Dr. Arjun Srinivasan: We’ve Reached “The End of Antibiotics, Period”
pbs.org
pbs.org
[1] http://www.nytimes.com/2012/09/04/health/use-of-antibiotics-...
It gets much dicier in-hospital when someone has a SIRS response and you need to presumptively treat them for sepsis.
I would be curious to know: of the antibiotic resistance burden that comes from human antibiotic use (specifically in countries where abx are physician-prescribed and not available over the counter), how much of this burden comes from broad treatment of presumed serious infections, and how much comes from treatment of presumed non-serious infections or even postsurgical prophylaxis?
The problem is much more with people who only take partial courses or are non-compliant, because if you don't clear the infection then round 2 is full of the slightly more resistant members of the species.
I believe there are some labs-on-chip that can detect multiple(even thousands) bacteria and/or viruses. I'm not sure if they are in commercial usage.
I'm just pointing out that the antibiotics aren't strictly being used for disease-prevention (hence better hygiene alone might not eliminate their use).
So treating with broad-spec antibiotic prophylaxis increases your healthy-at-slaughter-date yield, especially under cost-optimised industrial feedlots.
More incrementally, (if perhaps still somewhat controversially), normal gut bacteria accounts for some fraction of the energy intake provided by animal feed. By killing them off, it frees up nutrients for the host. Other mechanisms including reduced immune load may also be involved.
Quoting from [1]:
> According to the National Office of Animal Health (NOAH, 2001), antibiotic growth promoters are used to "help growing animals digest their food more efficiently, get maximum benefit from it and allow them to develop into strong and healthy individuals". Although the mechanism underpinning their action is unclear, it is believed that the antibiotics suppress sensitive populations of bacteria in the intestines. It has been estimated that as much as 6 per cent of the net energy in the pig diet could be lost due to microbial fermentation in the intestine (Jensen, 1998). If the microbial population could be better controlled, it is possible that the lost energy could be diverted to growth.
User shabble has some ideas (in a sibling comment to this one), but reading that gives me the impression that this is a little bit of a theoretical concept. It's not. It's very widely practiced, with the explicit intent of "promoting growth".
E.g., a search like [1] calls up a large number of references to it.
[1] https://www.google.com/search?q=how+do+antibiotics+fatten+an...
>We [sic] should also fine doctors for...
Why is violence an appropriate response to these non-violent issues?
Edit for clarity.
With such a leap, I can only logically assume you replied to the wrong comment.
C'mon. Do you really think every food regulation is being watched by military police who will come and beat you up if you break said regulation?
They start with a polite court summons, then send a police officer to your home, and if you don't come quietly they'll physically force you. If you manage to resist that, well now you're resisting arrest so it doesn't even matter what the original summons was for. They'll escalate to tasers, nightsticks, maybe tear gas. You probably need guns on your side to resist past that point, which means the police get their guns out, and they've got more guys and more guns than you. You most likely end up dead, but definitely not resisting anymore. At no point will they say "Gee guys, this is just too much effort, guess we better let him do whatever he wants."
There is implied violence in every government directive. You don't usually see it because almost nobody has the will and the means to push it that far, but it's still there. I think people would do well to remember that when casually calling for things to be made illegal.
That said, I actually agree with the idea of banning antibiotics in agriculture. It's quite important, and a classic market failure/tragedy of the commons situation that you sadly do need government to solve.
Also, in this case, the individual dosing livestock with antibiotics is actually harming society, in which case I think it would be okay to physically detain him/her from doing so, rather than just saying "this is just too much effort, guess we better let him do whatever he wants". In most scenarios though, I don't think this would be necessary.
So, we could equally say that there is implied violence in every transaction. (Well, yes sometimes the violence is leased from the government, which will happen if I bring my armed thugs to raid an Apple store. And I'd consider that a good use of the government's resource.)
The same goes for the requirements for a free market - which involves perfect information on the part of the purchaser. If you withhold information, you've violated the requirements... and if you continue to not comply, the system requires escalation, and libertarianism in particular relies heavily on the courts to fix things post facto, and of course, courts need to be able to enforce their dictates. So not providing perfect information to the market is an act of violence, using these flawed "chain-of-events-that-end-in-foo-are-literally-foo" terms.
The libertarian redefinition of 'violence' really needs to be abandoned.
I, for one, think we should pass laws that prevent people from doing harmful things to society..
If people who abuse antibiotics will lead to us having no good antibiotics, then they will inflict extreme violence on the entire human race.
My ex-girlfriend's dad died of an infection, quite possibly a superbug. I was there with her and her mom the second he stopped breathing. Go and be there at the moment of death by infection of someone you know, then tell me how you feel about people who needlessly weaken antibiotics.
(just trying to keep the discourse here as balanced as it would be if this discussion was out of HN)
Unfortunate the only nation who has the power to convince others joining this ban, is one of the worst abusers of antibiotics.
Consumers might have a choice, if they are wealthy enough to afford it. If you are a beef consumer, eat beef from Namibia, where antibiotics for animals are banned, and avoid US or South Africa. Ask you butcher, if he can offer antibiotic free meat.
I'm curious as to just exactly how you think the US is going to convince China, Russia, India, etc to ban antibiotics? The US could obviously afford to do so, as the incremental cost in the price of animal protein (due to smaller yields) could be absorbed by modifications to eating habits or redistribution models (i.e. food stamps).
I'm not sure the same could be said in some of the countries that are much larger and have huge difficulties with food production/distribution already.
Why? The problem isn't giving antibiotics to animals. Antibiotics are useful for animals the same way they are useful for controlling disease in humans. The problem is abuse of antibiotics.
So in short, yes the problem is giving it to animals.
If there is no safe use, then what matters is risk vs. reward, right? There is real utility (reward) to using antibiotics on animals, and I don't see how we can simply blanket rule it out.
If you cut back on keeping them healthy, you're cutting the amount of food available for human consumption.
I recently re-read the fantastic Ishmael[1] which does a fantastic job of explaining the crazy things we've done to increase our food supply in the last 10,000 years.
You are cutting the amount of meat and dairy available for human consumption, not food. Eating animal products is not a terribly efficient way of getting nutrients.
There are better ways of ensuring the supply of food than the abuse of antibiotics in livestock.
Given the pernicious and undemocratic over-representation of rural interests embodied in the structure of the Senate, I don't expect them to go anywhere.
[1] Preventing Antibiotic Resistance Act of 2013 -- http://thomas.loc.gov/cgi-bin/query/z?c113:S.1256.IS:/
[2] Preservation of Antibiotics for Medical Treatment Act of 2013 -- http://thomas.loc.gov/cgi-bin/bdquery/z?d113:H.R.1150:@@@L
I'm sure the rural interests have the same thing to say about urban interests & the House. Which, really, means things are working as intended.
A system which gives representation to rocks and cows rather than to people is undemocratic. That's not just my opinion man, it's a statement of fact. The House doesn't over-represent urban interests it represents them in the proportion that people of the country live there.
Your post smacks of the fallacy of the golden mean fallacy, which is unfortunately a serious problem in the United States today. There aren't two sides to every issue. Often some people are just wrong.
The debate over firearms is a simple example. Urban voters do not see why rural voters cannot simply depend on the police to maintain law and order. Rural voters on the other hand do not see why urban voters think the police can respond in time. The difference is their context. Urban voters are probably right- in the context of a city.
(I am not arguing about firearms, I just thought the debate was an easy illustrative example of how your context matters)
There aren't two sides to every issue. Often some people are just wrong.
I'm sure you are conveniently always on the side that is right? :)
For the first time in the memory of anyone alive today, we're going to see medical science step backwards. We're going to be more vulnerable tomorrow than we are today, and we did it to ourselves.
Perhaps most terrifying is that the mere act of hospitalization will likely be the highest vector of transmission of nearly untreatable infections. Go in for a routine procedure and end up in the isolation ward due to some highly infectious, deadly disease.
This is one reason to avoid hospitals at all cost. It's also why hospitals are terrible as a first treatment option for the poor. I can't recall a family hospital trip where someone didn't catch something new at the hospital.
I think generally, everyone avoids hospitals at all costs.
The way I perceive these stories is that hospitals are actually extremely dirty on a microbial level (as is most of the world), it's just counter-intuitive because I think a lot of people take for granted that a hospital is imagined to be a super sterile place. MRSAs could potentially reside on every surface; an act as simple as touching a bed railing could get you infected. You then have patients in recovery with healing wounds/depressed immune systems, which need antibiotic treatment of some kind when they have an infection. But it's not like you cannot become infected by a MRSA outside of a hospital, you can, and the same antibiotics won't work effectively for you just as they don't work effectively in the hospital. So the first step in my mind is making sure the hospital is 'clean'.
Yes yes make everyone wear gas masks and space suits the entire time, staff and patient alike...
We have robots that do that now.
http://loyolamedicine.org/newswire/news/uv-light-robots-kill...
Bacteria are just bloody durable, and people are shedding new bacteria into the environment at really absurd rates.
And the bacteria which survives all of this, i think it should look something like this:
http://www.imdb.com/media/rm617979392/tt0088944?ref_=ttmi_mi...
But, of course, you can't avoid keeping a hospital sterilized.
Yep, I have no idea how to actualy do that. There are all kinds of issues, but I'd guess that you can solve nearly all of them with tech.
I worked at a hospital for awhile, and one of the things I found interesting, though, is that the departments balance each other out. For example, our hospital did obstetrics more as a service to the community, since other hospitals were much further, but they always lost money on it. So maybe the reason we don't see surgery centers or things like that as often is that medical institutions are more stable providing a broader range of services.
There have been plenty of those before you and there will be plenty more to come. Y2K, Nuclear War, Swine Flu, Global Warming, Apocalypse, take your pick.
In each of these cases there seems to be a tendency to think that just because total disaster has not yet occurred, that the risks are nonexistent.
Why? Did the weapons magically disappear? That outcome is much more likely in the 2010s than the 1980s, for example.
I'm quite sure around the time HFC and HCFC patents expire we'll all have to suffer thru very well industry funded explanations of how R-141b causes excessive pr0n browsing or some such nonsense, so for the children, we'll all have to switch a new, ever more expensive refrigerant.
