The Black Death Has Shut Down a City in China, and Struck 4 People in Colorado – and That’s Just This Month.

Yes, that Black Death, also known as The Bubonic Plague, or simply “the plague,” has hit Yumen, a city of about 30,000, in NW China this month. On 16 July it killed a 38 year old man and as a result health authorities had to quarantine 150 other people. They also sealed off Yumen by setting up police roadblocks around its perimeter, stopping people from going in or out. China Central Television announced that the city has enough rice, flour and oil to supply all its residents for up to one month.

This is the same plague that was responsible for one of the most devastating pandemics in human history, causing the deaths of an estimated 75 to 200 million people, peaking in Europe in the years 1346–53, killing 30–60% of its population and reducing the world population from an estimated 450 million down to 350–375 million. All of which explains China’s swift response.

Unfortunately, the plague has not been relegated to the history bin nor is it confined to northern China. In Eastern Colorado, for example, at the beginning of the month, 4 adults were infected by the plague. They are believed to have contracted it from a single source, a dog, who died from it.

Since 1957, 60 human cases of the plague have been identified in Colorado alone, and 9 were fatal. Although human cases occur infrequently, the plague is severe and potentially life-threatening if not quickly treated with antibiotics.

The following graphics show us the extent of the problem at home and abroad:


So both the good news and the bad news is the same: antibiotics are needed to treat bacterial-based diseases such as the plague. The reason this is bad news is that our world leaders in health — e.g., the World Health Organization, the US Centers for Disease Control and Prevention, the New England Journal of Medicine — have sounded the alarm on the growing global crisis of antibiotics resistance. The Lancet puts it this way: “[W]e are at the dawn of a post antibiotic era,” with “almost all disease-causing bacteria resistant to the antibiotics commonly used to treat them. In other words, antibiotic-resistant bacteria, like the proverbial time bomb, are poised to wreak infectious havoc on a worldwide scale.

The global nature of the pathogen problem can be seen in the graphic below. Notice, though, it under-represents the problem because, for example, it doesn’t include current or recent epidemics such as C. difficile and MRSA in the US, Ebola in West Africa, not to mention the recent appearance of the plague.

Now imagine life without antibiotics – what then? Scientists warn us that even the 14th century plague bacterium could develop drug-resistance and become a major health threat. In 1995, for example – before the global development of antibiotic resistance – a new multi-drug-resistant form of the plague was found in a 16-year-old boy in Madagascar. The strain developed resistance to 8 antibiotics including streptomycin and tetracycline.

We don’t know which one (or more) of the multitude of microbes that live among us will develop resistance and become a runaway pathogen: who, for example, would have ever guessed the plague pathogen?

What the authorities are telling us, however, is that our 70 year old antibiotic shield has been permanently pierced. Leading organizations such as the Harvard School of Public Health also agree on the one thing above all else that we, the people, need to do: it is this.

Get Ready for the Sea Change in how we Think About Our Microbes and Therefore How We Treat Infectious Disease

Every so often someone comes around that changes the rules of the game, changes the very way in which we think about a subject. In medicine, in the world of bacteria, antibiotics, and the global crisis of antibiotic resistance, that person is the impeccably-qualified clinician-researcher Brad Spellberg, MD, Chief Medical Officer, Los Angeles County and University of Southern California. This is a man who possesses a unique blend of experience, youth and energy, and professional heft. In other words, he is not a dreamer, he’s a visionary, and he and the colleagues he runs with are on the leading edge of thought that I hope will transform infectious disease medicine, and more.

Excerpted below is what he said earlier this year during a panel discussion at an Institute of Medicine seminar, “Antimicrobial Resistance: A Problem Without Borders.” As you read what he has to say keep in mind that biological principles generalize, not just across organisms but also across species, up to and including the “highest” ones. What he says about the needed paradigm shift from one of war to one of peaceful coexistence is profound. And it took him all of 2 minutes to say it:

Brad SpellbergI like to go back to first principles before I tackle complex problems. This whole thing about winning the war against microbes … nah!

We’re not going to win a war against organisms that outnumber us by a factor of 1022 , outweigh us by a hundred million-fold, replicate 500,000 times faster than we do, and have been doing this for 10,000 times longer than our species has existed!

