that an educated and logical worldview would prevent?
The majority of the superbugs people become infected with are hospital acquired. It’s why every hospital I’ve worked at does routine MRSA, VRE, & in some cases Cdiff screening of al newborns as they enter the facility and on all patients being admitted to an ICU or a NICU floor along with weekly or biweekly screening for MRSA.
In most cases those infected are already carriers for the bug, but either in the hospital or some traumatic inury introduces the bug into the system. In theajoritu I the case though, colonization does not result in infection without traumatic introduction. The first defense against hospital acquired infection is good hand hygiene (if u don’t know if ur cargiver has washed their hands, there is no shame in asking them to do so in front o you).
As for those bugs that are acquired communicably like TB masks are the way to go, not much elase you can do if u are unaware that s person has TB other than using PPE all he time.
—Lamh -registered clinical laboratory microbiologist
@DonBoy: Two completely different things. Antibiotics work by interrupting the bacterial life cycle at a specific point, hence the need to take them over the course of many days to be sure to expose all the germs, who have a life cycle of a few days, max, to the anti-biotic. Antiseptics, like the alcohol prep you get on the way into the store or the chlorine in your local pool, kills everything on contact, usually by somehow overwhelming the protective cell walls and having the germ almost explode on contact. the mechanism is complex, but there are BIG differences between anti-biotics and anti-septics., mostly that there is no way for germs to develop resistance against anti-septics, while there are several ways for a germ to aquire anti-biotic resistance.
It would help if pharmaceutical advertizing was made illegal. It used to be you never saw any drugs promoted for sales.
The ads give people an idea that take a pill you’ll feel better.
People with colds go to the doctor for an antibiotic. They want a pill.
After I run an errand, especially if I handle money, I wash my hands with soap and water.
@Zifnab: Bacteria v. virus
The whole thing about disease resistant bacteria/microbes is so well known by so many people and yet there’s also the strain of people who also do not believe in evolution. How do bacteria become drug resistant? evolution, right?
Your New Yorker article just highlights this to me. Sigh.
Ms Martin has latent TB and is being treated for it. Becoming quite common among teachers out here. Too many little petri dishes running around.
A number of years ago I got a drug-resistant sinus infection. Lost hearing entirely in one ear, most in another. Lost the ability to talk. Started to lose vision in one eye. After two weeks of persistent fevers and I think 3 different antibiotics doing nothing to help, my GP gave me one last one to try. His warning was that if it didn’t show signs of working in 72 hours I’d be in the hospital getting vancomycin. Thankfully that last one worked. After I got better he told me that while it worked out, he should have been more aggressive, but I wasn’t entirely forthcoming with the severity of my symptoms, so he thought I was in better shape than I was. I got a little finger waving over that. Never gotten an infection that bad since.
@Zifnab: “I’m not really sure what we’re supposed to do about this, though.”
Stop feeding antibiotics to livestock for a start. Much antibitoic resistance occurs in factory farm animals. If we treated farm animals better, we wouldn’t need to include antibiotics in chicken feed and constantly dose cows and steers.
But that costs money……
The other night there was a near-altercation between a fox and one of my cats, which got me to thinking how terrifying it must have been to live before the availability of the rabies vaccine. Just one nasty disease out of many, but sheesh, it’s amazing what we can take for granted these days.
God punishing us for using birth control.
Just Some Fuckhead
I’m banking on dying of starvation from Colony Collapse Disorder or in the anarchy following Peak Oil before this becomes a serious threat.
Two babies were born while trapped under the rubble of that garment factory in Bangladesh. We’ve got a bit more work to do yet, but we’re getting there.
I suspect the 1% don’t realize they aren’t going to be able to buy their way out of this problem. They and their kids will be just as susceptible to acquired resistant infections.
We need to get routine antibiotics out of the meat-animal-raising process, and we need to socialize the search for new antibiotics.
Another big problem that is accelerating the creation of antibiotic resistant strains is the massive overuse and abuse of antibiotics in industrial farming.
In many cases it boils down that it is cheaper to dose all of your animals at a low rate for long periods of time than it is to watch large numbers of animals and try to get ahead of an outbreak when it does occur. Unfortunately low doses over a long period of time is a perfect way to breed antibiotic resistant bugs, and when they jump from animal to human, you have a real big problem
Tissue Thin Pseudonym (JMN)
@Ramalama: Nah. They created the fiction of micro-evolution, which they accept and use to explain something like microbe resistance, vs. macro-evolution, which they deny and involves the evolution of entirely new species.
Never, ever underestimate the power of rationalization.
America is one of the very few countries where prescription medications can be advertised to the general public. If I’m not mistaken, this was the result of a court ruling on such advertising as a freedom-of-speech issue.
I am on a Z-pack now due to a skull-crushing sinus infection.