I'm sure if the patent for CFC production expired in 2020 we'd still be pumping the classic stuff out, along with an industry funded denial movement and probably an alignment on political party lines to prevent any progress, etc.
Bringing it back on the original topic the best way to get .com (and since the merger, .gov) to fund antibiotic research in the modern real world would be to genetically engineer bacteria genome to contain an encoded .avi of the SuperBowl or an encoded Miley Cyrus .mp3 or something like that. Maybe glycophosphate resistant MRSA would get some attention from the usual suspects.
If someone could figure out how to patent global warming or global cooling we'd be on to something...
There are also at least several countries with little regard for patents and significant industrial bases that none the less signed on to treaties to limit and cease the production of CFCs...
But sure, Dupont made the US government strong arm India and China into paying for their new refrigerants. And Russia too.
Now, if doctors were to use antibiotics only for very serious infections, a last resort method, then pharmaceutical companies wouldn't have had the incentive to develop even the drugs that we now take for granted, because the market would have been so incredibly small to not give them enough reason to invest in development.
I think we would've ended up in this very same position anyway, it was just a matter of time.
I could agree (or at least agree to disagree) if you were talking solely about agricultural use of antibiotics or just-in-case prescriptions, but it's a bit tone deaf to complain about people using antibiotics to treat non-emergency diseases (like strep throat and gonorrhea).
Antibiotics were routinely used for ear infection even though there's no evidence of benefit. Antibiotics were routinely used for viral illness where there's no possibility of benefit, and possibility of harm.
(http://www.cdc.gov/std/Gonorrhea/STDFact-gonorrhea.htm)
> Untreated gonorrhea can cause serious and permanent health problems in both women and men.
That seems like a reasonable use of an antibiotic. But maybe we should have been working out how to get people to use condoms.
Whoa there. According to the article, we have few new antibiotics precisely because the old ones have been so effective:
>Infections are not that common compared to other types of conditions like high blood pressure or high cholesterol. [...] They have to develop drugs that will make money, and that’s not an antibiotic.
When we had lots of development effort put into antibiotics, there were lots of new antibiotics discovered. Expect that level of development to come back if / when infections again become a bigger problem than high cholesterol.
Not if you get killed by an infection first.
If a company is going to spend a decade and a billion attempting to develop a "management" antibiotic for continual profit, I'm willing to bet the profit motive exists for another company to make a normal antibiotic... that most doctors would happily prescribe over the ridiculous multi-year option...
It's a big risk and I doubt some company will attempt to make a maintenance drug out of antibiotics.
Unless you're implying that profit motive means they simply won't try because it's not insulin or something, which is ridiculous. Profit motive... there is profit to be made in a new antibiotic, there's the motive. Not every pharma company will just let money sit on the table in favor of older drugs nearing the end of patent protection.
I've actual found there's a fair amount of interest in antibiotic development among drug companies.
Basically Pfizer, one of the last companies working on antibiotics for gram-negative bacteria, pulled out due to pressure from shareholders, because there's little money to be made here. You spend billions of dollars on creating an antibiotic, and upon its release the recommended instruction is to "use it as less as possible"? -- there's no money in that obviously, there's more money in cholesterol drugs, ADHD drugs, and other drugs you'll continue taking for a long long time.
I feel bad to steer the discussion this way -- but this it, this perfectly underscores one of the scary faults of capitalism. Everyone wants to see a nice smooth growth curve. Growth is prioritized higher than long-term stability of society. We need to fundamentally re-think this.
It's not hard for the FDA to streamline approval process so that development costs are lowered or for them to offer extended periods of market exclusivity so that costs can be recouped over a longer period of time.
The FDA has already moved on the regulatory aspect and companies have responded. Antibacterials is a much more attractive market now than it was 5 years ago.
Then I left and lost track of it all. Wikipedia now says it's 100USD / pill.
If there's really a lot of resistance to Linezolid, that would be quite shocking.
In my project there was a lot more MRSA in "poorer" parts of the country, in hospitals with lower hygiene standards. Hospitals also refused to report their MRSA stats ("it doesn't exist here", not wanting to be known as a place where it's found since it is related to hygiene).
Interesting stuff.
Really? And whose lives are you willing to play that game with?
Your 8 y.o son, who just broke his arm and has new swelling three days after the arm has been set?
Your wife, with a bladder infection so severe it's bleeding and she has a fever?
"Sorry, son - your suffering is for the betterment of mankind. I'm pretty sure you'll survive."
"Sorry, honey - let's just see if you can make it another week or two."
Non-emergencies:
* sore throat * lots of chickens packed in one place
What's been happening for decades is things like kids getting a cold and doctors wanting to appease panicked parents by prescribing an antibiotic (that's obviously going to do nothing to a virus).
I have plenty of recent experience bringing kids to pediatricians, and they do not hand out antibiotics like popcorn.
They do lots of rapid in-office tests that detect strep, flu, swine flu, fungus etc. within minutes - so the diagnoses are much more accurate than in the past.
Last year NY state started putting out "when does my child need antibiotics?" pamphlets that they have in the exam rooms.
What I'm imagining is something like the Department of Energy, or even the CDC here, regulating the ability to prescribe antibiotics and establishing rules that must be followed for their use. Antibiotics would not be a privately exchanged commodity, but a highly regulated resource managed for the public good.
So, would this hypothetical future involve antibiotics for your hypothetical cases? Probably? Possibly? If doctors discerned that the cause of the swelling was bacterial infection, if the bladder infection was threatening to the wife's future well-being? Then I'd suppose so.
But you wouldn't get antibiotics just for being alive like you do now. They practically hand them out like candy at doctor's offices.
Oh, you have a cough? Have a z-pak. Doesn't matter if it's a viral infection going around, who cares if giving you this drug just ensures that some day in the future we won't be able to treat someone who is actually dying with azithromycin. What's important is that taking these pills will make you feel like we're doing something to help.
Does that exclude post surgery recovery to prevent infection? Or are you saying that people should get the infection first then it should be treated after?
For example, my company TeselaGen (http://teselagen.com) has developed a cloud based platform for biologists to design, build, and test a large combinatorial set of DNA constructs. Some of our customers use our software today to easily and effectively test an incredible number of DNA devices for identifying and developing useful antibodies.If you have an understanding of genetics and cloning you can try out the software yourself.
I am more optimistic than that.
Sure: as long as antibiotic resistance is crucial for bacterial survival, bacteria have a natural need to evolve it. And, they will.
But, this will come with a genetic cost to the bacteria.
The reason that antibiotics work is because they are attacking some function that has deliberately evolved, through natural selection, to be like that. Antibiotic resistance must literally cost bacteria some efficiency in some of their other functions.
This cost was originally such that the bacteria would die. Fantastic. But note: we wouldn't actually benefit from all bacteria dying at the mention of the word antibiotic, and some bacterial resistance is good for us.
Under normal circumstances, bacteria that don't need to carry around antibiotic resistance with them will most likely have a lower genetic cost and thrive better. This may be why we have seen MRSA predominantly in hospitals and rarely in the 'wild'. (If MRSA was necessary or not costly, all SA would be MR all the time).
This gives me some hope - that antibiotic resistance is balanced, genetically forcing bacteria to be less effective in other ways and less competitive in other circumstances.
We humans are not out yet.
I'm not convinced that there must be a cost; furthermore, I think it's unlikely that if there is a cost, it is high enough to be significant. Bugs evolve, but they do not necessarily evolve optimally all of the time. It is possible that an evolutionary step towards resistance might also improve the fitness of the germ overall (for example, by further optimizing the efficiency of a metabolic pathway). That evolutionary step might have been inevitable, but required additional selective pressure or the presence of a more active mutagen to actually occur.
Your claim is sort of assuming that each bug is already optimal for its environment, and any change must therefore be deleterious in some regard, but I hold that neither fact is necessarily true.
I think it's likely that those two claims are mostly true in bacteria. Since bacteria evolve quickly and have experienced a lot of evolution, I believe they are likely near-optimum and therefore the second claim (IMHO) follows from that: changes would typically be deleterious.
On the other hand, even allowing for that, it's possible we could be allowing them to escape a local maximum and reach a more-optimal state.
And, there is a more significant criticism you could make:
Even if I am right on both points, a population that evolved to be heterogeneous (with some small percentage of wildtype being resistant) could likely have the best of both worlds ;)
"In nature, plasmids carry genes that may benefit survival of the organism (e.g. antibiotic resistance),"
Plasmids cost energy, they are dropped in the course of natural selection if they stop conferring an advantage.
More quickly than you might think, too.
If we stop using antibiotics, the bacteria will become less resistant.
Adapting antibiotic resistance can take as little as a single nucleotide mutation in the right part of a bacterial genome. Many of the known antibiotic resistance mechanisms involve small mutations to critical proteins.
I really recommend everyone here read Power, Sex, Suicide, mitochondria and the meaning of life. Amazon link (no affiliation/referral) http://www.amazon.com/Power-Sex-Suicide-Mitochondria-ebook/d...
Bacteria both evolve resistance quickly, they also lose it just as quick. Because unless it directly is needed in the here and now, the bacteria that remove it and survive without it outcompete the rest of the bacteria.
This is my understanding at least, a real bacteriologist can comment what I inevitably got wrong. But the recent study that used existing antibiotics in a certain way to kill bacteria is a great demonstration of bacteria not being able to select for all simultaneously and retain the old resistance in the future.
I'm not overly concerned about bacterial resistance given there are ways we can work around it.
Alas, experiments have shown that it is possible for resistant strains to strongly reduce the cost of resistance maintenance. If there are no naive invaders, this can lead to an evolutionary stable situation where the maintenance of resistance is less costly than losing it.
See Lenski's (old) review "Bacterial evolution and the cost of antibiotic resistance"
The definition of "good enough" for bacteria has changed over the last 50 years, so these changes are occurring now. It doesn't necessarily require a cost, or at least not a cost that matters to humans.
I'm not saying opiates addiction isn't a genuine problem, but it's a largely individual one. There's no widespread negative externalities to prescribing opiates to a patient. Antibiotics on the other hand, present a classic limited pool resource allocation problem (the same species of problem as the tragedy of the commons).
It's antibiotics that should require a three part pad, with one copy sent off to the federal government and investigations into over-prescribers -- not painkillers. It's antibiotics that should be subject to intentional treaties governing their distribution and use -- not painkillers. It's antibioatics that should have criminal penalties for misuse -- not painkillers.