So what we need to do is flip it around. We’re not at war with them. What we need to do is, in the immortal words of Dave Gilbert, achieve peaceful coexistence. The question is, what strategy do we deploy to achieve peaceful coexistence?

I think we need to start thinking of infections, by and large, in most cases, as accidents. There is no advantage for bacteria in most cases to infect us. They are much better off being non-infectious commensals in our gut.

In some cases we do have to have treatment to remove them from where they’re not needed. That may be antibiotics, it may be phages [viruses that target pathogenic bacteria], it may be single pathogen therapies, it may be immune enhancers; it’s all of the above: there isn’t going to be a single strategy. We need to relieve the pressure on any one strategy so that they can’t immediately adapt to that strategy. And I really do think that in the future we will be increasingly treating infections by a combination of targeted therapies; targeted to the bug, and therapies targeted to the host. It is the host inflammatory response that does cause the majority of signs and symptoms of infections that patients experience.

Moderator, Harvey Fineberg, MD, PhD, President, Institute of Medicine:  That’s a very interesting turnabout in thinking about the microbial world in which we coexist as the natural arrangement; and, our job in a sense is to figure out how we coexist, peacefully, as you put it.

It does invert the usual way we think about, if you will, the war metaphors of invasion, defense, and, if you will, destroying the enemy.

Brad Spellberg: Absolutely.

Harvey Fineberg: So it does reverse things.

Further exposition of Brad Spellberg’s thinking can be found here, at the New England Journal of Medicine; and a useful backgrounder about the new understanding of our bacteria and us – yes, we’re a team – is this popular essay, recently published in the New York Times.

Here is the panel discussion:

Is MRSA a Security Threat?

The conventional security threat.

If you’re a writer or a filmmaker in search of a fresh storyline then look no further than the 172 page thought-packed report just released by Britain’s Ministry of Defence, “Global Strategic Trends – Out to 2045,” which warns us of emerging security threats over the next 30 years.

It features our usual suspects: climate change driving millions from coastlines creating havoc, and the increasing threat of cyber-attack as information and communication goes digital. Trending upwards, for example, are the rise of robots, drones and corporate armies, e.g., Blackwater, that will change how we do war, and; as a predicted 3.9 billion people are likely to suffer water shortages, it will replace, or complement, oil, as a primary cause of global conflict.

Then we’re introduced to the new kid on the block: for the first time in its 5 year reporting history the MoD lists antibiotic-resistant pathogens as a “security threat.” The reason is two-fold. First, as antibiotics are rendered useless, infections caused by battlefield wounds will result in more lost lives and limbs than is the case now.

Second, and more compelling, is the effect of the anticipated combination of 4 events: (1) an increase in world population from the current 7.2 billion to 10 billion, (2) the fact that the fastest growing segment of the population will be the elderly – the number of people over 60 will be 2 billion in 30 years, representing a quarter of the globe’s population, (3) urbanization – by 2045, the proportion of people living in cities will increase from the current 50% to around 70% of the world’s population, and (4) poverty – 1 billion people throughout the world already live in slums, lacking basic amenities, and there could be almost 3 billion people living in these conditions by 2045.

The best economic evidence we have says inequality is rising to unprecedented levels, especially in the United States. The MoD report says if we don’t handle the coming economic and demographic shift properly the result will be the overcrowding of a vast and vulnerable (elderly & poor) population. That, in turn, will drive an increase in communicable disease where “social unrest or even violence could ensue.”

The emerging security threat: The enemy within - a million of these guys fit on the head of a pin but they kill & wound us more than our recent wars have.

But if framing infectious disease as a security threat is where we’re headed, take a look at where we are right now using just 1 disease-causing microbe, MRSA, as a case study. In the US alone it kills at least 11,000 people a year and blinds, amputates, and disfigures, etc. more than 80,000. Compare those numbers to a known and conventional security threat, the Vietnam War. Over its 20 year history ending in 1975 it killed roughly 3,000 US military members a year and blinded, amputated, and disfigured, etc. just over 7,500 more.

And that’s just a comparison to MRSA. All known antibiotic-resistant pathogens in the US result in about 23,000 killed and 2 million wounded every year. Over a 20 year period, that’s 460,000 dead and 40 million injured. The Vietnam totals are 58,300 dead and just over 150,000 wounded.

So here’s the question. If you are wounded or dying does it matter whether the cause is bullets or bacteria? We can even take it one step further. If a security threat infiltrated the US killing and wounding 23,000 and 2 million people respectively, every year, we would call that domestic terrorism and we would be living under a state of emergency. So looking at the current infectious disease carnage in this way, and given that the British Ministry of Defence is framing the rising global crisis of antibiotic resistance as a coming “security threat,” why aren’t we calling it that right now?

Do the Right Thing

Margaret Riley, Ph.D.: When we use an antibiotic it is like using an H-bomb because we are decimating the majority of our body's microbial cells. Antibiotics are not "smart bombs," they're indiscriminate killers.

We expect a lot from our doctors. So when something comes along telling us they’re not doing what they should, it’s both surprising and disappointing.

Such was the case 2 weeks ago with the release of a survey that found that doctors prescribe antibiotics even when they shouldn’t, and do so for reasons that are highly questionable. For example, 28% of doctors will give an antibiotic simply because the patient asks for one, and 15% will prescribe them out of malpractice concerns – yikes!

But it’s another finding that’s even more worrisome: 11% of clinicians say their reason for prescribing an antibiotic when it’s not indicated is that, well, it won’t cause any harm and, besides, maybe it will do some good, perhaps in the way that a placebo will.

Oops. The problem with this “it will do no harm” school of thought is that it’s not only flat-out wrong, it’s also dangerous.

So says Margaret Riley, Ph.D., professor of biology at the University of Massachusetts, Amherst. She analogizes the taking of antibiotics to the ingestion of a hydrogen bomb on the basis that it kills everything, all of your body’s bacteria, the good and the bad. Antibiotics, she says, are not like a laser-guided missile that kill only the bad bacterial cells. Sound familiar? Think cancer.

Because in this sense, the effect on your body of a course of antibiotics is similar to the effect of a course of radiation to treat cancer: in both cases you’re using a shotgun to kill a fly and so you end up with “collateral damage,” examples of which are well-known in the case of radiation therapy – hair loss, fatigue, decreased appetite, radiation sickness, and so on.

The collateral damage caused by inappropriately prescribed antibiotics puts patients at risk for allergic reactions, super-resistant infections, and deadly diarrhea caused by Clostridium difficile, according to the US Centers for Disease Control and Prevention.

But remember, at least with radiation treatment there are cancer cells to be destroyed. But what this survey is saying is there are no disease-causing bacterial cells around to kill – but nevertheless 11% of clinicians write these collateral-damage-inducing scripts for antibiotics on the basis that, in their misguided view, it does no harm.

One more thing: it’s this over-prescription of antibiotics that drives the growing global crisis of antibiotic resistance. A problem so severe that even the Prime Minister of Great Britain, David Cameron, got on board this month publicly warning us that “We are in danger of going back to the dark ages of medicine to see infections that were treatable not be treatable and we would see many thousands of people potentially die from these infections.”

So back to our survey. The explanation for the physician-poor result, according to Russell Steele, MD, head of pediatric infectious diseases at the Ochsner Health Center for Children in New Orleans, Louisiana, is that “Education wears off in 5 years.” Residents and interns, he says, get it right when it comes to prescribing antibiotics, “but once they’re out in practice, they start sliding, and use antibiotics indiscriminately.”

Okay, that’s a start. And while we may appreciate this honest admission of indiscriminate use of antibiotics by physicians, on this critical issue at least, we expect more from our doctors – we expect them to do the right thing.

Here is Dr. Margaret Riley’s interesting (she has puppets!) lecture:

Why We Need Technology

Dr. Spellberg: Antibiotic resistance and the collapse of the antibiotic research-and-development pipeline continue to worsen. If we're to develop countermeasures that have lasting effects, new technologies that complement traditional approaches will be needed, he says.

Our last post featured Brad Spellberg, MD, a leader in the field of infectious disease, and his claim that the root cause of antibiotic over-prescription is fear among physicians. Namely, when they’re not sure whether to prescribe an antibiotic or not they will too often go ahead and do so, typically caving in to the demands of their patients. This drives antibiotic resistance, the phenomenon that is rendering our antibiotics increasingly useless.

But what, exactly, are these physicians afraid of? What is this fear based on? Perhaps not surprisingly, the answer seems to be income security – theirs.

