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Oct 29 2013

In the post-antibiotic era

I knew the situation with antibiotics was bad but I didn’t know how bad. It’s really bad. The part I didn’t realize (which was stupid of me, because it’s obvious once it’s pointed out) is how heavily most advances in medical treatment, i.e. surgeries, depend on antibiotics. We’re screwed.

Frontline did a big show on it last week which I haven’t seen yet. It has an interview with Dr. Arjun Srinivasan of the CDC on its website.

They really are miracle drugs, and not only have they saved the lives of millions and millions of people … but antibiotics have opened up new frontiers in medicine that would be impossible without them.

Like what?

For example, organ transplantation. One of the major causes of death in patients who would have an organ transplant would be an infection. Without antibiotics, we wouldn’t be able to treat any of those infections.

And stem cell?

Stem cell transplants, bone marrow transplantation, cancer chemotherapy would be largely impossible … because all of these are therapies that weaken people’s immune system, which of course makes them then vulnerable to infections. We don’t have to worry about that so much because we have antibiotics that can treat those infections.

A lot of the therapies that we use now for different types of arthritis, like rheumatoid arthritis — you see ads for that now on television — again, these are therapies that weaken immune systems. They make people vulnerable for infections, but because we have antibiotics, that’s not something that we have to particularly worry about as much as if we didn’t have the antibiotics.

But now we don’t, so much, so we do have to worry. And it’s getting worse not better.

We are quickly running out of therapies to treat some of these infections that previously had been eminently treatable. There are bacteria that we encounter, particularly in health-care settings, that are resistant to nearly all — or, in some cases, all — the antibiotics that we have available to us, and we are thus entering an era that people have talked about for a long time.

For a long time, there have been newspaper stories and covers of magazines that talked about “The end of antibiotics, question mark?” Well, now I would say you can change the title to “The end of antibiotics, period.”

We’re here. We’re in the post-antibiotic era. There are patients for whom we have no therapy, and we are literally in a position of having a patient in a bed who has an infection, something that five years ago even we could have treated, but now we can’t. …

And that is just scary as hell.

I talked to a friend about it the other day, and she told me she’d recently had major spinal surgery and the hospital told her to go home the next day. She was aghast, and said, “What? Surely I need to recuperate more first?” And they told her every minute she stayed was more risk of untreatable infection.

Oh.my.god.

18 comments

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  1. 1
    Pen

    Doctors prescribed them as placebos for the common cold and at one point every woman in labour was ‘purified’ of her unclean germs before birth. The result. Speaking of labour, I expect the rate of Cesarean sections will drop radically when antibiotics go offline – unfortunately we will no longer be able to risk them when there is real need.

  2. 2
    Ophelia Benson

    I know, and apparently there are still some doctors who will give them for colds if patients demand them hard enough. Jeezis, how hard is it to say “they don’t work on viruses” over and over really loud until it sinks in?

    And speaking of labor, the same friend also told me that when she had her babies the nurses didn’t check her dilation and she said “don’t you need to check the dilation?” and they said “every time we check it is another chance for infection to enter.” Holee shit.

  3. 3
    Pen

    Progress by unfortunate means – they don’t need to check the dilation. It doesn’t seem to reliably tell anyone anything and it is highly intrusive.

  4. 4
    Peter N

    On a more positive note, there was a good discussion about new, gene-based treatments for infection on the most recent Skeptic’s Guide to the Universe podcast. The article they discussed is here. These treatments will be very specifically targeted, be free of side effects, and, I would like to think (once we get the technology scaled up), cheap.

  5. 5
    monad

    You might note though that antibiotics aren’t obsolete in principle; bacteria are simply used to the ones we are using. It’s an arms race, and I haven’t seen anyone suggest that we couldn’t still be ahead if people had still been looking hard for new classes. We simply weren’t.

    There isn’t much immediate reward in finding new antibiotics while the old ones are still working, and so drug companies have been neglecting them for other things, like cancer and lifestyle drugs. It might be telling that one of the few leads on fighting MRSA is that it might be vulnerable to some statins, which have been under more serious investigation for their effects on cholesterol.

  6. 6
    carlie

    We simply have to get heavily into phage therapy research.

    The other thing we have to do is stop using antibiotics as growth enhancers in cattle. But no matter how many times the alarm is sounded, it’s still done. Studies in which antibiotic use is curbed show that the bacteria go back to normal susceptibility fairly quickly, because resistance is so costly.

