The Age of the Superbug Is Here
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People self-medicating on antibiotics end up taking an incomplete dose without fully understanding the implications. This has lead to the rise of superbugs like https://en.wikipedia.org/wiki/New_Delhi_metallo-beta-lactama...
Edit: a word
BTW, in my experience Brazilian doctors prescribe antibiotics a lot less than American doctors.
Others just walk to the pharmacy store and narrate the symptoms to the pharmacist. Typically: Sore throat, a little fever etc. Then they state their budget(10-20 rupees), the pharmacist gives two tablets of Azithromycin.
Every year that we fail to help India reach the superpower status hints at chinese-style authoritarianism being a superior model. I wish we would spend more time and effort helping them.
I don't understand why other countries (and the international community as a whole) still accept this behavior.
https://consumersunion.org/news/the-overuse-of-antibiotics-i...
Its like "I seem to have sore throat, let me take this anti-biotic right now, so that it doesn't escalate to something big later"
And they are right too. Most doctors write down the same regimen of antibiotics every single time.
Either way most doctors in India care about nothing apart from money and their immediate interests. Many realize they will never do a MD, so there are a lot of small time clinics, with rudimentary testing labs for blood work. They only care about maximizing per visit consultation fees and commission they get from the pharmacy store next door.
Its a huge mess, and there are no ways to fix it given the population scale.
- ALEXANDER FLEMING, Nobel Lecture, December 11, 1945
Improper dosage of antibiotics is like 'vaccinating' the microbes.
Here's a clip with a bit more information from the BBC Horizon popular science programme. http://v6.tinypic.com/player.swf?file=24goih4&s=6 (Sorry for the sub-optimal hosting, but YouTube's contentID blocks this clip.)
One of the things they don't mention in that video is what the safe human dose of that antibiotic is. I'm not sure where on that slab the dose of antibiotics starts killing humans.
Question that comes to mind is how easy would it be to take the bacteria that make it to the center, and put them on a new plate with a different antibiotic in the same configuration, and then repeat until you've gone through all available antibiotics, then scoop that last batch up and do something really nasty with it?
It must be harder than it seems, because otherwise why do terrorists and the like even bother with (seemingly much harder to obtain, though admittedly flashier) chemical and nuclear weapons?
Thus post attack the deaths would take a long time to add up and be hard to trace back to some attack.
PS: I had a foot of my intestines removed without being prescribed antibiotics or getting an infection.
Maybe that's considered a noble sacrifice, but I don't know what they think.
What terrorists are you talking about? Seems to me like 99% of terrorists use regular weapons I.E. explosives, guns, and knives.
Can anyone else with more knowledge of this confirm/refute this perspective?
EDIT: I should point out he wasn't saying it was a total non-issue. Just that some of the fear-mongering about global pandemics and such was completely unfounded.
But we don't live in that world.
In fact, in western countries, if we discover infection we treat.
If you have TB, your risk of becoming symptomatic is only about 1% per year, however you are potentially contagious the entire time. So in the health community we conduct TB screening, and most migrants are required to either show evidence of BCG status, or a series of chest x-rays often combined with the results of a Mantoux test.
A friend of mine, an emergency trainee, recently changed hospitals and had to have another Mantoux test. He lived in shanghai as a kid and would have been exposed in some manner, even though his body either cleared it or it is long dormant (his CXRs are clear). NSW health policy is that he needs 6 months of a course of antibiotics to ensure it is not latent in him.
The same approach is taken to would be migrants.
So you see, with tb the issue is not so much virulence, but our ability to control its spread in the community and prevent a potential pandemic of XDR TB, which all of a sudden would have TB as big of a public health threat as it was 50 years ago
What he's saying isn't inaccurate. The idea is antibiotic resistance generally carries some metabolic cost -- the bacteria disable or find some other way around whatever pathway is being targeted by the antibiotic. This means they operate "less efficiently" than their non-resistant peers. When the antibiotic disappears from the environment, the resistance no longer offers an advantage, so they get out-competed by their non-resistant "more-efficient" peers.
This is in fact one of the ways hospitals fight outbreaks of resistant bacteria -- they cycle antibiotics. More subtleties of course, but basically the head infection surveillance person says "alright docs, this month we're blacklisting these antibiotics, next month we're blacklisting these." (This is one of the interventions our infection software helped with.)
On the other hand, there are places where the widespread use of antibiotics extends far beyond the reaches of a hospital building. Commercial agriculture is infamous for overusing antibiotics (basically mixing them into the lot's feedstock so every cow gets it). Outbreaks like SARS and avian flu weren't antibiotic-resistance outbreaks, but they WERE caused by sizable quantities of people working in close proximity with livestock and then spreading the disease through their normal travel and social interaction vectors.
India is known for having antibiotics widely available over-the-counter for people. There are stories of people coming back from India with an infection resistant to literally everything (there's only about 50 antibiotics out there) -- when that happens, it's like the outbreak movies where the CDC comes in with plastic sheets and wearing bunny suits to quarantine the room.
So will the lower-metabolic-efficiency attribute of antibiotic resistance be self-limiting enough to prevent it from turning into another 1918 spanish flu global pandemic? Maybe. But as long as there are large city-scale pockets of heavy antibiotic over-use with people traveling in-and-out, there are going to be constant transmission vectors that will still kill people in largely preventable ways.
Patient visiting from India comes in with sepsis from urinary tract infection, and she has a history of multiple ones. ER doctor calls me to admit her. I come down and review her paper chart that the family brought with her and see where her last E coli UTI was resistant to everything except meropenem, and possibly gentamicin although I don't recall.
Until I had looked over this, the patient wasn't in any contact precautions (meaning disposable gloves or gowns for staff) and the ER doctor had given her the usual treatment for a UTI which in her case was going to do nothing.
Already, we're seeing some pretty scary bugs with CRE (carbapenem-resistant enterobacteriaceae) and XDR-TB (extensively drug-resistant tuberculosis) and others. Festering in hospitals, where patients are at a much higher risk almost by definition, can create a real nightmare scenario that spreads outward from there. Even if that's avoided, antibiotics are almost a fundamental aspect of modern medicine. When they first came out, they were quickly perceived as an almost magical cure-all by the general public. Most people aren't able to imagine a world without them, let alone support the necessary steps to fight such a scenario. Medicine pre-penicillin was a scary thing, and no one really wants to think about the possibility of returning to it.
The body count--figuratively, literally, and economically--will likely be higher than a feared superbug as a result of surgical complications, the impact on organ transplants (if they're even feasible at that point), and a host of other problems brought about by common antibiotic resistance under the worst case scenarios. It's not a scary picture, and it's already here with thousands of deaths annually.
Unless some of the many ideas already being explored start to pan out, along with the discovery of new antibiotics in the interim, we're looking at a major step backwards to the 1930s. But that's going to require a lot of public funding and support. Personally, my nightmare scenario isn't a pandemic or a drastic decrease in survival rates for routine procedures. It's that we'll wind up having to experience one or both of those before the public starts to understand the problem and change their behavior. Maybe I'm being too pessimistic, but then I look at how antibiotics are treated in foreign countries and in livestock management, and I start to wonder if I'm not being pessimistic enough.
0. https://www.asm.org/index.php/journal-press-releases/94465-a...
Bacterial populations that develop these resistances are certainly self limiting to a small extent - the resistance makes them less fit, less survivable and powerful, than other bacteria that lack the resistance trait - this means that bacteria WITHOUT the resistance out-compete bacteria WITH it -
That, in turn, means that when we take away antibiotics from the bacterial growth environment, the population with the resistance dwindles greatly or even disappears -
BUT
And this is a GIGANTIC BUT!
- often the mechanism that causes bacteria to stop expressing the resistance trait doesn't actually remove the genetic material from the individual bacterium, and even more, doesn't remove the trait entirely from the population. The end result of this is that you have a bacterial population that isn't DIRECTLY resistant to a given antibiotic NOW, but that if you introduce an antibiotic, you will almost immediately have a bacterial population resistant to that antibiotic. Through mechanisms like turning resistance genes back 'on' that were previously 'off', genetic material communication (essentially just bacteria passing genes back and forth amongst themselves, many bacteria are frighteningly efficient at this!) - we get the end result that's the functional equivalent of a a town full of regular folk who can go to a bunker in the event of an emergency and immediately transform into the hyper-militia from hell. Like a population full of terrorist sleeper cells, only with far more destructive capability than any terrorist group!