This brutally honest admission came to us last month by way of NPR’s On Point, in their show titled “A Wake-up Call on Antibiotics Resistance.” A guy who has been an ER physician for over 20 years, in addition to being a private practitioner, called in (at the 25:35 mark) and explained what I will call the Doctor’s Dilemma. It goes like this. A “major issue,” he said, “is that a patient will come into the ER and demand from the physician an antibiotic. And if they don’t get it they’ll complain to the administration who’ll complain to the doctor and say either make our patient happy or you’re fired!”

He described a similar circumstance faced by doctors in private practice. The pattern is that “a patient will come in to the office and say ‘I’ve got a cold, the sniffles,’ or whatever, looking for antibiotics. So you try to educate them and say sinus infections are usually viral, and they will go to some other physician and may not come back to your office, and so it becomes a business issue.”

Dr. Michael Bell, from the US Centers for Disease Control was a guest on the program and said this is common behavior across the board. Unfortunately, Bell went on to say, we live in a “pill for every ill” society, and made the interesting observation that while we trust doctors when they say we should take something, we apparently don’t trust them when they say we don’t need something – like an antibiotic.

And so the systemic failure of physicians to properly resolve the Doctor’s Dilemma is what led Spellberg to offer this solution in his address last month at the Institute of Medicine:

“How do we deal with that fear? [i.e. the Doctor’s Dilemma]. We need technology. Relying upon asking people to behave differently [think hand washing] in a sustainable way is not going to get the job done. [W]e need regulators and payers, especially payers, to help us push these technologies into the clinic so that doctors don’t have the fear that creates the inappropriate antibiotic prescription. We need to hold these healthcare systems accountable for implementing these technologies as they become available.”

Writing in the New England Journal of Medicine earlier this year, Spellberg was more specific about what we need technology to do: “Infection prevention eliminates the need to use antibiotics. Traditional infection-prevention efforts must be buttressed by new technologies that can more effectively disinfect environmental surfaces, people, and food”.

Canada’s Vancouver General Hospital is ahead of the curve on using technology to “disinfect” people. They’re the first hospital in the world to adopt a new light-activated disinfection method that is expected to reduce infections in surgical incisions by 39 per cent and save almost $2 million a year. A trial of 5,000 patients reduced average re-admissions for surgical site infections to 1.25 cases a month from 4 and shortened hospital stays for surgical patients.

“What we’re doing now isn’t working,” says Spellberg. “If we want to have a future state where we’re not living with a crisis of antibiotics resistance we need to think disruptively. Incrementally tweaking what we’re doing is not going to get the job done.”

Vancouver General leading the way:

The Fear Factor: A Leader in the Field of Infectious Disease Says Doctors Habitually Over-Prescribe Antibiotics Because They’re Too Afraid Not To. What is it They’re Afraid of?

Brad Spellberg, MD: Physicians need to stop being afraid to do the right thing. Sometimes you have to just say no.

Yesterday we reported on the Harvard School of Public Health’s plea to the public to please stop asking their physicians for antibiotics. In their view “They [the public] need to be a partner in using antibiotics properly,” and “We’re all in this together.”

Fair enough. But of course there’s someone else involved in this illicit relationship of over-prescription – our friendly neighborhood physician. And so the question arises: Why are they doing it? Why are they giving out antibiotics when they shouldn’t? Presumably they know better, so what’s going on?

Enter Brad Spellberg, MD; physician, researcher, and a leader in the field of infectious disease and antibiotic resistance. As far as doctor’s go this guy is not your average bear. Extremely well-credentialed, he stood in front of a select audience this year at the prestigious Institute of Medicine and revealed this uncomfortable truth:

The root cause of why antibiotic [over] prescriptions occur is simply fear. Fear of the unknown. We as treating physicians do not know what our patients have with certainty. We make our best guess. And that guess is haunted by the fear that we could be wrong. And that’s what leads to this ‘Well, what if it’s bacterial, how much harm could one prescription do?’ And so we need to deal with that fear. Everything else is putting a band aid on the problem.

Ouch.

Here’s what he’s talking about. Antibiotics don’t work for the common cold, the flu, most ear infections and respiratory problems, because they’re typically viral-based illnesses. Physicians know this. But they’re overrun with patients pleading for antibiotics, often-times for their sick kids. So the physician has a choice. She can order a diagnostic test to see what germ they’re dealing with, knowing that it will take 3 days to get the result. Or she can take 10 minutes to explain bacterial vs. viral-based disease, which the patient may or may not understand, and if they don’t they’ll leave the office disappointed and may well change doctors. Or she can cave in to the demand on the basis of “What’s the harm? Besides, who knows, maybe it’ll do some good.” It’s this faulty last choice that Spellberg is saying is too often made.

And we know that that choice does damage. An inappropriately prescribed antibiotic puts patients at risk for allergic reactions, super-resistant infections, and deadly diarrhea caused by Clostridium difficile. These practices also drive antibiotic resistance, further endangering the future of antibiotics and the patients who need them.

Notwithstanding this huge downside a report in the New England Journal of Medicine estimates that 50% of antibiotic prescriptions may be unnecessary. Health care providers prescribed 258.0 million courses of antibiotics in 2010, which translates into over 8 prescriptions for every 10 people. Prescribing rates were higher with kids under 10 years of age and persons 65 years of age or older. In other words, we’re getting it wrong half the time and it’s the vulnerable among us that are most hurt by this.

All we want to do is give the right antibiotic to the right people and not give it when it’s not necessary. However, before we can realistically think of getting there, Spellberg is saying his colleagues need to first fill this prescription: Physician, heal thyself.

Here is Dr. Spellberg’s talk:

A Message From the Harvard School of Public Health: Please Stop Asking for Antibiotics!

Dr. Stuart Levy: Because of antibiotic resistance "We're in danger of not being able to save lives. I think that's the issue," he says.

So now we know. Antibiotics are not what we thought they were, a miracle drug with no downside. As it turns out antibiotics have a huge downside. And that’s the message a panel of infectious disease experts wanted to get across in a public forum, “Battling Drug – Resistant Superbugs: Can We Win?” held at the Harvard School of Public Health this year.

Here’s the thing. Antibiotics don’t work for the common cold, the flu, most ear infections and respiratory problems, because they’re typically viral-based illnesses. So not only does the antibiotic not help, it turns out there’s an unintended consequence we didn’t anticipate: antibiotic use drives resistance. That means the more we use them the less effective they become, not just for the person taking them but for everybody else too. In that sense antibiotics are a “societal drug,” because individual use affects others in the community. No other class of drugs does that.

The upshot is a lot of unnecessary harm. In the US alone, for example, over 2 million people a year succumb to infections that are resistant to antibiotics ; over 23,000 of whom die, almost half of them because of MRSA. Even when MRSA doesn’t kill it does very bad things to you . You may face having to amputate a limb as happened to this NFL player, or it could leave you blind as happened to this robust teenage boy from north Detroit.

The reason for the “resistance movement” by bacteria – the ability to render antibiotics ineffective – is that they are “born” with the ability to fight antibiotics. Their only job in life is to survive, and they’re done that quite well now for some 3 billion years. In order to have survived that long they had to develop ways – “resistant mechanisms” – to fight the people in their world that threaten them; other bacteria, viruses, fungi, and so on. And that they did. Then along we come in the 1940s and try and knock them off with what we naively think are these invincible antibiotic drugs, and their response is like, “Whatever dude, we’ve seen all this stuff before.”

These critters are clever. Not only will the bug fight off the antibiotic you’re taking, penicillin say, but at the same time the bug will develop the ability to fight off other antibiotics too; for example, methicillin, amoxicillin, and tetracycline. The bug will then transfer the resistances it developed to those 4 antibiotics, to all his little bug buddies. This transfer will take place not just within a single species, E. coli to E. coli for example, but also between species, say from E. coli to Salmonella to Shigella (a bug that causes dysentery). In other words, when you take an antibiotic a whole other world of bugs that become resistant to multiple antibiotics develop inside you, thus leaving you more vulnerable to disease than ever.

But here’s the wicked part. Guess what you do with all these bugs you’re growing that are resistant to multiple antibiotics? You give them away, although not just to anybody. You’re most likely to give them to those closest to you, your family and friends. So when they get sick and need an antibiotic it won’t work for them. And it’s because of you: you’ve given your family and friends bugs that are already resistant to multiple drugs – you have effectively “immunized” them against antibiotics. That is not a good thing.

