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 Spellberg: I 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: