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 many doctors ever tell you that antibiotic use can increase your risk of infection?

MSSA- A Common Bacteria that Threatens Surgical Outcomes

A common bacteria, Methicillin Susceptible Staphylococcus aureus (MSSA), and its antibiotic resistant counterpart, Methicillin Resistant Staphylococcus aureus (MSSA) continue to plague patients who are undergoing major surgeries. MSSA is found on 25-30% of the population and is found typically in the warm and moist parts of the body.
When patients are immunocompromised and weakened following surgery, they are more vulnerable to bacterial infections from the bugs that they carry. Weakened by surgery, MSSA and MRSA often breach the body’s defences leading to surgical site infections.

MSSA inhabited in the nose has been typically treated with antibiotics) and the bacteria in the groin, armpit and anus areas are commonly treated with Chlorhexidine and/or alcohol wipes and baths. Studies have demonstrated that decolonizing the nose from bacteria such as MSSA and MRSA have resulted in significant reductions to the surgical site infection rate. A decolonization protocol is well worth implementing since the cost of an MSSA surgical site infection is greater than $34,000 per patient and the cost of an MRSA surgical site infection is over $100,000 per patient, representing a huge cost burden to health care providers.

The underestimated cost of surgical site infections, however, is the impact on the patient, their work and their families. Unfortunately, there are no good estimates to measure the impact on families for surgical site infections, making it difficult for health care administrators and policy makers to generate support for infection prevention therapies. Until there is greater visibility to the true costs of surgical site infections to our society, there will not be the adequate speed to development or adoption of important new technologies that can meaningfully reduce the rates of these hospital acquired infections.

What the MERS Virus can tell us About Life in a Post-Antibiotic World

Dr. Sally Davies, Britain’s Chief Medical Officer, says resistance to antibiotics is one of the greatest threats to modern health and poses an “apocalyptic threat.”

The World Health Organization released a major report 2 weeks ago warning us that we’re on the cusp of a post-antibiotic era, in which common infections and minor injuries which have been treatable for decades can once again kill. That’s because after 70 years of chronic overuse of antibiotics in medicine and agriculture the bacteria have evolved ways to fight back rendering the drugs impotent – hence a “post-antibiotic era.” But what exactly that means seems hard to fathom. However, another disease story unfolding right now offers us timely and uncommon insight into a world without antibiotics. That story is the global threat of the MERS (Middle-East Respiratory Syndrome) virus .

It has been front page news lately because the first 2 cases of this untreatable viral infection have struck the United States. The first was in Indiana 2 weeks ago, then yesterday we learned of a second case in Orlando, Florida. More cases are expected because of the recent surge of cases in Saudi Arabia, the source country.

MERS is a severe respiratory illness. As of Monday, 538 confirmed cases had been reported to the World Health Organization; 145 have been fatal. It’s spread to those with whom you have close contact. Health care workers are especially at risk; in fact the 2 patients in the U.S are health care workers who returned from working in Saudi. The symptoms are easily confused with the flu: fever, body aches, diarrhea, cough, and shortness of breath.

So what we have is that for the first time ever the virus has left the Middle-East where it has been contained until now. The reason for the escape is the emerging new rule of infectious disease, based on a growing and growing mobile world population: “Disease is just a plane trip away, and an outbreak anywhere is a threat everywhere,” says Dr. Thomas Frieden, Director of the Centers for Disease Control in the U.S. Or, as Dr. Cesar Arias, an infectious disease specialist at the University of Texas, puts it: “Bugs don’t have passports. They don’t respect borders. They can travel very easily.”

But there’s a more telling story at work here. You can see it if you take a moment to think about the elaborate efforts we have undertaken in response to the virus.

Remember, the response is to just 2 cases of MERS in the entire country. Yet disease detectives from the Centers for Disease Control in Atlanta went to Indiana and then Florida to assist in treatment of the quarantined patients and to retrace their contacts to see how many others are showing signs of MERS. Anyone showing such signs will be quarantined to prevent further spread of the virus. The tracing effort means getting in touch with about 500 people in each case. All those who had contact with the victims during their flights from Saudi to London, then to Chicago and Indiana in the first case; and from London to Boston, Atlanta, and Orlando in the second case. Passenger lists will be used to contact everyone who sat near the 2 men. Authorities in London are doing the same thing for passengers who disembarked there.