  7. 7
    FloraPoste

    Gah, I really don’t want to be hearing about this. I have a freshman in college on the opposite coast from me, battling a UTI, for which apparently we are now down to one effective antibiotic, and my mom has a hip replacement scheduled in 2 weeks.

    There was a piece on Fresh Air on this a few days ago, and the interviewee (can’t remember the name) pointed out that part of it is lack of financial incentives to develop new antibiotics. Not much payoff in drugs that need to be prescribed sparingly and which are only used in short courses. Unlike asthma or diabetes drugs where lots of people will need them every day for decades.

  8. 8
    Erin (formerly--formally?-- known as EEB)

    Yup. When I my intestines ruptured a couple years ago, once the initial trauma was stabilized, the biggest worry was infection. And I had everything, the poor infectious disease doctor was in and out of my room three times a day, constantly having to run new tests and cultures. He’d kill one thing and three more would pop up–sepsis, weird infections and fungi I’d never heard of, and then a yeast infection that spread to my blood because of all the antibiotics they had me on. After that, because of the time I remained in the hospital, I developed several “hospital” illnesses, like c-diff, MRSA, and there’s a colony of something or other living in my urinary track that I can’t remember the name of…anyway, a lot of it they straight up couldn’t treat, like the MRSA. They were pretty straight up with me: you have it, even if we got rid of it, you’d just get it the next time you came back, you’ll probably always have it. (The only good thing is that I always get my own hospital room whenever I’m admitted because of my history…annoying for the nurses and any visitors, though, because they all have to gown up before coming in.)

    Because I couldn’t get the nutrition or medications I needed orally, they put in a PIC line. Also because I have terrible veins and they weren’t able to get an IV to stay in. They ended up having to take out the PIC before I was quite ready to go back to eating, and when I had a relapse and ended up back in the hospital for a few weeks, there was a big fight between the gastro doctor who wanted to insert another PIC and the hospitalist who was dead set against it. Basically it came down to risk/benefit, and the hospitalist won–it was considered too risky to keep a permanent line in, because it would be too easy for it to get infected, especially because I was already carrying MRSA.

    I still get UTIs like clockwork, and unfortunately, it’s not a situation where I can just go see my GP and get a script–I always have consult the urologist (who I hate; he’s such an uncaring ass) because the normal antibiotics no longer work.

  9. 9
    Stacy

    There isn’t much immediate reward in finding new antibiotics while the old ones are still working

    We’ve known for a very long time that the old ones would not work forever, and the problem of antibiotic-resistant bugs is ongoing.

    The problem is that there isn’t much financial reward in finding new antibiotics, period. One more reason why “free market” malarkey and human welfare don’t mix.

  10. 10
    quixote

    Free market malarkey is at the root of all the antibiotic resistance issues: feeding antibiotics to cattle, prescribing it for colds, not working on new antibiotics, not working on phages (which have to be individually tailored, are hard to store, and are more expensive and labor-intensive, but which work like magic when done right).

    The good news, as carlie pointed out @6, is that resistance is very costly for bacteria. Without antibiotics to select for the resistant ones, the others take over again in a few hundred? thousand? bacterial generations. Five or ten years, our time. (So just don’t get sick or need surgery in the next twenty, thirty years….)

  11. 11
    quixote

    Erin, what a terrifying horrible set of problems you’re dealing with. I don’t have anything to offer, but just wanted to say {hug}.

  12. 12
    Giliell, professional cynic -Ilk-

    I know, and apparently there are still some doctors who will give them for colds if patients demand them hard enough. Jeezis, how hard is it to say “they don’t work on viruses” over and over really loud until it sinks in?

    Pff, they’re still prescribing them even when patients don’t ask. A few weeks ago my usband had a terrible cold, I guess it might have been actually the flu. His GP sent him home with antibiotics. I asked him: “did he check whether it was actually a bacterial infection?”
    He “I thought they could hear that!”
    Me: “WTF? If I were you I woudn’t take the antibiotics.”
    He took them anyway. Not that they did him any good, except for all the nasty side effects (and then I bullied him into taking them all because if there are bacteria at work that breeds resistancy, too).
    Well, two weeks later he was halfway healthy again, but then the cold came back. Now, given that the first antibiotics didn’t do a thing because it was most probably a viral infection, he prescribed him some more antibiotics, this time one of the ehavy duty ones you should only use on multiresistent bacteria. Still without running any tests…
    At least this time my husband listened to me….