While reading the article, that's what I was thinking: even if I limit my antibiotics use, it won't help me since this affects everyone, not just people who abuse antibiotics…
"Defeating the superbugs" (http://www.bbc.co.uk/programmes/b01ms5c6) has a segment showing bacteria developing resistance to antibiotics.
(http://v6.tinypic.com/player.swf?file=24goih4&s=6) (Sorry about the lousy host; YouTube's content sniffing detects this as BBC property and blocks it.)
They have a slab of nutrient jelly. The jelly has sections of differing strength of antibiotic. There's a section with no antibiotic, then 10x, then 100x then 1000x. (They cannot dissolve any more antibiotic into the jelly at that point, they've reached the limits of solubility)
They drop a bit of bacteria on the zero antibiotic section.
A time lapse camera shows the bacteria growing, and developing resistance to each section. After two weeks the entire slab, all sections, are covered. The bacteria has developed resistance to the antibiotic, and is resistant to antibiotics at a strength that could not be used in humans.
It's an excellent, scary, bit of video.
Would infecting someone with a non resistant strain, letting it sit for a while and then hitting them with antibiotics knock the infection low enough that your immune system could wipe up the rest?
The beauty of evolution is not to be stopped by limits, but to run near infinite instances of optimization algorithms over infinite time scales to over come the limits that exist.
The other big problem we face is that certain antibiotics are like steroids for farm animals. I believe that they kill the bacteria in the gut of a cow or big that signals when they should stop eating, resulting in larger stock (or something like that). This increases the exposure of bacteria to the antibiotics, making things less safe for all of us.
But drug companies and farmers aren't to blame for our antibiotic situation. Capitalism encourages profit and doesn't ask questions about how it's made. Corporations have a fiduciary responsibility. And doctors can't be faulted for overprrscribing antibiotics either. A sick person is the ultimate debugging task and most doctors will try anything that could help the patient. I don't know if this problem has a good solution.
If we research new antibiotics then bacteria will eventually evolve to resist them (kicking the can down the road). If we stop using antibiotics then more people will suffer, potentially unnecessarily (destroying the village to save the village). Trying to fight evolution is a losing game. I am, however, confident that someone somewhere will come up with a break through in the next few decades that will allow us to temporarily solve this problem once again.
Current antiobiotics are themselves mostly derived from "natural" chemicals emitted by microorganisms so that those microorganisms survive natural selection to go on reproducing in a world full of bacteria. Many of the early antiobiotics, for example penicillin, are derived from mycotoxins produced by fungi. Human medicine can use chemicals from fungi for protection against bacteria because human beings and all animals are more closely related to fungi than either fungi or animals are related to bacteria,[1] so fungi have a biochemical similarity to animals that makes it likely (although not certain) that a mycotoxin that is lethal to bacteria will be relatively harmless to human beings.
And this is the way forward to developing new antibiotics. As we reach a deeper biochemical understanding of the basis of all life, we will eventually understand the differences, which are biochemical differences at bottom, between human beings and bacteria, between human beings and protists, between human beings and fungi (yes, there are some systematic differences between animals and fungi) and between human beings and all other harmful microorganisms. Only human beings have science labs and clinical research studies to come up with new defenses against the thoughtless, largely immobile threats from other living things. We can form hypotheses, test those hypotheses rigorously, and perhaps make some lineages of harmful microorganisms as extinct in the wild as the smallpox virus and rinderpest virus now are. The intelligence that the hominid lineage has evolved gives human beings advantages that bacteria will never possess.
[1] http://ucjeps.berkeley.edu/DeepGreen/NYTimes.html
http://www.nytimes.com/1993/04/16/us/animals-and-fungi-evolu...
But the gap from a bacteria to something that can withstand the physical barrage of a thorough wash is huge in comparison to the relatively tiny changes to overcome some antibiotics. E.g. an antibiotic might disrupt a single process of the bacteria that is beneficial (for them) but that have a multitude of similar alternatives that are different enough for the antibiotic to fail. Compare that to even just being able to strongly enough attach to the skin to not be flushed away by sheer force from a wash.
There are many reasons that tends to be given for being careful about stronger measures: 1) it is not necessary. It's a matter of being cautious - by using the least effective means that is effective enough, we exert the minimum pressure necessary, leaving us with a larger arsenal of (to us) gentle alternatives to step up to. 2) the stronger methods, the more we kill off beneficial or neutral bacteria too, and by doing so we may make conditions better for bacteria that are nasty for us if we happen to pick them up. 3) we reduce our immune systems exposure to relatively harmless amounts of bacteria and some believe this may be sufficient to actually reduce our overall immune defence.
As DanBC pointed out in response to one of my other comments, there's also the issue of physical damage. While we can bring the heavy artillery and effectively kill anything that lives on our skin, we can as collateral damage cause damage to our skin that creates additional places to hide - effectively a worse variation of washing away good/neutral baceteria - not only may we be removing the competition, but we may be opening cracks and folds that'll be excellent hiding places.
The thing with anti-bacterial soaps is not that the use of the soap is bad. The problem is the anti-bacterial part. It puts amounts of a broad spectrum antibiotic into the environment (be it your hands, your countertop, or the water system) in concentrations that aren't enough to do much, but are enough to put a little bit of selective pressure on the organisms and promote resistance.
It's also not particularly effective - soap and water, through a combination of both mechanical action and how soap disrupts cell membranes, works swimmingly. So there's a cost, and no benefit.
The answer to 'why isn't there a resistance to soap' is that soap, as a chemical, is absurd overkill. It's hellish on lipids of all sorts (tough on grease...and lipid cell membranes), and there's nothing to evolve a resistance to. Not expressing a particular protein, or expressing an enzyme that does a number on an antibiotic compound is effective - to evolve a resistance to soap, you'd somehow have to develop an entirely new type of compound to build cell membranes out of.
And while evolution is rather magnificent, that's asking a little much.
I dated a heatlh care professional for a while who was pretty adament that it was causing detrimental effects in the same manner as antibacterial soap.
So I don't know if I'd want it gone from toothpaste, but I'd like to see it gone from the many products where its useless or nearly useless, but included so someone can put 'Antibacterial' on the label.
Like soap. Soap is already antibacterial.
Thinking about this more, I suspect there already has been some selection in this direction, but that it has little to no public health impact, as this defense is not useful in places where infections are typically a problem. Indeed, our body is teeming with bacteria (mainly in the guy) that are in fact beneficial, and they've presumably managed some resistance to shear stress and extreme chemical environments (e.g. high acid).
E.g. it does not help if a bacteria can survive a soap if it is still physically flushed away.
We also have a massive escalation ladder for external detergents beyond basic soaps that include a near infinite number of substances of increasing brutality than our arsenal of antibiotics. Essentially anything that will not harm us much with relatively limited exposure, yet will physically disrupt small organism. We can wash our hands in bleach. Or various acids. Or any of numerous agents that are massively disruptive on biological organisms through basic chemistry or even by being physically abrasive.
We don't even particularly need to care if we kill off a fairly substantial number of our own skin cells in the process.
If we had the same arsenal available for fighting bacteria internally as what we can safely apply externally, we'd be in a fantastic position.
(http://wwwnc.cdc.gov/eid/article/7/2/70-0225_article.htm)
> Skin hygiene, particularly of the hands, is a primary mechanism for reducing contact and fecal-oral transmission of infectious agents. Widespread use of antimicrobial products has prompted concern about emergence of resistance to antiseptics and damage to the skin barrier associated with frequent washing. This article reviews evidence for the relationship between skin hygiene and infection, the effects of washing on skin integrity, and recommendations for skin care practices.
On the contrary, we eliminated smallpox which was one of the most devastating diseases in history so this fatalism is basically disproved. More depressingly, we've also made extinct thousands of species who have not evolved to resist us.
Smallpox was not eliminated with antibiotics, and nor was polio. Both are viruses, and both were eliminated with vaccines.
So what if a species goes extinct? That doesn't mean it can't evolve, only that it didn't adapt quickly enough.
Understanding comes from truth, not casual simplifying lies.
No it isn't, it's misleading.
> It's like saying "Water wants to flow to the lowest point of a room"
Equally unnecessarily misleading. Water doesn't want anything, and before you claim people understand that let me tell you, they don't. It's a common belief that water has memory, there's an entire industry based on the concept and people fall for it. Walk into any grocery store and there are shelves of very expensive little bottles of water (homeopathy) being sold as cures for all kinds of things, it's disgusting.
> or "The arrow wants to follow the path of least air resistance"
Also unnecessarily misleading. Such talk may be fine among experts who "get" that's it's not accurate, but when talking to general public one should speak accurately, not loosely and "hope" they get it because the reality is many if not most don't and take what you say quite literally.
Bacteria don't 'want' anything in a purely technical sense. But they will eventually develop/are developing resistance to antibiotics anyway. You seem to be stuck in debating about the right sentences to describe that.
That should be least of our worries.
Humans aren't computers.
To some extent, but it is also impossible to do so perfectly.
> Semantics matter.
Semantic agreement is limited to the actual parties to the communication, and by location, place, time, and social context. You wouldn't explain something to a 5 year old the way you would a 25 year old and the same basic problems occur when you cross cultural or temporal boundaries.
When linguists discuss language, they usually start by pointing out that human language is defined by usage, not by prescriptions regarding definitions or grammar. This is a critical difference between natural languages and computer languages. Computer languages rigidly conform to specifications. Natural languages only approximate the rules we use to describe them.
So I think you are expecting too much from human communications.
The fact that lines of bacteria go extinct does nothing to disprove the fact that bacteria are developing resistance to antibiotics. Is it possible that there are antibiotics out there that can stop the newly-resistant bacteria? Of course. But it's getting harder and harder to find newer and more-powerful antibiotics.
A promising alternative appears to be bacteriophages.
From Wikipedia's Bacteriophage page: "Medical trials were carried out, but a basic lack of understanding of phages made these invalid".
I seriously hope alternatives like bacteriophages are being revisited and reconsidered within the medical community, as it's obvious that conventional antibiotics are increasingly becoming less effective each year.