Certified Mutant Enemy
It doesn’t help that in various libertarian utopias throughout the world, people can obtain antibiotics without a prescription…
This, I think, is a huge deal and a direct, if unwanted byproduct of our ag policies i.e., the Farm Bill. Feedlot cattle eating corn, which their guts are ill-suited to digest, being fed antibiotics to help them process said corn, seems to be a horrble idea but we’re evidently powerless to stop it.
We were glad my wife’s surgery last week was such that she was only in the hospital for 5 hours.
@Just Some Fuckhead: Always look on the bright side of life! Sing it fellas!
Advertising medicines, except for over-the-counter painkillers and cough drops and the like, is illegal in most countries. It’s just another side effect of America’s Medical-Industrial complex.
@Certified Mutant Enemy:
Former coworker hailed from Mexico and went their routinely to “stock up” on unregulated meds. Every time one of his kids became sick he’d give him/her a penicillin shot. I’d go apoplectic whenever he mentioned this, but he had all the “proof” he needed that it worked. Doctors are quacks, pharmacies don’t want us to have the good stuff, yadda-yadda.
Actually, we’ve never had a law banning it. It’s just the drug companies never felt it was cost-effective to advertise straight to the public. As more drugs have come to market and advertising costs have dropped, that changed. But I’m almost positive it’s never been tested in the courts.
The Moar You Know
I survived a bout of appendicitis because of antibiotics. If my ten-year old nephew develops the disease at the same age I was when I got it (44) he’s going to die from it.
We fucked up. Antibiotics were a gift from the gods and we squandered it by using them on everything.
Certified Mutant Enemy
I really irks me when people who should know better recommend antibiotics for viral infections.
Ah. I stand corrected.
Certified Mutant Enemy
@The Moar You Know:
My doctor was shocked when I told him I’ve never taken antibiotics…
@Trollhattan: That’s better than taking bear bile, I guess. At least for the bears.
I seem to remember Congress passing a law that allowed big pharma to advertize. Big Pharma “persuaded” Congre$$.
If so, Congre$$ can pass a law to get rid of (oh, sure) the advertizing.
I’ve lived in the Southwest (Sheriff Joe Arpaio County, AZ) for over half my life now (over 30 years) and I’ve instructed my grown son (who lives down the freeway from his mother and me) that he should seriously look into buying property in the ancestral homeland of NE Ohio because global warming is, IMAO, our greatest existential threat (my son believes the same).
The Great Lakes will become an even far more precious resource than they are now, while the Southwest and much of the Inter Mountain West – from S California to Central Texas, will be on the way to becoming the American Sahara.
We are, obviously, collectively doing not a damn thing about it, and will not (if we do much at all) until it is far, far too late.
Seems likely that the catastrophe will not be fully-fledged until well past my lifetime, and maybe not even until my children are elderly, but that’s about as far out as I think it will go before the shit is really hitting the fan.
Our politics focuses on stupid shit like the federal debt and some alleged shortfall in Social Security and Medicare decades hence, when the fucking zombie apocalypse (only for real) is barreling down on us.
That microbes have perhaps turned the tide on us in our war against infectious disease will only make said apocalypse that much worse.
The good news is that antibiotic resistance is expensive, evolutionarily speaking. This is a fixable problem, if you get people – and by people, I mean industrial feedlots – to stop using given types of antibiotics for a while.
Certified Mutant Enemy
There are some problems with this reasoning. By and large, the antibiotics used to promote growth are not the ones used to treat bacterial infections – in people or animals. The widespread use of antibiotics in food producing animals is to increase rate of growth, not to treat or prevent disease.
There is a huge over-treatment problem in human medicine, probably greater than use in food production. Studies have shown that 75% of the time antibiotics are given to people, they are not necessary. The problem is either a viral infection or a self-limiting condition.
So if the bug in your sinus infection can not be treated with any antibiotic, better to blame the 100 patients your doctor saw that insisted on getting antibiotics to treat their flu and simple ear infections than the feedlot 3 states over.
Maybe. I trust that science will see us through this as well. There might be some rough patches first.
I used to be 100% antimicrobial items, for fear of germs, but have changed my tune 180 degrees in the past couple of years. Besides a small bottle of sanitizer I keep in my jacket for specific applications (like visiting hospitals!), I am 100% antimicrobial product free.
Another big factor to this is a better understanding of the bacteria in our bodies. In many ways, we’re worlds to billions of bacteria who we are are dependent on for life. To carpet bomb the entire ecosystem in order to deal with a cold is madness. Targeted medicines, or not using antibiotics at all is the future. For example, stool treatments for a variety of intestinal issues.
Certified Mutant Enemy
To carpet bomb the entire ecosystem in order to deal with a cold is madness.