The CDC will also try to find everybody the patients were in contact with after they got off the plane but before they went to the hospital: family, friends, and co-workers, as well as all hospital treatment staff because the closer the contact the easier the virus spreads. That’s why 20 Orlando hospital workers who came in contact with the man before he was put in isolation are being quarantined in their homes for 14 days. The CDC has asked all American doctors to be “vigilant” about watching for new cases. And some hospitals have instructed triage nurses in emergency rooms to ask all patients with pneumonia symptoms where they traveled in the previous two weeks.

An Orlando medical hotline has been set up to field concerns from the public, and to receive tips about people who might be infected. The local authorities are relieved their patient did not go to any of the local tourist attractions thus avoiding contact with people who will eventually disperse worldwide.

So, we’re going through all this for 2 cases of a virus that can’t be treated. Now compare the bacterial case: Each year in the United States at least 2 million people become infected with bacteria that are resistant to first-line antibiotics and at least 23,000 people die each year as a direct result of these infections. MRSA alone is responsible for almost 12,000 of those deaths. Now imagine the carnage if second-line antibiotics and antibiotics of “last resort” also failed to help them – which they already do in the 23,000 fatal cases. Actually, we don’t have to imagine it because there is precedent, and there is also a prediction about what it would be like that comes to us from a very informed source.

The precedent comes to us from Martin J. Blaser, MD, an infectious disease specialist at New York University and author of the just published book: “Missing Microbes: How the overuse of antibiotics is fueling our modern plagues.” Dr. Blaser reminds us of the destructive force of pathogens, those disease-causing invisible creatures, so tiny that a million of them can fit on the tip of a needle, and so deadly that during World War 1, dysentery and typhus took a greater toll than combat. In 1918 and 1919, the great Spanish Flu spread across the globe to infect 500 million people, about a quarter of the world’s population, killing between 20 and 40 million of them, frequently from complications due to bacterial infection.

Why nothing like that since then? Antibiotics. World War 2 was on the horizon. No one wanted a re-occurrence of what happened in WW1, or during the Spanish Flu. Penicillin had been discovered in the 1930s but nobody could figure out how to make it in large quantities: until 1942 only drops at a time could be made. So the Americans, knowing full well that battlefield wounds could once again turn into a worldwide spread of infections, went full-court press and solved the problem. Penicillin thus became available for everyone, military and civilians alike, thereby avoiding the WW1 epidemics.

Germ Jail: Dr. Davies warns us that in a post-antibiotic world, the criminal law will be used to lock up mass 'colonies' of people with untreatable infections.

The prediction comes to us from the Chief Medical Officer of Britain, Dr. Sally Davies, in her recently published book “The Drugs Don’t Work: A Global Threat,” in which she imagines life in a post-antibiotic world. She says we’re headed toward a world where infection is so dangerous that anyone with even minor symptoms would be locked in confinement until they recover or die. This is the scenario she envisions:

[T]he government passed new laws making it a criminal offense for the infected to be in public. There were talks of random tests in the street. If you were contagious you would be committed to one of the isolation sanatoriums that were being built on the edge of all major towns. This was a death penalty. They were referred to as ‘colonies’.

Is this just the stuff of science fiction or is she onto something? Remember, the 2 MERS patients in the U.S. were quarantined as were the 20 hospital workers in Orlando who were exposed to that patient before he was diagnosed and precautions taken. Disease detectives in the States are on the hunt for about 1,000 more people there, and British authorities are tracking down however many disembarked from the Saudi flight in London. Anyone found with MERS will be quarantined as will anyone exposed to that person before they were diagnosed, especially people with whom the patient lives and health care workers. How close is quarantine to arrest? How many people do you quarantine in a locale before you have a ‘colony’ of them? A tip line has been set up to inform on people suspected of being MERS-positive. The CDC has warned all doctors in the U.S. to be on the lookout – read: an APB – for anyone with MERS-like symptoms. And all this for 2 known cases.

So, multiply what’s happening in these 2 cases by 500,000 or a million cases of bacterial infection at a time when antibiotics no longer work and where are we? We are in a post-antibiotic world: MERS may be just the taste test.

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