The Case Against Antibiotics
One of my longest nights of parenting began like this: My husband and I read to the children, washed dishes, and swept up mountains of cracker crumbs. We settled on the sofa with hot tea and the remote. Then our 2-year-old howled.
She clutched her crib railing, screaming, “My ear hurt.” I gave her ibuprofen and tried to rock her to sleep, but when she turned on her right ear, she wailed. No one got much sleep that night.
The next morning our pediatrician’s office was closed, so we headed to an urgent care. The nurse practitioner took a few minutes to confirm an ear infection.
“Now, I’m going to let you decide what to do next,” she told me. “We no longer automatically give antibiotics for ear infections. In most cases, they’re viral and clear up on their own. But, considering what a rough night you had, I leave it up to you. Would you like a prescription for amoxicillin?”
A generation ago, that would have been an easy decision. My mother, like many parents of her era, gauged doctors on how quickly they picked up their prescription pads. When I was growing up in the 1980s, it seemed that my classmates and I were downing doses of bubble gum–flavored amoxicillin four or five times a year.
Today, a global increase of drug-resistant pathogens, or “superbugs,” has led prescribers to rethink how often patients receive antibiotics. Antibiotic-resistant strains of familiar pathogens are emerging more often, making it harder to treat things like urinary tract infections, foodborne illnesses, and common infections. More than 2 million Americans are infected with antibiotic-resistant bacteria each year, and while powerful antibiotic drugs of last resort can cure most, some 23,000 die, according to the Centers for Disease Control and Prevention.
If left unchecked, these antibiotic-resistant bacteria threaten to return us to the days when routine illnesses or minor surgeries could lead to fatal infections. The outlook is more grim in the developing world, where poor sanitation hastens the spread of pathogens, and access to antibiotics is limited. The World Health Organization (WHO) reports that multidrug-resistant tuberculosis now strikes nearly half a million people annually.
Where do drug-resistant bacteria come from? And what is being done to stop them?
Bacteria created antibiotics billions of years ago to battle against competing strains. As bacteria evolved the ability to produce antibiotics, they also evolved defenses against them. That’s where antibiotic resistance comes in.
The problem, explains Ellen Silbergeld, an environmental health scientist with the Johns Hopkins Bloomberg School of Public Health, is that bacteria have been around a lot longer than humans. About 6 billion more years. And in that time, they’ve learned a lot about self-defense. We often think of humans as inventing antibiotics, but, in truth, we discovered them, beginning with penicillin in 1928. Bacteria created antibiotics billions of years ago to battle against competing strains. As bacteria evolved the ability to produce antibiotics, they also evolved defenses against them. That’s where antibiotic resistance comes in.
Bacteria can put up a biological shield of sorts, and even a small exposure to an antibiotic can activate the genes that produce this defense. And, most remarkably, one bacterium can pass along these genes. “Bacteria actually rule the earth,” Silbergeld says.
“There’s an assumption on the part of both patient and prescriber that everyone wants an antibiotic. We need a paradigm shift away from antibiotics always being the ‘right’ thing.”
In the decades after antibiotics were discovered, they were used sparingly. But, by the 1950s, the drugs were being widely prescribed. Today, 30 to 50 percent of antibiotics are handed out unnecessarily, according to Sara Cosgrove, a Hopkins epidemiologist and infectious diseases physician who studies antibiotic resistance. Most of these are given to patients complaining of upper respiratory infections, she says.
As marketers for today’s plethora of probiotic products will tell you, bacteria play an integral role in our bodies. Most are beneficial, helping us digest food, for example. But antibiotics wipe out both the helpful and disease-causing bacteria— leaving behind the resistant strains to survive and reproduce.
Overprescribing antibiotics spurs the spread of resistant strains. Their use can make oral contraceptives and other medications less effective due to drug interactions, and can trigger allergic reactions and gastrointestinal issues, adding to the list of reasons not to take them unnecessarily. Cosgrove and her team have launched a project to reform how hospitals, nursing homes, and physician groups dole out antibiotics. “There’s an assumption on the part of both patient and prescriber that everyone wants an antibiotic,” she says. “We need a paradigm shift away from antibiotics always being the ‘right’ thing.”
When you’re suffering from a bacterial infection, the benefits of taking an antibiotic outweigh the risks, she says. But if you have a viral infection, taking an antibiotic will not clear up the condition and it does more harm than good. Studies have shown that reducing the use of antibiotics in a hospital setting by 25 percent led to a reduction in the spread of resistant bacteria by 28 percent, Cosgrove says.