Especially considering antibiotics will have no effect on a cold…
There wasn’t a federal law. Pharma started making ads about prescription drugs in the 1980s.
We need a federal law banning pharma prescription drug advertizing.
@beltane: There’s a story about one of the Bronte sisters — Emily, the awkward genius — getting bit by stray dog. She walked calmly back to the house and cauterized the wound with a hot iron and then hid it form her family to keep them from worrying about her. Eek.
@Sourmash: But every time you use an antiseptic aren’t you, by definition, selecting for the antiseptic-resistant strains?
Aside from the cost-effectiveness (or not) of such advertising, there’s another reason most countries forbid it. Non-doctors are simply not equipped to select their own meds. Most of us have no idea what a drug does in the body, how it works, how it interacts with our other meds. Inviting lay people to pester their doctors for Wonder Medicine X That I Saw On TV is asking for all sorts of trouble.
Tone In DC
Teh st00pid, flying in tandem, upside down, with teh greedy, like a pair of dain-bramaged birds.
Take actual good care of livestock in industrial farms and other places? Oh HELL no. Better to let the animals provide us with the succesors to H1N1 and West Nile.
Tom, great post.
@Joel: What do you mean by this?
There is going to be a die off of the human population, we’re simply no longer going to be able to sustain the number of people now alive. Our petri dish runneth over. Choose your Horseman.
Anna in PDX
As someone who has contracted MRSA in the past and also is allergic to the entire family of sulfa drugs and cillins, I am quite scared of this. I try to take antibiotics as seldom as possible, and when I have to take them I always take the whole amount, and I agree with others about not trying to disinfect everything because I think increasing my own resistance is a good thing. I also try to buy organic meat, but damn, it’s expensive.
Just some Fuckhead: LOL.
@Dr. Omed: I got a very bad omen recently while reading up on what happened to the Mayans. It was population collapse from over-use of resources. It was catastrophic, and when the Spanish showed up, they conquered a shell of what had been.
@Booger: I think this is rather like saying every time you drop a 400-lb block of concrete on a person, you are selecting for the resistant humans.
Interestingly, sinus infections are associated with the absense of ,lactobacillus sakei a bacterium used to make sausage because it kills most other bacteria. Innoculating mice with L. sakei provides protection against sinus infections. The nose may be the ecological niche for L. sakei, because there hadn’t been one found, it can’t reside permanently in the intestines, and yet is found there often enough for sausage-making to work.
I’m not sure, but I did read somewhere that the phage approach will create resistance even faster than the antibiotic approach. Not sure about that, just repeating what I saw somewhere.
Tetracyline is widely used in animal feed and is still used as a human antibiotic today, where it is still of utility and that utility has declined from when it was introduced because is and was over used and bacteria, e.g., e. coli, evolved.
(Female Spousal Unit studied resistance transfer effect back in the mid-70s.)
Every problem is also an opportunity. We wouldn’t have a Medicare problem if you old folks would just keel over more appropriately.
I say we look for Gibsonian solutions – you can keep living, but at 80, you can be converted to a garbage robot.
We as individuals, maybe not. But there are several things we can do as a society to avoid these problems. One would be to stop some of the worst factory farming practices. Animals are raised in giant shit piles that require the constant use of sub-therapeutic antibiotics to keep them healthy. Keeping animals under more humane conditions would let us stop overusing antibiotics on farms and help prevent the development of resistant strains.
And hospitals could do a lot more to prevent infections. Many cases of antibiotic resistant infection are the result of transmission within hospitals; if we can prevent infections from spreading that way, we’re much less likely to run into multiply resistant strains. Medical professionals have gotten sloppy about all kinds of hygienic practices that were absolutely mandatory in the days before antibiotics. Being much stricter about hand washing, clothes changing, and room cleaning between patients could do a lot to cut down on transmission. So could things like anti-microbial paint or even whitewash, which kill bacteria using completely different techniques from antibiotics.
Yes, that is correct & why they are becoming resistant so quickly.
I posted a link in that other thread – could not find the interview but found an article where they state he could not get the data from Rogain and Garfunkle until well after he had worked the numbers
The problem with bacteriophages is that they can’t be used systemically, because they can’t get around in the body and they are recognized as foreign by the body and attacked by the immune system. They can only be used topically and in some body cavities (e.g. the intestines). As a result, they are not generally useful for life-threatening infections. Also, bacteria frequently already have phage-resistant subpopulations (else the phages would have already wiped them out) so even at the start you have resistance problems similar to what you get from food industry antibiotic use.
Medicare has been on the backs of hospitals about infections. The hospitals don’t like it.
Hand washing is number one. I bet most nurses and aides don’t wash their hands between patients. It has to be an ingrained habit.
I eat chicked that has no antibiotics. It tastes better.
