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Comment by decafninja | Hacker News Reader

Tangent, but my wife's side of the family is Korean, whereas myself and my side of the family is Korean American.

I was surprised at how liberally antibiotics are given out in the Korean medical system, even for health issues that shouldn't be bacterial. Many members of her family routinely pop antibiotic pills to treat the common cold or flu. They don't take a "full course" either - just a pill a day for a few days until they feel better. When they got Covid, they were again popping antibiotic pills to "treat" it. They swear it works, and this behavior is apparently commonplace there.

I have very positive views on the Korean medical system, and think it generally beats the American one in almost every aspect. But this attitude towards antibiotics was shocking.

My wife doesn't partake in this mainly because antibiotics are extremely rough on her stomach.

I don't think they're having problems with antibiotic resistance there either, so what gives?

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The idea that you need to take a full course of antibiotics came from studies which were done in patients with tuberculosis, which is very recalcitrant to treatment.

Depending on the infection that you have, finishing the course may not always be the best option since it nukes your microbiota and selects for more resistant pathogens. It depends on the rate of mutation of each pathogen, amongst other factors.

The antibiotic course has had its day

https://www.bmj.com/content/358/bmj.j3418

https://www.health.harvard.edu/blog/is-the-full-course-of-an...

In the cancer field, where resistance is also very common, there are some groups exploring 'adaptive therapy' also known as 'press-pulse' therapy, where you intentionally stop treatment when symptoms go away, in order to maintain a population of the drug-sensitive cells, which will compete with the drug-resistant cells (since being resistant takes energy). It's not curative but when resistance is inevitable, could pro-long life of the patient. I wonder if this type of thing has already been tried with antibiotics.

Modifying Adaptive Therapy to Enhance Competitive Suppression

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7761372/

Press-pulse: a novel therapeutic strategy for the metabolic management of cancer

https://nutritionandmetabolism.biomedcentral.com/articles/10...

I appreciate this comment, but I think it's misplaced as the real issue is the candid handing out of antibiotics instead of controlling their use both in livestock and humans.

I am surprised this happens in Korea. I know such attitudes about antibiotics are commonplace in the developing world. Pharmacists are in the business of selling pills - a doctor's prescription isn't always necessary, but Korea is a high income, well educated country...

1. New Delhi metallo-beta-lactamase 1. https://en.wikipedia.org/wiki/New_Delhi_metallo-beta-lactama...

"NDM-1[1] is an enzyme that makes bacteria resistant to a broad range of beta-lactam antibiotics. These include the antibiotics of the carbapenem family, which are a mainstay for the treatment of antibiotic-resistant bacterial infections."

2. Antibiotic usage and resistance in Mexico: an update after a decade of change. https://pubmed.ncbi.nlm.nih.gov/33956642/

"Ten years ago, a review on the status of resistance in Mexico was bleak: with antibiotics freely sold over the counter and poor regulation of generic drugs, among other conditions, resistance among relevant pathogens often ranked top, either among Latin American countries, or even worldwide. "

Antibiotic overuse is shockingly common in a lot of countries. A company I worked for had a lot of remote offices around the world that I interacted with over video. Whenever I had allergies or a runny nose, I'd get a lot of people asking me why I'm not taking antibiotics. They'd recommend different types of antibiotics that they thought "cured" their last cold.

There are many countries where pharmacies don't require prescriptions for common drugs. People can stop by the pharmacy and grab some antibiotics whenever they feel like taking some.

The United States isn't totally immune. Many people go to the doctor at the first signs of a cold and demand antibiotics. Most doctors will refuse, but some of them start writing prescriptions so the patients will go away and leave a good review. Anecdotally, online local parenting groups always seem to have some group of people swapping tips about which doctors will prescribe antibiotics so they can go get the drugs they want. There are also the people who order fish antibiotics and take it themselves, too.

Antibiotic resistance is only part of the problem. Unnecessarily destroying gut bacteria is not great. Getting C. Diff. Colitis is not fun.

The US may have gone too far the opposite way. Under-dosing also leads to resistance. I had pneumonia and was under prescribed repeatedly for 2 months before going to a doctor who was willing to write give me a high enough dose of simple amoxicillin (!!) to knock it out in two days.

My whole family had strep throat for a month. I'm convinced it's because they were reticent to prescribe antibiotics strong enough. They said "You'll feel better in 24 hours, promise", and when I called 3 days later with a fever still, they just told me to ride out the course.

I don’t think it’s clear that antibiotic resistance is a sustainable effective trait for bacteria to survive in an ecosystem that is not constantly under antibiotics (more so than what you’re implying about Korea). Thinking of it as a passive trait without trade offs may not be correct.

On the other hand, if that does hold true and it does become a common passive trait, then the world is fucked.

I think human use of antibiotics, even when used frivolously like that, are less of a problem than agricultural use.

Antibiotics-resistance is typically an expensive trait for bacteria to maintain, and without selective pressure, it'll typically be selected against. (It's why rotating antibiotics works.)

Also a pill a day, infrequently, is probably also not a big deal.

The problem arises in agricultural use when antibiotics are fed to cattle every single day, with every meal, to every head of cattle, in every ranch. That creates an environment where you're selecting for bacteria resistant to antibiotics. But even if antiobotics start being resisted, we just need to stop using them for a while and they'll become effective again. Sucks for the people infected the the bacteria though. So we can take some amount of heart in that abusing antibiotics is unlikely to end humanity, it just might create a huge humanitarian disaster at some point, which as we've seen, modern capitalism is very prepared to ~handle~ ignore.

We live in an interconnected world so I don't think there would be any localized antibiotic resistance - the effect of that will diffuse across the planet quickly.