Dr. Aaron Kesselheim: The number 1 thing his patients say to him is "I want an antibiotic." That public sentiment has to change, he says, because it drives the rising threat of antibiotic resistance.

So what’s the answer? Stop asking for antibiotics. One of the panelists, Aaron Kesselheim, MD, of the Brigham and Women’s Hospital, Boston, says his number 1 patient complaint is “I want an antibiotic.” That is the very attitude the HSPH is trying to change. So if your doctor prescribes an antibiotic for you be sure to ask her why. Ask how she knows you have a bacterial-based illness and not a viral-based illness. Because unless she has swabbed for the bug and taken it to the lab for analysis you cannot know for sure what germ is making you sick.

Stuart Levy, MD, another panelist, and author of the book “The Antibiotic Paradox,” (the paradox is that the more you use them the less effective they become), wound up the discussion with this thought: If I had $800,000 to spend on fighting infectious disease, he said, I’d spend $700,000 of it on educating the community: “They need to be a partner in using antibiotics properly.”

As Kesselheim points out, “We’re all in this together.”

Here’s the video of the enlightening panel  discussion:

A Date With Brad Pitt

Sometimes words just aren’t enough. Such is the case with the landmark report released 5 weeks ago by the World Health Organization that warned us we’re entering a post-antibiotic era in which common infections and minor injuries will once again kill us. The WHO says this is not an apocalyptic fantasy, it is now a very real possibility.

But reading about a “post-antibiotic era” is one thing, actually seeing it play out right in front of you is quite another. This is where Brad Pitt comes in. He narrates the Emmy-winning 6-part PBS documentary series, “RX for Survival – A Global Health Challenge,” that makes you an eyewitness to a world without antibiotics.

Watch, how without antibiotics, a simple scratch to a policeman’s face turns into a horribly disfiguring life-threatening condition where the bacteria eats through his body like a worm eating through an apple. Watch the raw emotion in Seattle teen Ryan Woerth as both antibiotics and surgery fail to fight his stomach infection and how his only option is to try an experimental antibiotic only available for “the most desperate patients.” Watch live footage of a 10 month old infant with pneumonia struggle to breathe, while his mother and doctors rush to find an antibiotic that could save the child’s life.

The Youtube video below is part 3 of the series, “Rise of the Superbugs.” Just after the 36 minute mark Brad Pitt says “Perhaps the most alarming threat is from the common Staph aureus.” We’re then introduced to Ricky Lannetti, a star college football player in Pennsylvania who just 1 week after winning his ninth game of the year is in the hospital fighting MRSA with heart, kidney, and critical care specialists at his side. And his disbelieving father who tells us, “He’s Ricky Lannetti. No little bug is gonna kill him. Not a bug. Not something that we can’t see.”

It’s harsh viewing. But it’s real. And it’s exactly what the WHO says we’re headed for because we’re losing our antibiotics.

Here’s the video:  Rise of the Superbugs

The Bronchitis Affair

Martin Blaser, M.D., of New York University, on our overuse of antibiotics: "Has any health-care professional ever told you that taking antibiotics would increase your susceptibility to infection?"

In Tuesday’s blog we addressed the emerging topic of how antibiotics leave you more vulnerable to infection. The reason is that antibiotics work more like a shotgun than a target rifle: they kill all bacteria in sight. So the “good” bacteria that help us fight infection are killed too, leaving us more vulnerable to the next microbial invader. So the lesson is only use an antibiotic when you absolutely have to and for goodness sake don’t use them for something they don’t work on.

The trouble is we’re not doing that. As the Centers for Disease Control points out antibiotics do not fight infections caused by viruses like colds, most sore throats and bronchitis, and some ear infections. And a study just released tells us we’re getting this wrong more than we thought.

When you go to a doctor’s office or the emergency room and are diagnosed with acute bronchitis, 71% of the time you will be prescribed an antibiotic. The only problem is you should never be given that script because bronchitis is a viral-based illness not bacterial. So aside from the usual harm associated with a wrongly prescribed antibiotic – diarrhea, rashes, and stomach distress – we’re creating a huge pool of people who are more vulnerable to disease.

Oh, and as for the 15 year program the CDC has engaged in trying to educate doctors about the appropriate use of antibiotics, how’s that working out? The bronchitis study was over 14 years ending in 2010. It found that the number of antibiotic prescriptions for bronchitis actually increased over that period.