Good luck with that. Our current courts will almost certainly consider any restriction on advertizing to be a 1st Amendment violation. We’re lucky that Big Pharma hasn’t already sued to stop the FDA from requiring them to talk about adverse effects in their ads.
Buck up little camper – and try not to fuck anyone while you are in port. Just to be safe.
I despair…this article immediately preceded this one begging us to write to Our Dear Guv’nor Jan “Headless bodies” Brewer to veto a bill that would let foster parents in AZ refuse to vaccinate the kids in their care.
WooHoo! Drug-resistant Whooping Cough, anyone?? Maybe if we try really hard we can arrange a scarlet fever comeback!
Odd Coincidence: the hospital where both my brothers were born started as a tuberculosis sanatorium back in 1927.
@Fair Economist: I’ll take that as an endorsement that I should eat more sausage for my health. I’ll inform Ms Martin of your recommended course of treatment.
@Another Halocene Human: Yo! Pedant. Got back from some errands to see I needed to go back and dot the ‘i” on what I thought was reasonably obvious. Happy now? (Seriously — fair point, though I do think the sense of the phrase was reasonably discoverable…)
@hilzoy: Yes, absolutely. There are other reasons too, but given some space constraints (I originally wrote over 4,000 words, and the final piece clocked in around 2,400) I took refuge in the “many reasons, including” dodge — and picked the most general one (IMHO) as the one to spell out.
MRSA is now well established in the community, and Maryn’s been covering the increasingly evident pathway from farm animals to people. Controlling hospital/nursing home infections is crucial, of course. But there’s a lot else going on.
@Sourmash: The other important difference is that you wouldn’t dare dose yourself with antiseptics. The consequences for your internal organs are just as catastrophic as for the bacteria you’d be killing.
Sure, but that isn’t necessarily a big problem. Bacteria can’t be simultaneously adapted to every environment. If we select for bacteria that are resistant to harsh conditions very different from the human body, we’re also tending to select for ones that are less well adapted for living inside our bodies. Bacteria that have evolved to survive alcohol hand cleaners or thorough washing with detergent are unlikely to be really dangerous pathogens.
Similarly, as somebody alluded to above, antibiotic resistance comes at a metabolic price, so resistant bacteria tend to be selected against when there are no antibiotics around. If we stop using a class of antibiotics, resistance to that class should be selected out of the bacterial population. What we need are enough new antibiotics that we can give up on using some of our current types for long enough for the bacteria to lose their resistance.
OT: Can anyone give me recommendations for a webhost based on their own experience. Efficient, cheap and responsive. I also would like to register a domain name so a host that lets me do that and has an FTP server would be nice.
@Maude: any hospital that wants to keep it’s medicaid/medicare certification has hand hygene as the number one thing that is harped on from day one.
At all of the hospitals I’ve ever worked at, every room you enter into has a hand hygiene gel and at least 1 day of orientation is dedicated to infection control practices of which hand hygiene is NUMBERO UNO for stopping the spreading of infectious agents from employee to patient and vis versa.
Now since I work in the lab, it’s very different. We wash our hands constantly, particulary in the micro lab. I don’t even see patients, but we all have to follow complete universal precautions on every specimen.
It’s been my experience that the majority of hospital acquired infections investigations I have been involved in, have all been traced back to nursing or medicine staff.
A major portion of the blame goes onto the backs of doctors as well. They know, for example, that an antibiotic won’t do anything for a viral infection. But they get tired of whining patients demanding something to take so they give them a prescription and send them on their merry ways.
And that brings us to another main cause, whining patients. People go to a doctor and demand a specific treatment, even if it isn’t appropriate. They demand specific tests, even though they are unnecessary. This country is composed of a bunch of whiners and a lot of doctors placate the whiners just to get them out of the office so they can see another patient who might actually take their advice.
If hospitals had to eat the costs of hospital acquired infections instead of passing the cost on to insurance companies, you can bet they’d be much tougher about hygiene. As it is, they seem to care more about keeping their staff moving as quickly as possible than they care about protecting their patients’ health.
Thank you for this information.
What you do is impressive.
I do wash my hands as a habit. That came from Mom.
I was at a doctor’s office and over the sink in the exam room is a wash in, wash out sign. They have electronic charts with netbooks. The nurse and doctor didn’t wash in or out.
I have a different doctor and they use paper charts.
@Roger Moore: I agree. Some of the mechanisms of antibiotic resistance are fairly well understood. And contra a commenter above, some antibiotics do not work by interrupting the life cycle, but by destroying cell structures (essentially blowing up the bacteria like some antiseptics do). The bacteria develop little pumps to selectively pump that gunk out of them before they ‘blow up’. The resources for developing that pump have to come from someplace, and often comes from resources for rapid reproduction or for virulance (efficient transmission from one host to another).