When antibiotics were introduced, it was heralded as the end of disease. Now, not that many decades later, we are dealing with super bugs.
I have read research on how to effectively reverse antibiotic resistance. I think this is a problem we can find solutions for in terms of societal level changes to reduce this issue. But, for the time being, you are screwed if you get one of these and my big concern is that this may be solved by having enough billions of people die so as to serve as a natural means to reduce population densities and interrupt the path we are on currently. This would majorly suck, even if you are one of the lucky survivors, because it would destroy a lot of things we currently take for granted, among other things.
The Nature article hints that the main barrier to adoption is that it's difficult to for pharmaceutical companies to make a profit out of phage therapy: the cure is entirely natural, bacteriophage are the most common organisms on the planet, they reproduce very quickly, and evolve to overcome bacterial resistance.
Evolution doesn't necessarily mean positive mutations that assist. See http://evolution.berkeley.edu/evolibrary/misconceptions_faq....
The challenge for drug companies is that they would need to isolate and get regulatory approval for each pathogenic bacteria that they wanted to treat. Today one of the challenges that drug companies face with developing new antibiotics is that the profit models for antibiotics are poor compared to drugs that treat chronic conditions. With an antibiotic you sell one course of treatment per patient but with a diabetes drug , for example, you're selling a lifetime supply. With a phage your taking the already small pool of money for antibiotic treatment and dividing it by a hundred or a thousand.
The other challenge is that using phages as part of a treatment protocol the diagnosing physician would need to culture and identify the pathogenic bacteria and then order a specific phage for treatment which would increase the cost of diagnosis. One possibility would be creating cocktails of phages that would target many different strains of phages but that would require complex revenue sharing agreements unless all the phages were developed by one drug company.
And while phages work great in vitro the don't always work as well in vivo because they are ... viruses ... which the immune system will attempt to identify and destroy them. Phage therapy for a sore throat, for example, requires gargling a phages in liquid. Not as simple as popping a pill to treat a blood infection.
It's worth noting that phage therapy was successfully used in the Soviet Union, and is still used in Georgia where the phage was "farmed", and that attempts to commercialize it have (as far as I know) invariably failed.
The clinical problems in administration of phage therapy to patients you mention are well-known and limit their use somewhat. But phage therapy could still be a valuable addition in the fight against pathogenic bacteria, rather than a replacement for antibiotics, which are more convenient, and work very well most of the time.
This was also why Germany, during the 2nd World War, were probably the world's experts in Sulfa.
They target very specific bacteria. Instead of identifying the bacterial strain (which if I'm not mistaken is done using phages), a cocktail of phages would be administered. Even if that doesn't work, finding a strain of bacteriophage from the environment which does kill the bacteria would still be quicker than developing a new antibiotic.
Phage therapy is neat, it really is, but there are a couple major issues:
- There is no such thing as a "broad spectrum" phage. You can't do empirical treatment using phages, and there's not really "off the shelf" phage therapy - it tends to be a bespoke creation for a particular infection.
- There's some serious regulatory problems, similar to those experienced by fecal transplant treatments. We're not yet really equipped to think about handling evolving, custom microbes as a treatment. - Because of the first, it's going to require a considerable amount more lab capacity than most clinical settings currently have, and considerable delays until treatment.
- There's also some biosafety issues around phage prep, but those are easily solvable.
It's a great way to treat particularly resistant or hard to treat infections, but it's not a particularly great general solution. There's a reason it was abandoned in countries with easy access to antibiotics - they're just roundly superior in basically every respect.
NB When you are warned not to wear contact lenses in swimming pools - take it seriously! We're almost certain that's how he got the problem.
Now freshwater lakes or oceans under certain conditions I could understand
Edit: As a note to the pedants, of course sterile" is a binary, I used that casually to mean "less microbrial than a lot of the places where our eyes go." ;) <- right eye unfortunately hit the unsterile waters of a chlorinated pool.
This (and mrob's post) is definitely incorrect. It's the opposite, in fact, there is no "sterile" in the absolute sense. You'll never kill everything.