With phages you'd need a large library to counter different bacteria, you'd have to successfully identify the bacteria which is causing the problem which may require culturing. If you wanted to maintain phage effectiveness in a heavily selected environment you'd also need to design phage "reactors" where the phages can be continually evolved against current bacterial populations.
There was a whole club that met regularly around phages. Much of it was popularized by Delbruck. http://en.wikipedia.org/wiki/Phage_group
The early days of 'phage therapy' were pretty bad - because we really didn't understand what was going on, the "purified" phage solutions still had bits of bacterial cell membranes and the like in them, including endotoxins. People died.
But phages were still being looked at for most of the antibiotic period, especially in countries without quite such widespread access to antibiotics. The Soviet Union had a very active program in Georgia, which was ongoing before the trouble there a few years back, I don't know the status of it now.
It's a promising avenue, and there's some decisive advantages phages have over antibiotics. But it's also quite hard, and right now we lack a generalizable form of phage therapy - it tends to be a bespoke solution to specific intractable cases. But the incentives might increase as antibiotics become less and less effective.
For awhile I wanted to work on phage research before I realized wet-lab Biology was not my forte.
Several phages even encode for bacterial virulence factors such as exotoxins (stx, diphteria toxin).
Fortunately, we are much better equipped in the molecular biology department to do research.
In fact, a bacteriophage may or may not be the most promising vector, but a bacteriophage engineered to attack pneumonia or specific infections would be the work of a sighted watchmaker, not dissimilar from ideas of targeted radiation or chemotherapy that are moving forward in the area of cancer treatment. I recall an experiment (not that this is my area of expertise at all) in the recent past that was attempting to use magnetized medicine along with some sort of electrode insertion, I believe, to coerce medicine to specific areas of the body.
One imagines a future in which we have a dwindling supply of biodiversity to 'sacrifice' in order to keep ourselves safe from bacterial onslaught.
Not unlike oil -- millions of years to produce, but destroyed in a few generations of exponential human growth.
It might make sense to speak of an antibiotic peak, like we speak of peak oil. I wonder if you could draw the same kind of curve.
This is the stuff of the Nobel prizes of yore, and it is the mechanistic basis for how antibiotics kill bacteria and not humans. Penicillins destroy the cell wall as it is remodeled (humans don't have a cell wall); lincosamides block protein synthesis at the ribosome (humans have a different ribosomal structure); amphotericin binds ergosterol and forms ion channels in fungal membranes (humans lack ergosterol).
As we continue to explore biochemistry, we will continue to understand (and perhaps even discover) new antimicrobials, though I suspect most of the future advances will come from large-scale screens of discovered or synthesized compounds without taking much biology into account until secondary stages (to increase potency or reduce toxicity).
However, right now the first part is happening and the second part isn't, so until medical science and technology advance sufficiently far -- if indeed they ever do, and specifically if they ever do before a devastating plague hits -- we're in trouble.
I'm not sure I understand your point though, beyond "with more knowledge we will get better at this." What is the timeline? Is there any current research that may lead to this breakthrough, whereby we no longer have to borrow evolved tools from other life forms and can actually develop a precise and resistance-immune treatment?
The organism of the bacterium doesn't have desire the way humans do, but the idea of a virus or manifestation of bacteria can have a figurative desire to evolve and grow.
Yes, it's inaccurate, but it is what often happens when you want to get across the message and can live with a bit of inaccuracy at the expense of message reach.
Some problems are just very difficult to evolve around, and it's hard to predict what they'll be even if you have a complete working knowledge of an organism's genome and biological workings. If the problem space doesn't contain a solution that can be climbed toward without sacrificing fitness in the short term, it is unlikely that it will ever be found by evolution.
Evolution is actually a really crappy optimization algorithm. The reason it has worked so well is not that it is so effective, but because it's the only game in town. It took evolution billions of years to make machines that can run 60 miles per hour. It took humans a few thousand years to create machines that run about 12 times that fast.
Bacteria work on a faster time scale than animals in terms of evolution, but five orders of magnitude? Somehow, I think we'll win in the long run.
This is a stunning visual - thank you. I see a multi-dimensional space of possible organism "configurations". Each dimension is a set of related alleles, spaced by the amount of energy it would take to shift from one to the other, i.e. the likelihood of switching that allele independently. Angles between dimensions indicate correlation, or more fundamentally the cost of holding similarly positioned alleles simultaneously. Each organism is a point in that space with a species being a cloud.
When one shines a "light", i.e. an antibiotic, on the space it lights up with warmer colours signifying configurations which take less energy for the organism to survive as (are more favourable) and cooler colours denoting deadlier configurations.
Thus, antibiotics become a game of chess. Humans try to box the organism into coolly coloured regions. That way, the amount of energy it would take to "tunnel" through the wall would be high. The organism, on the other hand, is trying to find warm "tunnels" by which to escape regions which are being boxed in. Advantage to the organism is it can build new dimensions.
It took evolution billions of years to make machines that could make machines that run about 700 miles per hours.
You come off as being dismissive of the power and beauty of evolution, although I don't think that's your intent. Evolution assembled the most complex system known to exist, starting from a handful of molecules, without any "thought" or "reasoning." The entire concept/illusion of life and consciousness was fabricated out of simple natural elements and physical processes. Amazing. Sure, once all of that has been put in place, it's trivial to expand upon. I'm sure you agree, I just like to take any opportunity to point this out. :)
It's a recurring pattern. SAT, the NP-complete problem, is at first glance a ridiculously simple task, yet solving it means being able to solve all other problems. When designing a language or a machine, it is very very simple to accidentally make it Turing compatible, the barrier is just so low, despite the reward being.. everything.
If I come across as cynical about this, it's a response to the way evolution as a process has been fetishized by people who don't understand it. People look at the application of evolutionary algorithms to solving difficult problems and conclude that evolution is smarter than humans. But evolution's power really comes from its dumbness. It works without understanding the problem, and so it can be used to solve problems we don't understand very well. But when we learn how to model a problem intelligently, we're generally able to crush the results of evolution.
What's really huge and what no is really a limit and perception of our brains, no?
For a evolutionary process that has started at the earliest stars after the Big Bang. Those species are currently so powerful, that we are very likely to them the same as bacteria are to us. Might as well perceive that to be a very reasonably efficient process.
There may have been a lot more complexity early on than that statement assumes. Static systems, after all, pretty much by definition can't evolve (and this is why a reductionistic assessment of evolution as biochemistry doesn't work).
The beauty behind evolution is the same beauty behind Feynman integrals in quantum physics. You take the integral over all possible paths and something is likely to work. Many paths will end or cancel eachother out.
It's like open source software.
However, it's one that doesn't need an agency to implement it. It just happens. A lot. Especially in the case of bacteria. You have a slow, crappy algorithm, but it's constantly running relentlessly in parallel in many trillions of instances. It doesn't need human attention. It doesn't need investment. It doesn't need society to be aware of its importance.
On the other hand, progress in antibiotics needs all of the above. If one of those things flags a bit, bacteria gain the upper hand. This is the problem.
I.e. they act as if they are selfish.
Blame this way of phrasing it on the limits of language.
In his book 'Toward a New Philosophy of Biology" there is a chapter on this very topic - how teleonomy has pervaded almost all of Biological science and how teleological statements, which are just plain incorrect, are the major way in which Biological processes are explained. I think this has only increased in severity and effect as we have consolidated our systems level view of the world and I've often been in awe of the general ignorance toward fundamental principals such as this.
My own personal take on the situation?
I think it is a very dangerous and ignorant thing for our species to continue with it's genetic hegemony of our ecosystems, creating vast evolutionary plateaus where the slightest advantage can run amok and adapt into something that could wipe out entire species. There is _probably_ enough genetic diversity in humans to avoid this, but I doubt so amongst our crops and livestock.
But I share your optimism/pragmatism in that I feel our human ingenuity will overcome, and if so then the prizes are great indeed. From new drug delivery systems and entirely new ways of treating illnesses, to a more mature approach to our interactions with the biological inheritance we have here on Earth 1.0 - I would like to see our crops and livestock diversified, farming practices overhauled to focus on the long term and most importantly more serious study devoted to analysing and utilising the solutions evolution has put in front of us for the taking.
Not only are these things (IMHO) essential to the prolonged survival of our species, they are also achievable. The organic farming movement took only a generation to go from grass roots to industry standard (and I know there is all sorts of controversy surrounding it but the point is that the industry IS open to disruption), here in the UK there is a debate simmering under the surface of the popular media that could end in more wild deer providing venison for the pot, Canadian geese too, and everyone knows of the whole insect protein debate, and the practical applications of bio-tech and nano-tech are only getting more interesting as the fields begin to find their feet.
We're giving bacteria (which reproduce rapidly and mutate quickly) the perfect natural science lab to mutate and select for antibiotic resistance. There are 10^14 bacterial cells in the human body vs only 10^13 human cells [1]. Their reproductive cycle is over one million times faster than ours.
We're creating the perfect conditions for rapid evolution of these organisms. This system is executed by billions of billions of bacteria continuously and we're trying to combat that evolution with a few thousand humans in labs.
It seems to me that the take-away here is we need better engineering of our own solutions and we need to find a way stop enabling this rapid evolution of bacteria.
Recall the very mechanism that makes bacteria resistant over time: an antibiotic is deployed over a population of bacteria that have largely the same genotype but there are lots of mutations thrown in because they divide so fast. If any of the bacteria are resistant to the antibiotic, they survive and create a new population, again with largely the same genotype with lots of mutations thrown in, but this new population is entirely resistant to that antibiotic.
Now you've probably been visualizing a human body or a petri dish when I talk about "a population of bacteria", but consider the entire Earth. You'll never deploy an antibiotic across all the nooks and crannies of the entire Earth, and even if you were to, you'd just get an ~evenly spread population of bacteria, resistant to that antibiotic.
I guess you could _try_, if you were a supervillain or something.
Consider 'fly by wire' as an analogy. There was great emotion (and still is) around taking the pilot of an aircraft out of direct control of that aircraft. First required by dynamically unstable aircraft (the F-117) this is now a standard feature on large passenger aircraft. The problems are still the same though, one bad line of code (or perhaps a few bad lines) and the plane flies into the ground killing everyone.