There is actually a big literature from agriculture on how resistance is developed, modified and decays in bugs, both micro and macro. And what are the best strategies for using that what we know about how they do that to control resistance.
Some interesting stuff that the bugs can’t counter is being developed. Like hospital materials coated with with nano tubes that actually spear the little critters. Sounds very cruel and medieval, but I guess necessary.
I’ve heard docs who research this say that very effective antibiotics made standards of care ‘lazy’ and people were just given pills while older techniques that helped the immune system beat the bugs were completely abandoned. Probably need to integrate both more.
One thing is true, been shortage of funds for basic research and development and production. Social benefit can’t be captured the way drug markets and Big Pharma operate now.
BTW: alot of hospital infections are not due just to people not washing hands. Bacteria form invisible protective films and crurts all over all sorts of equipment and it is almost impossible to keep the stuff clean. I know a doc and a pharmacist and a microbiologist who are working on clever non-antibiotic approaches to kill the bugs that hide under films and crusts inside all those tubes they stick into you in a hospital. Too bad the market doesn’t seem all that interested in what they do, so they have to scrape for dinky gummint funding.
You’d actually probably have to rub it inside your nose to get it there. L. sakei in the sausage you eat can’t establish itself there, although it might help keep the nasties down in the intestines on its way through (i.e., what it does in sausage). I also have chronic sinus infections, albeit not with the kind of consequences your wife had to deal with, and I actually did try rubbing a piece of dry italian sausage in there. My impression was that it helped but wasn’t curative. I seriously doubt L. sakei is the only “good” species.
One thing to remember is that sinus are *not* sterile, not even remotely. The researchers found hundreds of species in any person’s nose. This makes sense, given that the nose filters air and necessarily gets an endless flood of bugs in it. This is in distinction to say, the lungs, which *are* sterile normally. Antibiotic use to “clean out” the sinuses can’t possibly work – the most they can do is wipe out the residents so a new batch gets in.
What John uses here works well. They can fix stuff and it’s a good hosting service. I like wordpress, but then again I’m nuts, so take that with a grain of salt.
A vector in disease transmission in hospitals is also things like the doctor’s stethoscope, white coat or tie. Doctors don’t clean those things as often as they should. Their hands may be clean but that stethoscope may just have been used on a patient who has a resistant infection
@Maude: What does he use, do you know? Is it Bluehost?
I know you are right about pharma ads. I just wish they’d be gone. People are influenced by them.
HostingMatters. They have a nice website and it’s easy to get signed up and running.
One thing I never understood with this story is what can we do to slow down this process. On one hand, it seems natural, that the more you use antibiotics, the more evolutionary pressure, and the more resistant bacterias take over the ecosystem from the non-resistant. On the other hand, we use antibiotics because we are sick.
One often given recommendation (which, at least on surface, seems to contradict the above) is that we should always complete the antibiotic treatment as prescribed by the doctor, and not finish, when we are “healthy”. The justification can be found in Tom’s article:
If a bacteria is resistant, why would it have lowerchances of survival if we keep taking antibiotics for longer? If bacteria is not resistant, then there is no problem, right?
I know some people get relief from nasal irrigation. Maybe you could make it do double duty by coming up with a probiotic version that would help to colonize your sinuses with commensual bacteria like L. sakei. It seems worth a shot.
This is precisely why relying on the “free market” to create a rational medical system is crazy—too many market failures.
I assume it’s along the lines of “if you take this poison long enough, it will kill you; if you stop doing so in time, it won’t.” Except “you” is now the bacterium with a little bit of resistance.
I went on a rant a few months back when Florida closed the only remaining TB hospital and dumped the remaining indigent patients back into the homeless demi-monde. Of course, our legislature must have appropriated money so that caregivers monitored that the patients continued to take their TB meds, lest MDR-TB appear. Wait, they didn’t? And Gubner Luthor musta told Our Legislature about new TB outbreaks before holding the vote to close the TB hospital, right? No? Well, that’s OK– the story sank like a stone. And why not? Since there’s no such thing as Ebbilution, multiplying drug resistance by pathogens obviously can’t happen. It’s the greatest liberal hoax since Global Warming.
I’ve heard that bow ties are much better, because they don’t dangle all over touching everything.
@Marcin: Note Moore’s comment above, antibiotic resistance comes at a price. Incomplete treatment means that you are selecting for a population of resistant microbes. There are always a few microbes are developing resistance in any population, but resources that they use to develop resistance means they grow slower, and less able to infect cells (Edit: well, not ‘infect cells’, but rather slower in establishing a colony among healthy body cells that can evade immune response). If there are only a few of them in the population of the infecting bacteria, then the immune system, with help from partially effective antibiotics, will take care of them. (Edit: and also that less resistant microbes, even while they are being killed off, are out-competing them for resources and in reproduction)
But you do a series of incomplete treatments, or switch from one drug to another in a haphazard fashion, then you have a population made up mostly of very resistant bugs and you have a problem.