    As for labour: I actually insisted on getting the American protocol and not the German one. In the States the standard is to test women for Strep B and then give those with a positive result IV antibiotics during birth. Because Strep B is a baby-killer (2% chance of transmission, 100% serious, high mortality). In Germany you don’t test women and hand out antibiotics to those who have additional risk factors like a long birth.

  13. 13
    Jonny Vincent

    Not much payoff in drugs that need to be prescribed sparingly and which are only used in short courses. Unlike asthma or diabetes drugs where lots of people will need them every day for decades.

    The true horror of the medical industry. There’s no money in cures or prevention. All the money is in ongoing treatment. For all we know, they could have cures for cancer suppressed because they’re making too much money from treating the dying until they’re dead.

    They’ve prohibited the 20th century’s penicillin, Desoxyn. I wonder how many people know that the world doesn’t actually have a methamphetamine problem but a corruption / ignorance problem. I wonder how many people know WWII, the Korean and Vietnam Wars were largely fought on methamphetamine. To this day, USAF pilots aren’t allowed to fly without taking methamphetamine first. Who knows what the media doesn’t tell them?

    In Thailand, they’re still giving out antibiotics to nearly every hospital patient. Any excuse for doctors to make money but to be fair, fairness and integrity long ago ceased to be competitive in a world gone down the drain. People don’t reward those who save them from pain. They only reward those who relieve pain. It’s self-inflicted suffering but those who shoot themselves in the foot with their love of feeling good and hatred of truth always scream, “Why me?”

    Why, indeed.

  14. 14
    Omar Puhleez

    Antibiotics are found in nature because they kill and/or repress bacteria. Penecillium notatum was the classic (fungal) example. It had been presuably making penecillin for yonks in order to compete with bacteria.

    But then it’s discovered for medical use. So the population of Penecillium fungi is multiplied God knows how many fold to provide penecillin for us humans. That in turn acts as a powerful selection agent AGAINST vulnerable bacterial strains, and FOR the penecillin-resistant ones. So penecillin resistance becomes established. Same for the rest of the antibiotics.

    Carlie @#6 is dead right. Antibiotics have been blown by the INTENSIVE livestock industries, where animals are concentrated at huge population densities in crowded and inevitably humid sheds and bans. Intensive piggeries, poultry farms and cattle farms are particularly to blame. Antibiotics are fed to animals as a disease preventative rather than as a cure post infection. But there has also been no political will to regulate antibiotic use in animal husbandry.

    It seems that humanity is headed to learn epidemiology the hard way. Black Plague #2, here we come.

  15. 15
    Ophelia Benson

    Giliell – jeezis! That’s appalling.

    At least, it is unless there’s more to the story. The rules as I understand them via my HMO’s manual (which I’ve had for years so maybe this is out of date) is that there’s no point in seeking treatment unless/until you’re coughing or blowing green, or the cough goes on for more than 2 weeks, or various other indications like that. I’ve always vaguely assumed that green meant bacterial infection.

    Never mind. I’m rambling.

  16. 16
    rnilsson

    Once upon a time, at least one big pharma co had a policy that all its researchers, whenever they went to conferences all around the world, which they did pretty regularly, should pick up a soil sample to bring home for analysis and breeding of whatever organisms might be present. The plan was to find and exploit new variants of antibiotics.

    Now, one lazy summer one researcher actually did the tests on one of those samples and found it was on the one hand pretty potent, but on the other hand useless because it killed the immune system. So he shelved it again.

    Fast forward some time. Another bright person realized that this effect could in fact be used to advantage. Enter Ciclosporin or Sandimmun(TM), the patented immunosuppressor that made organ transplantation routine. And once that drug was registered for use in the U.S. the company simply had to expand and export much of its business State-side, in order to reduce tax on those massive profits. Hundreds of thousands of patients who simply HAD to take the expensive drug for the rest of their lives, well that translates into some cash. Much much more than just another antibiotic would have netted.

    An interesting spin-off side effect of this side-effect is that the company then had opened a whole new market for other drugs in order to combat opportunistic viral infections. Someone I know actually produced specific antibodies for a few of those, and retired at 50 to play the stock market full time.

    … you’re getting sleeeepy … and vote Republican! SNAP

  17. 17
    rnilsson

    Oh, another side effect was countless lives saved or vastly improved by permitting those vital organ transplants. Let’s not forget that. Well worth some money?

  18. 18
    Giliell, professional cynic -Ilk-

    Ophelia
    Nothing more to it. He just needed another week to get over it again. After that he was well again, no need for the antibiotics.

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