Similarly with engineered RNA. We actually do this a lot these days (very interesting bio hacking going on) and with DNA printers you can pretty much design your own bug, print it out, load it into a waiting husk of an E. Coli bacterium and boom, new bug.) Understanding isn't quite there yet but it will be. And knowing the risks of a particular DNA pattern will be just as understandable as a knowing the risks of a piece of flight software.
[1] http://www.3ders.org/articles/20130324-synthesizing-dna-time...
(I think your analogy hides the potential impact of a mutating virus. Fly by wire only puts air travel at risk.)
Bacteria are not fully understood and there are things such as Quorum Sensing which implies some method to the chaos.
While they might not desire anything, they do definitely seek out things.
I personally think there is much potential in Phages in the future. It has already show to be one of the ways to go fighting resistant bacteria.
[2] is a good book to get a perspective on antibiotic resistance.
[1] http://en.wikipedia.org/wiki/Horizontal_gene_transfer [2] http://www.perseusbooksgroup.com/dacapo/book_detail.jsp?isbn...
That being said, I have no problem with the statement that bacteria want to survive. They most certainly have mechanisms that are engaged actively in order to increase chances of survival. Horizontal gene transfer (http://en.wikipedia.org/wiki/Horizontal_gene_transfer) allows bacteria to evolve in means other than traditional reproduction.
To add to my pedantic argument, it's not a conscious desire of theirs, but I'd argue that the basic things that humans do to survive (eat, drink, sleep, and have sex) are not conscious desires either. I'd argue that sexual reproduction is a mechanism that directly represents the biological success of greater genetic diversity and sharing of genes between organisms. We desire sex, and we desire sex with the best genetic candidates, and it's all a biological process encoded into our DNA that represents our desire for survival, so in that sense, bacteria desire survival as well.
And what does desire even mean? Does desire require consciousness and the ability to choose? It's a horribly imprecise term if you stare too long at it, so what I'm saying is that I don't think it's useful to pick on the doctor for his choice of words in this case.
Anyway, you have great points otherwise, but that first paragraph is not a point worth tripping over.
I respectfully note the disagreement of several participants here have with me. They disagree with my disagreement with the interviewed expert's casual language about thoughtful agency by bacteria. Noting your statements that this is just everyday conversational usage, I stand by my objection to that fallacious manner of speaking. Most people in the English-speaking world think erroneously about biological evolution and especially about the implications of evolution for human medicine. I am not alone in thinking that popular thinking about biology needs to be improved by rejecting the idea of organismal agency in evolution,[2] although it is remarkably hard to find this kind of careful thinking by a Google search amid the flood of webpages that specifically assert a purpose or intention to evolution by natural selection. Ernst Mayr, mentioned in one reply to my first comment here, is indeed a rare example of a reliable author on that issue. Human beings have a cognitive bias of attributing agency to inanimate objects,[3] and the reactions to my first comment suggest how deep-seated that cognitive bias is.
The entire revised introduction to the thirtieth anniversary edition of Richard Dawkins's book The Selfish Gene[4] appears to be available for free online reading, and Dawkins writes explicitly about what level of analysis can be useful when pretending that genes have intentions and goals while thinking about problems in evolutionary theory. The University of California Berkeley website about evolution has a good page about antibiotics[5] that makes helpful medical practice and public policy suggestions with more cautious language.
There is a testable prediction here of course: either bacteria outrun human antibiotic development or they do not. I'm confident that more bacterial lineages will be wiped out before human medicine is seriously compromised by natural selection of bacteria that are resistant to most antibiotics used in human medicine. The precautionary principle suggests that we follow the quoted expert's policy recommendations, but meanwhile conduct research for a deeper understanding of the biochemistry of harmful microorganisms and their ecology.
[1] https://news.ycombinator.com/item?id=5674781
[2] http://whyevolutionistrue.wordpress.com/2011/02/21/natural-s...
[3] http://cogsci.stackexchange.com/questions/3951/is-there-a-co...
[4] http://books.google.com/books?id=koaD_Aod_V0C&printsec=front...
[5] http://evolution.berkeley.edu/evolibrary/article/medicine_03
Two other comments at this level express the nub of the argument:
I'm slightly bugged by "desire" type language because it does actually cause problems in how laymen think about evolution. It's not uncommon to hear them make the mistake of thinking evolution will "think ahead". But the bigger problem I have with it is the "anything we do ... bacteria will eventually discover".
Some problems are just very difficult to evolve around, and it's hard to predict what they'll be even if you have a complete working knowledge of an organism's genome and biological workings. If the problem space doesn't contain a solution that can be climbed toward without sacrificing fitness in the short term, it is unlikely that it will ever be found by evolution.
Evolution is actually a really crappy optimization algorithm. The reason it has worked so well is not that it is so effective, but because it's the only game in town.
That is very well put, and deserves your upvote.
At what point do we start designing RNA with a delivery mechanism that attaches itself to a specific bacterial type and eliminates it?
A good question. It is an empirical question about the future, so it has no definite answer yet, but that is the general research direction to follow to get around the legitimate problem mentioned in the article kindly submitted here.
> There is a testable prediction here of course: either bacteria outrun human antibiotic development or they do not. I'm confident that more bacterial lineages will be wiped out before human medicine is seriously compromised by natural selection of bacteria that are resistant to most antibiotics used in human medicine.
Do a dumb test. Walk into your nearest hospital, I don't even want to know which it is. Ask how many patients are infected with mRSA. Collect your jaw from the floor when they give you an answer that's 15% if you're lucky, 60-70% if you're unlucky. We have lost the fight with bacteria. It's over. We aren't "about to" lose it, we lost it ~1 year ago, and medicine is fast losing the ability to treat bacterial disease. We lost the fight with viruses a decade ago. If you get infected with a deadly viral disease, like rabies, it's curtains. There's nothing any hospital can do for you except sedate you until you're dead.
We are in fact well on our way to transform hospitals into deathtraps.
> Evolution is actually a really crappy optimization algorithm. The reason it has worked so well is not that it is so effective, but because it's the only game in town.
First of all, the obvious advantage of evolution is it's running time, 3.5 billion years. Second you probably subscribe to the naive notion that evolution, in 3.5 billion years running time, somehow failed to realize that mutation + natural selection is very, very slow. It didn't. The algorithm that, today, controls evolution of pretty much any species works entirely different from what most textbooks teach you. There are very, very few species that evolve through mutation and selection. We evolve through copying of other's genes, simulation and symbiosis (yes, genes can simulate the effect other genes will have on them. Also, most "life" functions of a human body, like breathing, metabolism, ... are actually performed by symbiotic bacteria on our behalf. Human cells can't actually do it themselves).
Unfortunately, if you study how evolution actually works you'll realize what it means for resistant bacteria. Once a fully resistant bacterial strain evolves, a process that takes between decades and centuries, all other species of bacteria will quickly copy the resistance, in a matter of months to years. Which is exactly what we've seen happening.
You'll also quickly realize that no matter how well-intentioned your use of bacteriophages is, it is very, very likely to make things worse, not better.
This, for instance:
"If you get infected with a deadly viral disease, like rabies, it's curtains. There's nothing any hospital can do for you except sedate you until you're dead."
The very low rabies incidence and near zero fatalities of rabies in the developed world actually show that it's a very winnable fight. The issue is, we have to show up to said fight. In the developing world, we're not always good at that.
The Centers for Disease Control and Prevention (the same organization that employs the expert quoted in the article submitted to open this thread) reports that "Although MRSA is still a major patient threat, a CDC published in the Journal of the American Medical Association Internal Medicine showed that invasive (life-threatening) MRSA infections in healthcare settings are declining. Invasive MRSA infections that began in hospitals declined 54% between 2005 and 2011, with 30,800 fewer severe MRS infections. In addition, the study showed 9,000 fewer deaths in hospital patients in 2005 versus 2011."[1] So there are responses already in place that are gaining on antibiotic-resistant bacteria in hospital settings in the United States.
I care about the spread of antibiotic-resistant bacteria. I am gravely concerned about the medical and public-health practices in India that have resulted in a massive increase in patients infected there with multiple-antibiotic-resistant tuberculosis.[2] I am 100 percent behind the idea that antibiotics have to be used cautiously and responsibly, and meanwhile we have to keep researching other means of infection control besides antibiotics.
You wrote,
We evolve through copying of other's genes, simulation and symbiosis (yes, genes can simulate the effect other genes will have on them.
Do you really mean "we" there? Are you saying that this mechanism in any way makes it impossible for human beings to eradicate harmful microorganisms? How? Please connect the dots to back up your conclusion that
Once a fully resistant bacterial strain evolves, a process that takes between decades and centuries, all other species of bacteria will quickly copy the resistance, in a matter of months to years
because the "all" there and the time scale you talk about both appear to be exaggerations, especially in light of the progress that has already occurred in limiting MRSA infections in the United States.
[1] http://www.cdc.gov/mrsa/healthcare/index.html
[2] http://online.wsj.com/news/articles/SB1000142405270230344420...
http://articles.economictimes.indiatimes.com/2013-06-23/news...
Just that bit of factual nonsense leads me to believe you are speaking far out of your area of expertise.
That's not a big deal in the U.S. because rabies is quite rare, but in the developing world it's still a thing.
Ceol may also be referring to the incubation time for rabies usually being more than a week - if you've just been infected with it and you present at day 7, then a prophylaxis will be administered.
Rabies infection is very survivable if caught before symptoms start to show up. We have a post-infection vaccine that can be used during the incubation period. We've had a vaccine for over a hundred years, and it works very well. In fact, the original rabies vaccine was the second vaccine ever developed, after smallpox.
What's lethal is symptomatic rabies -- but even that is not 100% lethal. There have actually been a few (under a dozen) documented cases of human survival after symptomatic rabies. Look up the Milwaukee Protocol.
Problem is, the treatment lies within the realm of heroic medicine, works less than 10% of the time, and requires a long period of physical therapy afterwards. The cost easily goes into the seven figures. And we don't even know if the treatment works. Survival might simply be the luck of the genetic draw.
So, $10 million to save the life of one patient with symptomatic rabies, vs. $2000 for the vaccine. So you can see why the treatment protocol emphasizes post-infection vaccination.
As for whether or not I used the right term, I'd actually suggest that "infection" is kind of a fussy term to begin with. But I also never used it in my post, so I'm curious as to how I could have used it wrongly.