@Booger: Booger, no such thing as an anti-septic resistant organism. Antiseptics, think Bactine, or bleach for that matter, kill everything and anything, which is why we can’t use them internally since they would kill us as well. Nothing can survive bleach or copious amounts of alcohol at concentrations above 25% or so and the evolutionary arms race required to develop resistance to antiseptics like that would take humans out long before that level of resistance was achieved, if you follow.
@Marcin: There’s a lot going on; in the case of TB the fact of naturally occuring resistance is why you use multiple front line drugs for even non-resistant disease; you gotta knock out everything. Other bugs present different issues, but the basic notion is that not all resistant bugs are equally so, or totally capable of warding off enough of a drug…so you have to eat all your antibiotics every time….
@certified mutant. Mother Jones has a really great article up right now on why you shouldn’t be on that z-pack for your sinus infection.http://m.motherjones.com/environment/2013/04/sinus-infections-antibiotics-resistance
Resistance isn’t necessarily an either/or thing. Bacteria may be able to survive one dose but not a higher dose, or live longer in the presence of an antibiotic but eventually die. If you stop the course of antibiotics too soon, there will probably still be some surviving bacteria, and they will very likely be more resistant than they were before. The real danger is stopping so early that the infection recurs, now with bacteria that have survived a partial course of treatment. That’s how you select for resistance.
The real start of these antibiotic resistant strains got their big foothold from big Ag and its greed, and our drug war creating a lower class of sick too concerned with obtaining their fix and avoiding jail to care about proper med schedules. Amazing how our two great monsters – corporate greed and our war on American’s have so helped to spawn another monster.
The good news is that antibiotic resistant bacteria can not complete with normal bacteria – given time, and very little miss-use of antibiotics and the resistant bacteria will die out. Little chance with big Ag and thugs deregulating everything.
I do know that some Russian companies sell viruses that can defeat a few types of infections and bacteria can’t become resistant towards those agents (the body does most the work but the virus so weakens the bacteria, the bodies defenses easily win. And no, the virus cannot infect human cells so these treatments are utterly safe.) Just need to figure out the correct virus agents for a given pathogen – that takes time, mony and someone who will only get to sell a single does per sick person (the virus uses the bacteria to multiply so a single treatment is all that is needed.)
@Tom, @jl, @Roger,
I guess the argument that @jl provides makes sense:
Without it (without some better performance of our immune system on small number of bacterias), I don’t understand how the complete treatment would help. Complete treatment, kind of tautologically, will eliminate all non-resistant bacterias, which creates room for the non-resistant ones to grow happily.
I am kind of interested in it. I remember trying to find literature that would explain (or evaluate) the justifications for various strategies of how to deal with the problem. There is a large and reasonably sounding literature on overusing antibiotics in animal population. But I could not find a good (and somehow scientific) justification on full treatments.
@Roger Moore: I’m so excited you posted this because it makes my book recommendation even more relevant. I’ve been reading a book called Evidence of Absence that makes the argument that many of the parasites that co-evolved with and infect humans might actually provide protection from other conditions humans get, thus eliminating them prompts rises in the other conditions, for example asthma. I don’t know the science in enough detail to tell, but the author cites numerous peer-reviewed studies and it’s a fascinating idea. Also, since I’m kind of a slob, it can make me feel virtuous about that. But worms, bacteria, and other forms of life can work symbiotically with their hosts. It’d be interesting to hear Tom’s take if he knows about this book.
I guess one thing that I wanted to add is that there is a tendency to think about resistance in a kind of Lamarckian fashion, that the more drugs we use, the fancier defensive mechanism will be developed by a single bacteria. Of course, it does not work that way – the reason we get more resistant bacterias is because we kill the good ones (i.e., non-resistant) with antibiotics. The use of antibiotics does not speed up the mutation rate.
Also, bow ties are cool.
” The use of antibiotics does not speed up the mutation rate.”
That is one of the insights that has helped in agricultural pest control policies.
Coming from a small farm that grows non subsidized crops, I am no friend of Big Ag. I’m not sure how much use of antibiotics in meat growing Big Ag results in antibiotic resistance, but the crop growing part of Big Ag has developed lots of strategies for dealing with antibiotics, pesticide and herbicide resistance, that could be adapted to medicine (maybe not in the US system, but in other high income developed country health care systems).
I disagree, though, with commenter above who defended use of antibiotics in meat industry. Just because it is used to promote growth in animals without patent clinical disease, and no one is sure how it works to promote growth, that does not mean it does not cause antibiotic resistance. I believe there is a body of published evidence that it does. The only question is how harmful is that type of resistance for human health and medical treatments.