This is measured in multiple ways, depending on field: sterility assurance level[0] is one, similar to the way the USDA specifies cooking temperatures to hit 6- or 7-log reduction in bacteria populations. This is also why we crash probes like Cassini into Saturn to not risk contaminating any possible niches that could support life even though the probes have been built in a clean room, cleaned, and irradiated.
I suspect that there's some level of heat at which you've done exactly that. What organic molecule is going to survive a bath in liquid tungsten? ~6100F
There's also flaws in procedure -- was it at the required temperature long enough -- and, of course, the real world that your target is going to be exposed to when it leaves the tungsten bath -- clean rooms aren't all that clean.
I think dailies are somewhat safer, because you're starting each day with a sterile pair. But splashing any non-sterile water onto them is a mistake.
http://www.nhs.uk/Livewell/Eyehealth/Pages/Contactlenssafety...
"“It doesn’t matter if it’s fresh water or a chlorinated pool,” Gibbons said. “There are bugs and pathogens that chlorine doesn’t kill, which could potentially cause damage to the cornea, infection or ulcers.”
http://healthcare.utah.edu/healthfeed/postings/2015/07/07141...
They can't really become resistant to high concentrations of cleaning products like chlorine bleach because they just physically ruin the organism - the best explanation I've heard is that that would be "like a human becoming resistant to lava." Not gonna happen.
But in really low concentrations like in a pool, perhaps they could resist the oxidation effects...
If you wear contacts and follow all the rules exactly (like always taking them out before swimming/water sports, taking them out after X hours of wear each day, etc), I feel like they lose a lot of the convenience that made them so appealing in the first place.
You really want to just stick them in your eyes first thing in the morning and then forget about your crappy eyesight until bedtime, but it never seems to quite work out like that. (At least not for me, I have friends who wear them day in, day out with no apparent issues).
My son had them for a week and run into that problem and hasn't worn them since.
The one time I had to switch to softs, I had an infection in 2 weeks. My lens hygiene procedures are not compatible with softs apparently.
He had only been using them for a week or so and wasn't that good at getting them out so I suspect he must have scratched his eye while getting them out after swimming.
or give extreme tax benefits to those that don't use antibiotics.
Either way I've got some bad news for you
Easy to say when you're wealthy, no so much when you consider yourself healthy but poor.
But at the end of the day, not everyone can afford organic pasture raised eggs at $7/dozen. And the problem is that we've all gotten so used to eggs at $0.50/dozen or chicken at $1/pound that I don't think society as a whole could deal with the cost of meat equalizing to reflect the true cost of non-factory farmed production.
We certainly could if we had to, but so far we haven't had to.
one gives antibiotics to one's thousands of chickens to spur growth (body growth - gaining mass), not to protect the consumer from disease.
giving antibiotics to poultry extremely increases mass gains. post-slaughter processes add chemicals that keep meat from rotting, eradicating some of those living harmful bacteria that just so happen to turn flesh into unwanted dark piece of s+=t.
But in reality, meat is an inefficient form of producing food, with complements humans can easily shift to. So the way you get less antibiotic use in livestock in a capitalist decision market is by reducing the demand for livestock. Taxes do a great job at reducing demand.
There are some vegetables that are easily grown in unsuitable areas with GM, and some people do use pesticides and GMOs to "defeat" the market but if international logistics weren't so hard it would be easier to just import the stuff.
Similar industry, completely plant driven, is cotton agriculture for clothes - to ensure proper demand you need GMO or pesticides.
When it comes to beans, lentils, soybean for humans (although most of it is for fish farms, poultry and livestock), wheat, corn, rice, all sorts of fruits, pesticides come in hand, but there's more than enough if space was taken from dairy/meat and given to those.
91% of Amazon is cut for animal agriculture. http://www-wds.worldbank.org/servlet/WDSContentServer/WDSP/I...
It's just 7 billion people, while you have to raise 50 billion chickens, 1 billion cows, -- about 150 billion animals yearly just to get them from baby form to somewhat of an adult form. That requires a lot of food, way more than 7 billion avg. 150 pound humans.
edit: realistically, this problem is unsolvable, just like US and China and others won't really struggle lowering their CO2 footprint, so will not Brazil, USA, India, Australia, Denmark and others when it comes to reduction of their meat/dairy output. If we were some nice unified Humanity maybe things would be different.
