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Comment by jvanderbot | Hacker News Reader

I've wondered about that for a while. There is some environmental cost to resistance, right? Like a bacteria strain won't necessarily proliferate resistance worldwide if we just stop using an antibiotic it reists (for long enough).

If that premise is true then it should imply two things:

1. If we have "enough" "orthogonal" treatment options, we should be able to rotate on long enough time scales to avoid resistance to all treatments. Like cicadas with their prime numbered long sleep cycles.

2. Maybe we can find a treatment whose resistance is so difficult that it makes the newly resistant bacteria too vulnerable to other threats to survive in the wild, or at least at a serious disadvantage against non-resistant variants.

Are these completely off base?

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The concept of a “hospital acquired infection” is a drug resistant infection that came from the human petri dishes living in the hospitals taking antibiotics and breeding resistant strains which don’t survive in the wild.

So, yes you have the right idea. There is a general push to not do outpatient procedures in hospitals for this very reason.

Rotating on a long time scale invokes a tragedy of the commons problem. You would need to get all the world's drug manufacturers to agree not to make certain products at certain times.

But if small exceptions (because you know some rich person is going to get sick and hire a rogue lab to make something that's supposed to be paused) wouldn't ruin the whole scheme then it seems feasible.

But there's not necessarily an advantage to breaking the rotation. The point is that the currently allowed drugs stay effective the whole time. There's a coordination problem, sure, but I don't see the incentive to hire a "rogue lab".

I agree that a "rogue lab" is silly, but there is an incentive to use old stock before it goes bad but after the rotation has switched to a new drug.

Eh, you can plan to allow some overlap. As long as the manufacturing is in disjoint intervals, you'll get basically the same effect.

If you have enough antibiotics, there won't be an incentive to do that because, when someone has an antibiotic resistant disease, that will just mean it's time to shelve an old antibiotic and start using one that has been out of circulation for a while (e.g., no bribes/rouge labs required - just a call to the WHO).

If you do not actually have enough antibiotics to cycle through, then yeah, it would not really work.

> 1. If we have "enough" "orthogonal" treatment options, we should be able to rotate on long enough time scales to avoid resistance to all treatments. Like cicadas with their prime numbered long sleep cycles.

This is something that has crossed my mind in the past. We rotate antibiotics in a logical fashion, in a manner similar to the way we rotate crops.

But as someone else responded more eloquently, you're gonna have a hard time telling grandma's family that the most effective antibiotic is currently "out of rotation." And honestly, I'd be pretty upset if it were my grandma, too.

That's a user interface problem. Just tie a brand to "whatever antibiotic is on rotation now". Grandma gets used to Activir, but Activir changes active principle every couple of years.

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