My problem with
is that this goes a little bit against the other strategy considered here, i.e. use less antibiotics.
Both of these approaches go in opposite directions. It is possible that there is some subtle mechanism (that I don’t get) which makes both of these approaches work together, but I kind of feel always suspicious about “subtle” mechanisms. (I am an economist, so this might be my professional bias.)
One of the problems with antibiotic resistance is that the bacteria aren’t developing resistance de novo. Most of our antibiotics come from other microorganisms that use them as a way of killing off competitors, so the microbes have had eons to evolve resistance strategies. When we use antibiotics, we’re selecting for a pre-existing resistant population. And many of the traits involved in resistance exist on plasmids that can be shuttled from one bacterium to another, so it’s possible to cross two strains that are resistant to different antibiotics to get a new strain that’s resistant to both.
You can provide therapies that allow the human immune system to work more effectively in tandem with antibiotics. For example, rather than just throw pills at respiratory infections, first start other therapies that will allow immune system better chance to control infection, and then if that does not work, try antibiotics.
Also there are several dimensions (aka ‘margins’ in economist speak) to intensity of antibiotics use. Are three or four sloppy and incomplete courses of (Edit: maybe poorly chosen) antibiotic treatment ‘more’ or ‘less’ than one well designed and adhered to and complete course, with a big punch of very effective antibiotic up front?
@Roger Moore: thanks for reminding me about that. A big reason why repeated incomplete courses of poorly chosen antibiotics, especially with different ones, is a very bad idea.
The point I think you’re missing is that they are applied on different levels. The “use less antibiotics” is about refraining from using antibiotics at all unless they are clearly called for, e.g. not giving antibiotics for viral infections, not giving them routinely to farm animals, etc. The “you gotta knock out everything” bit is that when you do decide to use the antibiotics, you need to be thorough, so you completely wipe out the infection. So the goal is to use them selectively but thoroughly rather than promiscuously but haphazardly.
@PeakVT: Antibiotic resistance is usually the product of
1) a new enzyme being synthesized that destroys the antibiotic (i.e. penicillin resistance)
2) a mutation in the target site
3) a new pump being synthesized that transports the toxins out of the bacterial cell
each of these things is energetically costly. In the absence of antibiotic, there would be no need for bacteria to express these things at all, and often they do not.
while antibiotic resistance hangs around in the gene (in this case, plasmid) pool a while after selection stops, it isn’t forever.
@Joel: I’ve seen research articles in ag journals with estimates needed for designing application, rest, and switching schedules to control resistance for these mechanisms. Not sure how much of it is for macro versus micro bugs though. So it’s not like humans are starting from zero here. Not sure how anything like those strategies could be adapted to US health care system (DEATH PANELS!), and I am not sure how they are practically implemented in agriculture.
As an economist, I have also read articles explaining why ag and Big Pharma market incentives are to develop drugs that control bugs, but there are big disincentives to developing drugs that work too well, or to cooperate with strategies to allow socially efficient levels of infection control.
More profitable to always have a little ‘too much’ infection around, since then you have a longer and more profitable market for your drug or ag chemical. Name I remember on this is Tomas Philipson, if anyone wants to read up on it.
Act I, Scene 1: The Kitchen
Wife [entering the room]: What the f***k are you doing standing around with a pair of bratwursts stuffed up your nose!
Husband [standing in front of fridge]: eeess summmthon i red un a bluggg. Eeet halps wif mai bakteeereeeaa.
Wife: OMG! Have YOU LOST YOUR FRIGGING MIND! That’s it! I’m cancelling our broadband connection NOW!
@schrodinger’s cat: I use Rage webhosting which I picked because it was iWeb friendly. Support is quick but via e-mail (not phone). And it comes in at $5 per month with a 3 year plan.
@Roger Moore: Medicare tried that, and it didn’t work.
@Joel: Do we have any idea how long energetically costly mutations hang around?
Quoted for truth!
But also, animals on antibiotics fatten up faster — there’s new research suggesting that antibiotics change the gut flora in a way that encourages microbes that absorb calories better. The faster a meat animal [unit] reaches ‘kill weight’, the more profit for the farm [conglomerate] producing it.
Which spins off into another branch of human health… some of those microbiologists are beginning to suspect that the generous use of antibiotics in human infants is a contributor towards the “obestiy epidemic”.
Everything is interconnected!
Sister Rail Gun of Warm Humanitarianism
One of Mother Jones’ recent articles on the subject.
as i am allergic to every antibiotic but one this topic scares the living crap out me!