That said, I wonder what their IBS rates are like. That can't be great for their gut biome.

Sample size of one, but even a half course of antibiotics wreaks havoc on my wife's gut. Which is why she doesn't follow the rest of her family in popping antibiotics for the common cold.

In contrast though, she had a surgical operation last year (in the US). The hospital refused to give her antibiotics immediately following the operation, saying she probably wouldn't need it. This was shocking for her - and the surgical site actually did end up getting mildly infected.

I constantly hear about this, but I've never experience bowel issues from antibiotics, nor has anyone in my family, adults or children, from a wide array of them.

I know gut biomes must be different but they must be orders of magnitude more different than I assumed. I don't know what else would explain a little dose nuking people's gut biomes, while we experience absolutely nothing.

I was put an antibiotics for acne as a teenager. Once I stopped I had IBS, and still have it to this day. What helped the most was a fecal transplant.

Of course, going on them for years is pretty different from a course of a week or two, and different antibiotics will have different effects.

On a side note, putting people on antibiotics for years seems like a great way to turn your body into a gain of function experiment.

Probably countered by Kimchi.

Perhaps it has to do with Koreans eating kimchi, which are high in probiotics (compared to food in typical western diet)?

Antibiotics would wipe out much of the bacteria in your gut, providing space for deadly bacteria to colonize the gut. But kimchi's probiotics would repopulate the gut bacteria to reduce the chances for deadly bacteria to grow.

Does your wife eat a lot of kimchi?

Of course, we're Korean, so that goes without saying.

However my understanding is that while antibiotics will wipe out your gut bacteria pretty quickly, it takes a much longer time for it to repopulate, probiotics or otherwise.

I believe this is partly caused by competition. As I'm sure you are aware, there are gazilion private clinics in one block competiting for business. You could be a sensible doctor and tell the patient with the common cold that it will get better naturally and send them home (or maybe prescribe them some painkillers). But giving them big piles of antibiotics makes the patients more content as they believe it is going to help. And content patients leads to better businesses.

Those small clinics live and die by local ajummas' word of mouth, so anything helps.

e.g.

"I went to Haeng-bok clinic and the doctor told me to just rest up but it just won't go away"

"Aigo, Unnie~ I went to Sa-rang clinic last time I caught a cold - you know the one at that intersection - and the doctor gave me all these pills. The cold was gone the next day!"

It’s the same in China. My wife’s family is from there, and they hand out antibiotics for everything. Everyone seems to have a stash of them as well.

When my in-laws were visiting Australia for a couple of months and my wife’s mother got a minor cold, she started demanding we get her some antibiotics. We tried to explain that there’s no way a doctor would prescribe them for a minor sniffle, and she totally went if the deep end, acting as if she was going to die if she didn’t get them. But in the end, she survived.

Same. Every doc relative would have some, despite their current crackdown on antibiotics prescribing online (not sales -- you can still fudge some paper and get it done).

The most striking thing about antibiotics use is not human use, however. Colistin, mentioned in the article, became the last line of defense against resistant bacteria while China was still liberally giving it to livestock. Thankfully use of this one is going to end…

This happens in a lot of developing countries, but I'm surprised at SK. I've spent a lot of time in Mexico and Colombia. It's that way down there - antibiotics for everything.

Just because it's a first world country doesn't mean its people have first rate knowledge of biology. Japan also overuses antibiotics, as does many other countries we might think know better.

The simple fact of the matter is most people don't differentiate between bacteria and viruses, they're both germs that cause disease and antibiotics are just one kind of medicine that can cure the disease. Placebo effect also obviously is a significant factor because of that.

That is actually pretty similar to what Americans did before 2000 or 2010, until antibiotic resistance started being generally known.

You’d need to go back further than that. Way back in 2002 I was shocked at my then girlfriend’s family’s overuse of antibiotics.

Her family was from Mexico and they regularly bought them without a prescription at the Mexican grocery store. They’d use them the way I used Tylenol.

Now that's impressive. Yow.

I doubt this comment. Antibiotics for humans have been under prescription only since 1951.

https://en.wikipedia.org/wiki/Durham%E2%80%93Humphrey_Amendm...

You might have the occasional fast and loose doctor overly prescribing antibiotics but it's been impossible to source your own for a LONG time.

What preceding poster said, it was prescribed very liberally, not that it was OTC.

Another aspect to this story is that people stockpile antibiotics - probably resulting from doctors prescribing a very large number of doses to begin with.

For even her family that reside in the US, whenever they make a trip back to Korea, they come back with bags full of antibiotic pills to replenish their local supply.

"Occasional" is a vast understatement. Yes, you had to have a prescription but you could get that by phone, without getting an appointment. Or the doctor would give you a prescription "just in case" when you were in for some other reason or with something obviously viral.

Oh, and "In 2014, 266.1 million courses of antibiotics are dispensed to outpatients in U.S. community pharmacies. This equates to more than 5 prescriptions written each year for every 6 people in the United States." (Which is somewhat later than the time I was thinking about.) (https://www.cdc.gov/antibiotic-use/data/outpatient-prescribi...)

For comparison, that page links to annual reports:

* 2011: "Healthcare providers prescribed 273.3 million antibiotic prescriptions—equivalent to 877 antibiotic prescriptions per 1000 persons." (https://www.cdc.gov/antibiotic-use/data/report-2011.html)

* 2021: "Healthcare professionals prescribed 211.1 million antibiotic prescriptions—equivalent to 636 antibiotic prescriptions per 1000 persons." (https://www.cdc.gov/antibiotic-use/data/report-2021.html)

Same in Singapore. No matter what you have, the docs will throw antibiotics at you.

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