Studies have shown that reducing the use of antibiotics in a hospital setting by 25 percent led to a reduction in the spread of resistant bacteria by 28 percent.
Heather Sateia, a Hopkins internist, divides infections into those for which antibiotics are never appropriate, such as the common cold, flu, or acute bronchitis; and those for which they are not usually needed, such as sinus and ear infections. Finally, there are those for which they are always needed, such as strep throat and bacterial pneumonia. Although decades of research support this approach, it can be hard for doctors to explain to patients in the throes of a cold. Patients pressure them for antibiotics, and some doctors prescribe them despite guidelines that recommend waiting until evidence of a bacterial infection is clear. “For many physicians in today’s overstrained medical system, it’s easier to write a prescription than to have that conversation,” Sateia says.
In her practice, Sateia begins by assuring her patients that she understands that they feel rotten. Then she explains that antibiotics aren’t an effective treatment for a viral infection, but other remedies can help them feel better: rest, fluids, saline nasal sprays, humidifiers, and over-the-counter medications. She sets clear expectations for follow-up, instructing patients when to call if they still feel sick or seem to be getting worse.
Her practice is also experimenting with a checklist of symptoms to help patients better understand whether their complaints are caused by bacteria or viruses. Everyone in the office has been trained, so receptionists don’t make offhand promises of antibiotics to patients.
While health care providers are trying to change the way antibiotics are prescribed, the battle against drug-resistant bacteria is playing out in surprising places—on farms and poultry-processing plants. About 80 percent of the antibiotics produced in this country are given to livestock, and most of the animals don’t need them, Silbergeld says.
The practice dates to the 1940s, when agriculture companies came to believe that indiscriminately dosing livestock with antibiotics sped their growth. Farmers began routinely mixing antibiotics into chicken feed. Although studies have shown that chickens treated with antibiotics don’t grow faster than their drug-free counterparts, the practice remains deeply entrenched.
Since bacteria develop defenses when exposed to antibiotics, chicken farms are hotbeds of drug-resistant bacteria. These resistant bacteria fan out from farms, floating through air, trickling into streams, even hitching rides on the feet of flies and mice, says Silbergeld, who detailed her research in a 2016 book, Chickenizing Farms and Food: How Industrial Meat Production Endangers Workers, Animals, and Consumers. They wind up in the supermarket. One of Silbergeld’s grad students analyzed the liquid in a package of raw chicken. A single drop—the sort you might haphazardly wipe off your kitchen counter— contained multiple antibiotic-resistant pathogens. “You really have to consider that food is your enemy,” Silbergeld says. “Do not use wooden cutting boards. Do not share knives with other food. Cook things well, and when finished cooking, put them right into the fridge.”
In most cases, our bodies’ natural defenses contain these drug-resistant pathogens within our digestive tract. But when they escape, they can make you very sick. Drug-resistant urinary tract infections—caused by bacteria making the leap from the gut or from improper hygiene—have become more common, even in healthy people, Cosgrove says.
There is some positive news: Two of the nation’s largest poultry producers stopped routine antibiotic use in chickens. Silbergeld hopes others will follow.
While changes on the farm and at the doctor’s office might curb the creation of resistant bacteria, there are few efforts to find new weapons against evolving bacteria. Drug companies focus resources on treatments for chronic conditions; new antibiotics are seen as poor investments.
WHO wants to change this. Since the initial discovery of antibiotics in nature, we have learned to synthesize them, and WHO has issued a call for the development of new drugs. Late last year, several European nations committed nearly $90 million to the effort. Yet much remains to be done. The WHO estimates that an annual commitment of $800 million is needed to curtail drug-resistant tuberculosis alone. The WHO also recently published guidelines, written with the help of Silbergeld, to reduce and restrict uses of antimicrobials in agriculture.
As for our family, I wish I could say I turned down the antibiotics. But, like so many Americans over the past six decades, I agreed to a course of antibiotics that was likely unnecessary. Now, after learning more about the hazards, I know what I’ll say next time: No thanks, let’s just wait and see.
Your Quick Guide to Antibiotic Use
If you have a confirmed bacterial infection, such as strep, fill that prescription.
Doctors can’t often tell by symptoms alone whether sinus or ear infections are bacterial. If symptoms persist 48 hours after using palliative therapies, ask about antibiotics.
Always disclose your other medications. Antibiotics can make contraceptives less effective or create dangerous complications with drugs like blood thinners.
Should you pop a probiotic? The evidence isn’t conclusive on whether these hasten the recovery of healthy gut flora.
When suffering through a cold, remember: Limiting lifetime use of antibiotics could keep you healthier in the long run.
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