I stated that after the treatment window closes for PEP, we're in the realm of very difficult treatments that are really only workable in the developed world. I don't see anywhere that your post and mine are contradictory.
http://www.cdc.gov/mrsa/statistics/ (Center for Disease Control)
And the numbers of infections were far lower than you're claiming here - rather than approximately 20,000 in 100,000 as claimed above, the numbers (in 2011) were 4.5 in 100,000.
http://uk.reuters.com/article/2013/09/16/us-hospital-mrsa-id... (Reuters quoting numbers from a JAMA / CDC study).
As for rabies, according to Wikipedia quoting Sherris Medical Microbiology (4th ed.),
"Treatment after exposure is highly successful in preventing the disease if administered promptly, in general within 10 days of infection."
There's more information here:
http://en.wikipedia.org/wiki/Rabies#Treatment (Wikipedia)
Hurray for these protocols, but that won't do all that we need. It won't be possible to scrub the whole world with poisons the way we have begun scrubbing hospital rooms. We need ways to stop infections that we can't prevent.
It's a very worrying situation.
Breathing? Where are the bacteria in the gas-exchange process? And 'metabolism' is a catch-all term that refers to so many different chemical reactions, plenty of which are conducted within the human cells themselves.
The fight we have not yet one is the fight against poverty. Not many wealthy people die of rabies.
AIDS which was once fatal, is no longer, provided you can afford the treatment.
Its very common in a lot of of places in the world to ask for euthanasia in case of such diseases.
Compared to a chronic, wasting disease that will take years of opportunistic infections before you die, that's damned good.
What? We never had effective antivirals. We have a few useful drugs (oseltamivir, protease inhibitors, etc) for particular viruses, but there has never been a point in human history when rabies was a treatable disease. The Milwaukee protocol, which is the only effective[1] non-vaccine treatment for rabies, isn't even drug-based!
You may of course be confused. The major antiviral used in replications of the Giese case, amantadine, was also an anti-flu drug, resistance to which is now widespread in influenza (see http://en.wikipedia.org/wiki/Amantadine#Veterinary_misuse ). However, I do not believe amantadine resistance has ever been described in rabies, which in any case is usually treated with vaccination -- the challenge is to get the immune system to respond to the virus before the host dies! Giese herself was treated with both amantadine and ribavirin. In any case, your claim is confusing at best, misleading at worst.
[1]: controversial, see http://www.medscape.com/viewarticle/712839_7
Secondly, what on earth do you mean when you say we lost the fight against viruses a decade ago'?
We have only got better at treating viruses; we had almost no treatment for viruses a decade ago and we have some treatments now; for example we are now much better at treating chronic hepatitis c infection which is a leading cause of liver failure and cancer; we have good HIV drugs which can lead to long term management without significant comorbidities (although many of the pieces were in place a decade ago), and your illustrated case, rabies, has long been a problem child like many significant viral illnesses that are discovered close to the end of their course, has caused so much pathology by tr time they present that the course is terminal.
But there have only been a handful of cases of fulminant rabies in the developed world in the last decade, so it's hardly a thing that we are getting experience in treating.
We do not have any drug against any retrovirus (ie. a family of viruses) to which viruses do not show at least partial resistance.
As for the AIDS case, prevention of AIDS has pretty much failed in Africa and the middle east, as well as in significant parts of Asia. It is a matter of a decade or so until ~80% of those populations are HIV positive and the rest of the world will follow in the next few decades. All currently know anti-AIDS drugs will cease being effective in 5 years or less, and the rate of adaptation that the virus exhibits is still accelerating (we wouldn't be able to keep up with the current rate, so sadly, that doesn't even matter).
This is of course assuming we don't have another pandemic like the Spanish flue. We have had several near-pandemic panics in the past decade and all incidents have one thing in common : we failed spectacularly at containment. If, for example, bird flue had been ~6% more infectious than it was, it would have killed ~20% of the world's population (at least), and would have reaped >90% of it's death toll before a vaccine would become available. Absolutely nothing would have stopped it. Bird flue itself was only one of 5 incidents that could have exploded into a pandemic. The big message of these incidents: yes, they stopped, hurray. Sadly it wasn't us who stopped it (but rather small flaws in the virus' design).
- The prevention of HIV in developing countries is hampered not by the ineffectiveness of drugs, but the expense and difficulty administering them. HIV in the developed world is, in many cases, now essentially a chronic disease. Indeed, it is the use of HAART drugs to prevent transmission in discordant couples that is providing a glimmer of hope for reducing the burden of HIV without a vaccine.
- While serious, prevalence of HIV is nowhere near 80%. Also, increasing prevalence is a function of disease duration, so better treatments will, mathematically, cause prevalence to rise.
- I'd contest rather strongly that we failed spectacularly at containment for several recent outbreaks.
- Antiviral drugs are not our only means of fighting viruses. If "Anti-X drugs" were the solution, we'd have eliminated many bacterial diseases - we haven't. The key to fighting viruses is vaccination, and we've wiped two viruses off the face of the earth, and are largely facing political/social problems, rather than scientific ones, with adding two more to that tally.
This is the important point that people forget. Bacteria are experiencing an extremely accelerated time course and can evolve and exchange advantageous mutations very quickly. We have only had antibiotics for 100 years, which is 3-4 generations of man, but billions of generations of bacteria!
> Indeed, I am on record here on HN[1] saying that I'd like to see the United States follow the lead of the EU immediately in banning antibiotics used in human medicine (especially last-line antibiotics used for antibiotic-resistant human disease) from use on farms. That seems like a sensible way to segregate the ecosystems in which microorganisms develop antibiotic resistance by haphazard evolution through natural selection.
Exposure to one agent can make bacteria more resistant to other agents, even ones that are unrelated. This is surprising, but confirmed through experiments. Bacteria have ways of flushing out toxins that become up-regulated, and they become more resistant to toxins in general. Agriculture only uses a few antibiotics, ones that are cheap in bulk, nontoxic to livestock, and can be mixed with feed, but the ramifications could extend to other, more critical, antibiotics used in medicine.
> As we reach a deeper biochemical understanding of the basis of all life, we will eventually understand the differences, which are biochemical differences at bottom, between human beings and bacteria, between human beings and protists, between human beings and fungi (yes, there are some systematic differences between animals and fungi) and between human beings and all other harmful microorganisms.
I think you're underestimating what we already know. Current antibiotics are based on the differences between eukaryotic and prokaryotic cells, and we understand a lot about the underlying biochemistry and drug targets. Lack of fundamental knowledge isn't a primary issue.
> I'm confident that more bacterial lineages will be wiped out before human medicine is seriously compromised by natural selection of bacteria that are resistant to most antibiotics used in human medicine.
Here you're underestimating bacteria. Bacterial lineages don't really go extinct, because they have no well-defined boundaries. Bacteria are very different from eukaryotes and they pick up genes from the environment. See horizontal gene transfer.
This is one of those vicious problems, like cancer, that resists being solved not for lack of our best efforts, but in spite of them.
[1] http://www.perseusbooksgroup.com/dacapo/book_detail.jsp?isbn...
> "Agriculture only uses a few antibiotics, ones that are cheap in bulk, nontoxic to livestock, and can be mixed with feed..."
The reality is much worse. Factory meat producers will abuse any antibiotic if they are allowed, even the most powerful last-resort antibiotics. For example, many poultry producers were routinely mixing fluoroquinolones into their feed until very recently. The practice was outlawed in 2005, but there is good evidence that some poultry producers continue to do it in violation of the law:
http://www.sciencedaily.com/releases/2012/04/120405131431.ht...
Incidentally, I think the intuitive idea that the last resort antibiotics are the most powerful ones is a bit of a misconception. The ones used as a last resort tend to be the more toxic ones and the ones that have to be given intravenously. The reason they still work is probably because they were used sparingly while there were better alternatives available. That delayed the development of resistance.
The black death bubonic plague killed around a hundred million people, almost half of Europe's population. World war 2 got close to that number of deaths, but the black plague bacterium remains the most efficient killer of humanity on record.
Something that terrible sometimes has to be personified, just to make it comprehensible.
Bacteria may be blind and and random in their micro-level behavior. But the speed at which they replicate is multiple orders of magnitude faster than the speed at which we can test and iterate new defenses.
It's a race of blindingly fast random iterations VS top-down snail-paced logical defense. If human's are to win, I think they will need to bump up the defensive iteration time an order of magnitude or so.
cf. "Information wants to be free."
consider what they have: vast numbers and the ability to evolve much more quickly than we can develop new antibiotics
scary stuff
You are taking this too literally. But in any case just because bacteria aren't intelligent doesn't mean their behavior is purposeless. Evolution acts as an optimization process. It's not too far from the truth to ascribe it "desires".
On the frontline episode this was from talked about how pharmaceutical companies have all stopped investing in new antibiotics. It might be possible to make better ones but I don't know how much research is actually going on at the moment.
I'm kind of skeptical. We are fighting against millions of years of evolution. The drugs we have we only got by copying things evolution already found, and they became resistant in mere decades, an extremely short time from an evolutionary perspective. Any simple way of killing bacteria would probably already have been developed by evolution. Likewise pathogens have spent millions of years evolving to defeat everything thrown in their way, and they continue to do so.
We are joining into this ancient arms race as entirely new players.
Examples: controlled release polymers, iPS cells, neurogenetics.
"Someone saying a thing cannot be done is liable to be interrupted by some damn fool doing it."
When you say this, aren't you are making precisely the same mistake you claim the expert was making?! I am sure Dr Arjun knows very well that evolutionary goals are local and specific to the circumstance a creature finds itself in.
>The intelligence that the hominid lineage has evolved gives human beings advantages that bacteria will never possess.
:-) how anthropomorphic! Intelligence may not be a survival trait as you seem to assume. We simply don't know that. Btw, bacteria has been a lot longer on this planet than primates. We are way out of our depth when it comes to understanding how they work (I am simply paraphrasing a friend's statement, he is doing fundamental research on biochemical pathways)
They've reduced MRSA from 18-24 hours down to 6 hours. Salmonella from 24 hours to a 30 minutes. Mycobacterium tuberculosis from 21 days to 1.5 hours. Etc.
http://nanologix.com/test_results.html
Stopping these problems before they get the chance to spread is how I believe these infections will be slowed, as antibiotics become less effective.