Things like the fall of the Soviet Union, desegregation in the US, man on the moon, etc. Even things that required great international cooperation have happened. Like the eradication of smallpox and polio, the creation of the United Nations, etc.
But the reduction of meat consumption and reliance on factory farming need not be done on a global level to be worthwhile. It can happen one country at a time. Even one person or one animal at a time will be helpful, even if it won't solve everything. It doesn't have to be all or nothing.
Farming without prophylactic antibiotics--where antibiotics are only used to treat sick animals, as they are in humans--could meet the demand for food easily.
nice AMA from the experts directly.
First answer:
> First, a lot of antibiotic resistance appears to be driven by the agricultural use of antibiotics as growth enhancers. Thus, we can be savvy consumers and support and be willing to absorb the costs of the efforts to get antibiotics out of the meat industry.
https://scholar.google.com/scholar?q=livestock+last-resort+a...
Here's a nice batch of results.
It's a well known problem, not some esoteric trivia. It is also the biggest cause of selective pressure, not antibacterial soaps or human medicine misuse of antibiotics.
With these bans in place, it doesn't seem necessary to implement a tax on their use. Perhaps a ban on importing meat that was produced using antibiotics for growth.
Seriously though, we can forget about getting 7 billion people to use antibiotics safely. Really- forget about it. Not even education helps- after all it's doctors and pharmacists who are primarily responsible for this mess we're in [1].
Our only chance is to find some other way to deal with bacteria -perhaps that phage therapy thing- otherwise we may as well just accept that X million people will die every year because of bacterial infections. Not to mention, of all the conditions that might be safe to treat given antibiotics, but not without them (you know, open heart surgery, brain surgery, that sort of thing).
[1] Here's a childhood memory: my family doctor telling me I have a viral infection ... and prescribing antibiotics. Almost every year until I was 18 and stopped taking the damn things on my own, for entirely irrelevant reasons (I thought they were making me worse) (I got better).
Among some of the advancements:
* Group B Strep results under one hour (traditionally 48-72 hours)
* Salmonella results in 30 minutes (traditionally 24 hours)
* Listeria results in 5 hours (traditionally 18 - 24 hours)
And they're still funding studies for Fidaxomicin.
This backwards process is actually observable. Many fish living in underground caves have lost their eyes through evolution. While eyes don't aid a fish in surviving in the dark, they certainly don't hinder the fish from surviving either... Yet cave fish have lost their eyes despite the lack of negative selection pressure.
some have, yes. but in order to get the antibiotic benefit we're looking for, you'd need to have ALL fish having lost their eyes. That's a much higher bar. ( https://en.wikipedia.org/wiki/Blind_fish seems to be a reasonably comprhensive list ). We also need the antibiotics to be viable again in a reasonable timespan ( a decade or two?), in order to be useful -- not on the timescale that was involved in cavefish eye degeneration.
The second part is in the works, constantly. The first part, however, is proving difficult.
DNA is good at accumulating, and relatively poor at editing out. Some bacteria will lose resistance, just like your ancestors lost the ability to make Vitamin C. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3145266/ but you only need one single bacteria to have not lost the ability.
> What if we cycle certain antibiotics on an annual basis?
it helps. We can also stack them, and use multiple attacks at the same time. which also helps. But it just delays the inevitable.
> When we reintroduce them, they'll be more powerful. Right?
the bacteria, yes. because they'll have accumulated defense mechanisms.
Ultimately, I think we win this race, because we can intelligently and actively edit DNA.
The downside to this is that the process of losing a trait is much more slower than gaining a trait. Think about it: Natural selection is a targeted process where by favored traits are directly selected and built up. Thus each generation gets a step closer towards a final selected outcome.
On the other hand, losing a trait involves one waiting for random mutations to basically destroy the trait by random chance, no direct selection is involved. By probability the complete destruction of a trait not maintained under selection pressure will eventually occur given enough time.
It is however basically comparing a blind folded dart game with a dart game that isn't blind folded. Hitting the center of the board in the blind folded game will take much longer than the other game but the center of the board will always eventually be hit given enough turns.
We have seen experiments (and the recent amazing video) of bacteria evolving resistance to antibiotics. Does anyone know of any research that studies the length of time it takes for these bacteria to lose a trait?
http://www.vox.com/2016/9/8/12852924/evolution-bacteria-time...