Can Taking Antibiotics Increase Your Chances of Getting an Infection?

Martin Blaser, M.D., is the Director of the Human Microbiome Program and a Past President of the Infectious Diseases Society of America. He asks an important question about our overuse of antibiotics: "Has any health-care professional ever told you that taking antibiotics would increase your susceptibility to infection?"

The utterly counterintuitive answer is “yes,” as Dr. Martin Blaser, an infectious disease specialist at New York University, tells us in his superb just-released book “Missing Microbes: How the overuse of antibiotics is fueling our modern plagues.”

First, some quick background. Dr. Blaser’s concern is with the huge overprescription of antibiotics. In 2010, 258 million courses of antibiotics were prescribed in the United States – that’s 833 prescriptions for every 1,000 people. What Blaser and others such as the U.S. Centers for Disease Control contend is that far too many of these prescriptions aren’t necessary. For example, only 20% of upper respiratory tract infections are caused by bacteria. Yet patients demand and doctors routinely prescribe antibiotics for sore throats, runny noses, chest colds, pneumonia’s, and so on, without first checking to see if the cause is viral or bacterial. So what happens then, if you take an antibiotic when you shouldn’t? Or perhaps worse, what happens if you have simply taken too many courses of antibiotics over the years? The answer in both cases is that you make yourself more susceptible to infections.

Dr. Blaser offers us 3 pieces of evidence to explain this unintended consequence of antibiotic use.

As usual we begin with our animal friends, the mice. Researchers fed normal mice a species of Salmonella that causes disease in them and us. Although infection occurred, it took 100,000 Salmonella organisms injected into a mouse to infect half the population.

But the researchers wanted to know what would happen if you first gave the mice an antibiotic, in this case streptomycin. Since antibiotics kill bacteria, the mice should be immune. But that’s not what happened. Instead they found that it now took only 3 Salmonella organisms – not 100,000 – to infect half the mouse population: that’s a thirty thousand-fold difference.

Subsequent research substituting Staphylococcus bacteria and penicillin for Salmonella and streptomycin showed the same results: i.e. taking an antibiotic before being exposed to a germ greatly increases your risk of infection.

Next up is the Chicago Salmonella outbreak of 1985 where at least 160,000 people became ill and several died. Scientists tracked down the origin of the Salmonella to contaminated milk from a single grocery store chain. The health department asked people who became sick a simple question: Have you received any antibiotics in the month prior to becoming ill? They found that those who had taken antibiotics got sick at a rate five and half times greater than those who hadn’t taken antibiotics. So just like with the mice, the taking of antibiotics before being exposed to a germ increased your risk of that germ making you sick.

Then, in 2001, researchers wanted to know whether people who received a one week regime of antibiotics would exhibit an increase in the quantity of their bacterium Staphylococcus epidermidis, which is naturally found on your skin. The result: subjects given an antibiotic had a “dramatic” increase in the Staph skin bacteria; whereas the “controls,” the people not treated with antibiotics, showed no increase in their Staph count. What’s more, the increased amount of Staph remained on the skin for 4 years, which is when the experiment ended. So we don’t know how much longer the organism would have persisted.

So how do we account for the result in these 3 cases – the mice, the milk, and the skin Staph – where taking an antibiotic before being exposed to a germ actually increases your chance of that germ making you ill? It’s that seemingly innocuous phrase in paragraph 5 above: “Since antibiotics kill bacteria.” Antibiotics kill ALL bacteria, the “good” and the “bad.” Good bacteria operate in conjunction with your immune system to protect you from disease. So if you knock them out with an antibiotic and are then exposed to a disease-causing germ, your chances of that germ making you sick go up – way up.

One more thing. That alarm sounding mouse experiment that showed a thirty thousand-fold reduction in the number of germs it took to infect you after being inoculated with an antibiotic – - it was done in 1954. But at that time the study came as an inconvenient truth. That’s because antibiotics had only been available for 10 years and they had just served a noble purpose in World War 2, warding off countless infections in soldiers due to battlefield wounds. So antibiotics were a good thing and we didn’t want to hear anything different.

But now, some 60 years later Dr. Blaser says it’s past time that we confront this inconvenient truth. As he puts it: How manydoctors ever tell you that antibiotic use can increase your risk of infection?

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