The profit motive is almost as blind a watchmaker as natural selection. We've built an environment which encourages bacteria to develop antibiotic resistance. Let's structure a pharmaceutical industry in which antibiotics are profitable.
The problem appears to be myopia. Antibiotics make money for a few weeks, chronic diseases for a lifetime. Fortunately, finance long ago solved the temporal shifting of incentives and payoffs. We need smooth the lumpy, often in-the-future, demand for antibiotics.
The government could tax the pharmaceutical industry, medical insureres, or the public. The proceeds would fund tax credits for the developers and/or producers of antibiotics. Alternatively, a more elaborate system by which health and life insurers incentivise antibiotic research, perhaps by issuing credit default swaps on pools of their reinsurance liabilities to antibiotic developers, could be structured.
1) assuming said government exempts the company from court claims on the approved drug
http://www.nature.com/clpt/journal/v87/n3/pdf/clpt2009298a.p...
I attended a talk by an economist (whose name I don't recall, alas) who discussed establishing a futures market for drugs, with portfolios which would smooth out variabilities in what works and does not. It's pretty much the same as what you described.
No more anti-biotics, for anyone.
Recently I had a wisdom tooth extracted. The dentist prescribed anti-biotics, but (unknown to him) I didn't take them. I healed fine. And so it was in the 20's and before that. Plenty of people survived and thrived before anti-biotics. And life will go on when we don't have them anymore.
No doubt these super bugs have had to give up certain advantages to attain what is (for their species) a very specialized survival mechanism. Which means that if we ease off of the drugs for a while, the bacterial populations will compete, and the less drug resistant ones will thrive. Then we can use our drugs again. Or that's the idea.
What I'd really like to see are the internal assessments of big pharma of these gram neg bugs. Why isn't it economically feasible to create new drugs for them? This article makes it sound like there is a large and growing market of suffering people who'd be more than willing to spend every last cent for a pill to make the pain go away. And if the prospect of people willingly bankrupting themselves for drugs doesn't perk big pharma's interest, I don't know what would.
It's not that you couldn't make a profit off them. It's that the opportunity costs can't be justified (today).
There's a finite amount of R&D funds available to any firm. And if I'm maximizing profit, I'm not going to spend my money on difficult research, seeking and developing a drug useful to a handful of patients in 4% of hospitals, that's taken for a few weeks by each patient.
Not if I can instead spend it tweaking known drugs, useful to 30-50% of the entire population, that they'll take for the rest of their lives. (e.g. blood pressure medicine)
And particularly not when CDC, WHO, et al are actively campaigning for changes to antibiotic handling/prescription/use which may well mean your potential future market for "a better antibiotic" is actually smaller than today's.
I was under the impression that in a population of bacteria, genes express themselves in any number of random ways. If we expose the bacterial culture to antibiotics, the bacteria susceptible to the antibiotic dies, while the resistant bacteria lives on free to reproduce, leaving the descendant bacteria with resistive characteristics...
My question to the HN scientists is, doesn't this just destroy some subset of bacteria? Is new genetic information produced that did not exist before? Taking this trimming tree down the line, wouldn't the "superbug" antibiotic resistant bacteria have been created/survived and thrived anway? Or does the antibiotic exposure actually cause, "the bacteria to want to survive", in the sense that exposing them to antibiotics leads to more rapid mutation of descendants? Why wouldnt the antibiotic resistant bacteria be created with or without overuse of antibiotics? Isn't the spectrum of the genetic tree just trimmed?
I have no credentials or background to know the answer, but I wonder if this is something where the use of antibiotics decimates most the bacteria population so that it's easier for the resistant ones to thrive, as opposed to cohabitate and possibly be overtaken by the non-resistant ones. I'm thinking of it like Conway's Game of Life where a cell dies if surrounded by more than 3 cells. With antibiotics, you limit the number of living cells around and are more likely to keep others living.
Or maybe the non-resistant ones would have another trait that make them thrive more than the resistant ones if both are mixed?
That means, in theory, with no antibiotics, you should have very few resistant organisms.
The problem is that's all "in theory". Right now, the level of evidence for community-acquired MRSA and the competitive advantages of susceptible versus resistant S. aureus has thrown that all into question.
That's why it's so important to complete a course of antibiotics rather than stopping once you feel better. Once you've started antibiotics, you're basically enriching the population in bacteria that aren't affected by the antibiotic. This is normally a very small population, but if you stop half-way, the pressure on those bacteria from other bacteria (the ones that died) is lower, allowing the resistant population to flourish.
If you finish a course of antibiotics, you not only kill the susceptible bacteria, but you also give your own immune system a chance to take down the few remaining bacteria that are resistant.
Does it clinically happen that stopping a course of antibiotics early causes an antibiotic resistant form of the infection?
(I couldn't find evidence either way, but I did find a few articles saying typically prescribed course lengths could be safely reduced in the effort to reduce antibiotic use generally)
I can't share because that's exactly my point - as far as I can find, there isn't a single clinical example of stopping antibiotics early causing any problem of antibiotic resistance.
I can only speculate, but here's how I imagine it.
Your body can kill a certain number of bacteria on its own. Antibiotics help reduce the infection to the point where your body can do the rest.
If the resistant bacteria are a small minority, taking antibiotics long enough to kill most of the non-resistant ones will let your body kill the remaining resistant ones.
If you stop too early, the battle tide has not yet turned. Instead, by killing, say, half the non-resistant ones, you've made the resistant ones a larger proportion of the whole infection. Then both groups continue to multiply.
If you repeat this several times, starting and stopping the antibiotics depending on how you feel, the resistant bacteria could go from being 1% of your infection to 50%.
[1]: http://en.wikipedia.org/wiki/Gram-negative_bacteria [2]: http://en.wikipedia.org/wiki/Phage_therapy [3]: http://en.wikipedia.org/wiki/Gram-negative_bacteria#Medical_...
If all else fails, I guess we'll depend on the cycles of nature's adaptations and break out a new set of antibacterials every 50 years or so depending on the resistance trends we see crop up and hope we don't lose too many humans in the process. At any rate, I'm glad lots of smart people are working on this problem.
The capacity to resist antibiotics extracts a small metabolic/competitive "tax" on bacteria. In the presence of antibiotics, the costs of this tax are outweighed by the obvious benefits of antibiotic resistance.
In an environment without antibiotics, the costs of the tax outweigh their benefits, so these antibiotic-resistant bacteria will eventually be outgrown by "normal" bacteria.
If we can discipline ourselves to use antibiotics only when necessary, gradually antibiotic-resistant bacteria should become less common. Unfortunately, I doubt this will happen until the antibiotic-resistance problem becomes much more serious.
To my knowledge, bacteria don't have an agenda, they don't want to survive and they certainly don't change in order to survive. Instead, they change at random, which sometimes helps an individual to survive and sometimes not.
This coupled with multiple ways that bacterias can use to protect themselves against antibiotics, like enzymes, better shielding, or even pumping the antibiotics out, also increases the chance for successful mutations. And they've also developed this mechanism for spreading their DNA around to other bacterias.
The result is almost the same as if bacterias would have an agenda. Although it can happen for mutations to lead to worse fitness in contact with older and forgotten antibiotics. And it can also happen for these random mutations to drive a whole population to extinction. But these two outcomes have a much lower probability than bacterias becoming highly resistant to all antibiotics.
Our feelings (wants) and actions are a result of evolution just the same as bacterial action.
We may choose not to ascribe feelings to bacteria, but the origin of the motivation is precisely the same as it is in humans - the motivation to survive and reproduce is universal to organisms.
To me this seems like the big problem here. Antibiotic resistance is an inevitability regardless of our usage rates - there's too much selective pressure for it not to. To co-opt the Red Queen hypothesis slightly, we have to constantly be developing new antibiotics just to keep pace.
I suspect this problem will self-correct eventually, with the unfortunate side-effect that the cost of effective antibiotics will skyrocket for awhile.
That being said, we're obviously not doing ourselves any favors by dispensing them like candy, especially to the agricultural industry. It definitely encourages cycles - Effective antibiotics are rare and therefore profitable so tons of $$ goes into R&D -> Lots of new antibiotics are created -> price goes down because there's so many options/patents expire -> Overuse -> Resistance develops quickly and we're left with few effective options.
MRSA was a bit of a wakeup here in the UK, but the main 'solution' was concentration on cleaning hospitals rather than developing new anitbiotics.
It is my opinion that unfortunately it will require high profile people to start dying before support is galvanised.
It would seem from the outside that HIV/AIDs started to be addressed when superstars like Freddie Mercury started succumbing.
http://www.thelancet.com/journals/lancet/article/PIIS0140-67...
Think about it. We always say humans who don't finish their prescription are allowing some of the most resistant strains to survive, when taking the full prescription would generally finish off everything (even the moderately resistant strains) preventing selection. Farm animals that never stop taking antibiotics never provide that window of opportunity for unresistant strains to take hold and then undergo selection due to antibiotic regimes that are ended too soon.
Maybe I've got the wrong idea here, but is this particularly different from, say, a petri dish full of sulfuric acid, and a petri dish that periodically has some acid introduced for a short period of time? Drop a culture in the first dish, and they all die. Drop a culture in the second dish, and they have time to develop resistance.
Are people who have avoided prescribed antibiotics in a better position than those who haven't? Then, what is the effect on such people of the antibiotics taken in by eating meat from animals which have been give antibiotics? Have the people who have been avoiding completely wasted their time?
If your immune system works fine, there's less to worry about. The most urgent danger is to the very young, old, or immunocompromised because of illness or therapy. (That said, MRSA infections do happen in otherwise healthy people from time to time)
If you've been avoiding meat raised with antibiotics, you're part of the solution, because you're pushing the market away from the cheap short-term fix (antibiotics) towards more sustainable solutions without the societal consequences.
it's possible that antibiotic-resistant bacteria have more chance to take hold (asymptomatically/latently) in people who are regularly exposed to antibiotics.
You could be carrying around MRSA but you wouldn't observe symptoms unless/until you are otherwise in a critical state - wounded or immune-suppressed.
It's not currently obvious how antibiotic-resistance spreads in the wild and so it's still plausible that avoiding antibiotics gives you some degree of protection.