Has anyone else heard about medical honey? My husband had a huge (c. 5 x 4 x 1/2-inch deep) leg wound. His doc sent him to ER, which sent him to the hospital system’s “wound center,” which applied not iodine or an antibiotic or betadine but medical-grade honey with a gauze wrap.
And it’s healing nicely. It may not even leave a scar.
@JoyfulA: Something about high concentrations of fructose, glucose, and sucrose inhibits bacterial growth. I forget why. Anyway, honey has lots of all three, I think.
Edit: just make sure no random protein gets mixed in and sugar diluted too much. Then I think that makes a very nice breeding ground for micro bugs. Again, I forget why. I’ll check back to see whether I remembered right and if some helpful BJ bio-wonk can explain.
Vancomycin is why I am not dead. And I’m grateful for that. Though it made me so ill during the course of taking it there were moments of not remembering that gratitude so clearly. Though everyone is different in their reactions to drugs. (I can’t take morphine either. Makes me so sick I’d rather have the unbearable pain. Knock wood I never have to make that wretched choice again.)
I had major surgery of the organ removal kind with a Noted Surgeon at a Noted Hospital in NYC. (Rhymes with Mt. Why-Try? Consider other options in your health care needs.) Excellent surgeon, filthy hospital. The bathrooms looked like the picture in this post.
A few days after release I was in the emergency room with a 103 temp and a mystery infection. They couldn’t find anything to stop it. Except Vancomycin.
Infection prevention requires vigilance. And cleanliness. Neither are glamorous. But both necessary. Because when the antibiotics run out, what will we do?
(Health care tip: If you have to have surgery in a big city which usually has limited room size and bed space, and no matter how famous they are, a wide range of patients, don’t rule out mortgaging your house to get a private room with no infectious “roommate”. And recognize the wisdom of specialty hospitals – like only have orthopedic surgery at an orthopedic hospital. Specialty hospitals do one thing only, so no diseases to infect)
@jl: This is “medihoney” from New Zealand, and it comes in a tube.
Just want to add that Usnea is an herb – well, actually a lichen – that works wonders for low grade staph and infection things for which one might take antibiotics. Like sinus infection or ear infection.
Take the tincture. (Herbs, etc, makes a blend called “Phytocyllin” that’s pretty widely available and online. But other suppliers have an Usnea tincture. There is an alcohol free version, too.)
People vary in what works for them, but for acute situations I take a dropperful every twenty minutes to start. Then hourly for a few hours. Then a few times a day for a few days. This is not a prescription. Just mentioning what works for me and has worked for others. Susun Weed, well known herbalist, swears by Usnea.
Snarki, child of Loki
Not so much, if you’re living in rural Africa.
Read a story about a village kid, bitten by a rabid animal. The question was: would they get vaccine in time?
If not, the “traditional” treatment was to trap the kid in a hut until they died, then burn the hut.
The vaccine arrived in time, but it was close.
We, as a species, as a phylum, and as individuals, have always been at war with bacteria and viruses. As a species, we’ve been winning some battles, but as individuals we always lose eventually.
And then they eat us.
Here is Wikipedia explanation on honey and microbes:
Honey has an osmotic effect. Honey is primarily a saturated mixture of two monosaccharides, with a low water activity; most of the water molecules are associated with the sugars and few remain available for microorganisms, so it is a poor environment for their growth. If water is mixed with honey, it loses its low water activity, and therefore no longer possesses this antimicrobial property.
from Wikipedia entry, ‘Honey’
@Snarki, child of Loki: But Gdammit, for everyone of us they get, we take down BILLIONS of them!
Studly Pantload, the emotionally unavailable unicorn
Considering that fundies are pretty much across-the-board dead set *against* birth control/family planning, I don’t think that’s the explanation for their existence.
In the absence of Joel, the answer is that it depends. It depends on how detrimental or beneficial the mutation is in the environment the population is in.
Which, BTW, is one thing that really bugs me. Creationists will often claim that antibiotic resistance isn’t REALLY a beneficial mutation because the resistant bacteria are often less healthy than non-resistant ones absent the antibiotic.
But in the presence of the antibiotic, the non-resistant ones are fucking DEAD, so that mutation, in that environment, is pretty fucking beneficial!
It’s all about the environment. That’s what makes many mutations beneficial or deleterious. It’s not an absolute.
Quite the contrary, I think. Fundamentalism seems to be an r-selected reproductive strategy.
That Rojas painting is amazing.
No comment on the rest; fatalistic about it.
@The Moar You Know: Goodness gracious, we came in at the end. No sex that isn’t dangerous, no money left to spend. We’re the cleanup crew for parties we were too young to attend. Goodness gracious me. http://www.youtube.com/watch?v=8TG7l1aveok
Phages are receptor-dependent, so a small mutation to a single gene could remove the binding site for a phage. And, not all bacteria are infected by phage (the gonorrhea organism for one).