There is work in progress toward a MRSA vaccine[1,2,3], though it won't be easy. Nevertheless, the way I see it, vaccines are a strategic approach, while antibiotics are tactical.
Obviously we need to continue to pursue both, but I just think it's important to consider and even maybe refocus our efforts to deal with MRSA and other tricky fast evolving bacteria that become widespread and problematic in our communities by pushing hard for vaccine development.
[1] http://www.trefis.com/stock/pfe/articles/205872/pfizers-vacc...
[2] http://www.huffingtonpost.co.uk/2012/02/15/scientists-create...
[3] http://www.fiercevaccines.com/story/pfizer-glaxo-and-novadig...
(did you know there was a website called "fiercevaccines.com"???)
Hopefully we'll be able to create some alternatives, but let's stop the bleeding if we can.
Antibiotic resistance will continue to be a problem (obviously), but we're going to have effective antibiotics available to us for the coming decades.
If this is the end of the Age of Antibiotics, I hope its the beginning of the Age of Probiotics. Working with the good bacteria and developing more targeted strategies of taking out the bad. Snipers, not nukes. (Im no scientist but perhaps learning from how good bacteria fight off bad bacteria is a good place to start) http://www.sciencedaily.com/releases/2010/03/100324094717.ht...
Beyond that, you now have things like extensively resistant Gonorrhea, which has taken a disease that is fairly common, but easy to treat if caught and thus embarrassing without being dangerous, and turned it into a serious problem, especially for women.
The answer for "How do we tell" is that epidemiologists (like me) do a lot of surveillance for antibiotic resistance. We ask why hospital patients died, and what organism killed them - and what is was susceptible to.
And the answer is this is a rather serious problem.
[...]
> When I hear people claim it was wanton use of antibiotics that caused all of this.. I wonder if they ever read a word about biologic evolution
Natural selection describes the shift in characteristics of a population due to some environmental pressure which favours individuals with specific characteristics. How they acquire those characteristics is largely immaterial, be it through random mutation, sexual reproduction, viral transduction, etc.
So yes, natural selection is the process by which the resistant bacteria outcompete the vulnerable ones, and thus become the dominant population. But the reason that occurs in the first place is because of the environmental pressure induced by the antibiotic.
Or am I missing something here?
The only argument I can think of against antibacterial cleaning products would be that our bodies get less exposure or "practice" against ordinary bacteria?
Not sure where the thread is but the story here: http://www.nature.com/news/silver-makes-antibiotics-thousand...
To put the above into simple English: Our problem isn't that we give antibiotics out like candy, it's that we give them to the elderly, people with AIDS, the poor, etc. This massively increases the chance of antibiotic resistance developing.
What can we do about it? To start with, run the numbers, make some cost-benefit calculations, and think about the problem. There may be technical as well as social solutions.
Not thinking about the problem, making it harder for the healthiest people to get antibiotics, and pretending that you are doing something is also a viable option. It's what we're doing now.
Do you realize what you've just said? Are you arguing that we shouldn't have had given antibiotics to people that needed antibiotics?
Also, I don't know how your society is or does, but in our country the poor have a better immune system.
Moralizing doesn't save anyone from gangrene and sepsis and a slow death. It doesn't prevent the diarrhea to dehydration to death sequence. It doesn't do an ounce of good for anyone.
Immunocompromise (poor, sick, elderly, AIDS, etc.) + long-term antibiotic use = Antibiotic resistance.
That equation is death, and we need fixes, not the crap in your comment above.
"Also, I don't know how your society is or does, but in our country the poor have a better immune system."
No doubt you live on Mars or Venus.
God forbid say your dad is sick- Will you go and tell him- 'Dad, you better die for the sake humanity and than take these antibiotics and have you pain reduced'.
If you are poor, will you tell your kid- 'Sorry son, I have to sacrifice you for the sake of humanity, no more antibiotics for you'
The parent comment to yours is correct. Poor have better immune systems, because theirs is trained to handle such situations from their birth than yours and mine which live well sanitized environments and have never been exposed to them before.
That's at least true in a country like India. I'm not sure where you live, poor people dying out of fatal infections is one thing. But its also a fact, some that requires me or you take a sick leave doesn't even bother them.
My 18mo daughter has had a half dozen ear infections and two staph infections. Antibiotics each time.
Would it be better to leave a staph infection untreated with antibiotics? How? Lance and clean the infection site... and then what?
Or ear infections? I had frequent undiagnosed ear infections as a small child and now have reduced hearing to thank for it. My entire life I've had people annoyed with me asking them to repeat themselves. Some ear infections may clear up on their own. The ENT has told us this is unlikely in 12mo or younger ages since cranial structures aren't in place that allows excess fluid to drain. We can let her have a fever for a day or two, and give Tylenol, but all that's going to do is delay the necessary antibiotics. We could also have tubes inserted in her ears, but it's not like those are without risks or downsides either.
Since people don't have to play the lottery with their hearing or their lives anymore because they have access to antibiotics now sure, maybe that has some scary consequences. But it's not like people are popping them for a headache or skinned knee. And insulting people may make some feel superior, but it doesn't actually solve anything or even hint at a possible solution. You don't just "ride these things (staph) out" and hope for the best. There are consequences to going all granola "nature will take care of itself".
I think I've been prescribed antibiotics for an obviously viral infection one time in my adult life. I can count the number of times (in my late 30s) that I've been prescribed antibiotics as an adult on one hand.
When you factor in that people just don't go to Dr's all that often in the US, especially the poor, I'd need to see some actual data before I believe this is a grossly American problem. Because given other factors, you'd be forgiven for thinking something doesn't add up with that characterization.
I would for example, imagine it's much more of an issue in the UK with people having cheap convenient access to the NHS.
In the US I'd have to find a Dr, and if I'm uninsured that means spending a half-day at the ER, and then I'd have to take that Rx to a Pharmacy, who's going to offer me a generic at an uninsured price that's probably somewhere around my grocery budget.
If it's an issue at all (comparable to countries with socialized medicine) in the US it would almost have to be an exclusively middle to upper class behavior.
That's a good deal of the population that just doesn't play the game.
Honestly, framing this as a Stupid Fat American problem reads like "Are Antibiotics Going to Kill Your Children?!? Find out tonight on XYZ News at 6PM!!!". Those stories are definitely out there and pretty pervasive. It would be pretty ironic if Geeks with Superiority Complexes were being feed their dogma by "common knowledge" based on soundbites from the nightly news...
Not to dismiss this as a problem. But insulting people (even comparably low quality-of-life Americans) doesn't get us any closer to a solution. And blaming those people, already stretched thin by work hours, insurance costs (if they even have it), day care, trying to ensure they get to sit down for a family dinner, go to work sick so they can afford the time off for a family vacation that they're the problem because they're just dumb Americans is... It's to express in words how petty and mean spirited that comes off as.
30 pills - $5.90. So a normal cycle would be about 3 dollars. In the United States. Antibiotics are so inexpensive.
Here's what my daughter was prescribed: http://www2.costco.com/Pharmacy/DrugInfo.aspx?p=1&SearchTerm...
So $230 for the course. So sure. Amoxicillin is cheap. So is Tylenol. What's your point? After the Dr's visit you're still likely out at least $100, not to mention time off work, and that's if the "cheap stuff" even works. You can't get this stuff OTC.
I stand by my statement: Without data I think it's a lot easier to believe that places with socialized medicine and generous labor laws for things like sick time are much more likely to see abuse.
You do need to get a prescription though, which doctors don't dole out with a smile. Companies don't have to pay to advertise drugs though.
http://www.spokesman.com/stories/2010/jan/03/norways-mrsa-so...
All citizens will be required to carry a smartphone or other GPS tracking device that reports their location every 5 mins to a central database run by the National Security Agency. When a new infected person is discovered, National Bureau of Health agents will contact everyone who was close enough to the infected person to have possibly transmitted (given or received) the infection over the previous two months. Those people will be tested and infected people will be incarcerated in National Health Concentration Centers for healing. They will stay their for life, or until no longer infected.
Will it come to this?
What about mandatory death penalty (plus confiscation of all family assets) for anyone who gives antibiotics to an animal or who supplies antibiotics to a farmer?
I believe this is quite likely a worse issue than the other problem: the blatant overprescription of antibiotics by weak and obsequious family doctors looking to defend themselves from lawsuits and approbation from wealthy and stupid patients with colds and coughs, which has also accelerated resistance.
In other words, Aikido not Karate. Use their own energy against them.
Just a thought. Probably nonsense. Not a biologist.
This seems like another area where libertarianism is crashing against the rocks of reality-- as socialism, communism, and all other political ideologies have already done. I have a profound sense that all political ideologies are failed, and that we're entering a post-ideological age of pragmatism driven by either populism, oligarchy, or technocracy... take your pick.
Antibiotics use fits the "Tragedy of the Commons" scenario to a T.
^1 who names these things and are they purposely trolling conspiracy theorists?
Perhaps silver in nanoparticle form will make a comeback, as bacteria don't seem to be as able to survive the cell wall disruption that silver can cause.
1. Patients ask for them. For a long time, the thinking went 'What's the harm?' in giving Mr. Jones some penicillin for what's probably a viral infection.
2. There is the potential for lawsuits, and the desire to have 'done something' to cover your ass, but I think this is widely exaggerated as a threat.
3. It's hard to diagnose many conditions. Like juries think all crimes get the full CSI treatment, patients often think doctors can just pop down to the lab and find out what you have, like in House. The answer is that's often hard, expensive, and failure prone. So they give antibiotics, especially broad spectrum ones, because of the subset of things you might have, antibiotics can treat some of them.
4. This is really 3b, but it's also possible, when you have no clue what your patient has, to try different antibiotics to try to get a handle on things. This...ends up using a lot of antibiotics.
5. Doctors, at their core, want to treat their patients. To make them better. They're trained to deal at the individual level - antibiotic resistance is a population level concern.
Linezolid has no clinically significant effect on most Gram-negative bacteria. Pseudomonas and the Enterobacteriaceae, for instance, are not susceptible.[90] In vitro, it is active against Pasteurella multocida,[2][91] Fusobacterium, Moraxella catarrhalis, Legionella, Bordetella, and Elizabethkingia meningoseptica, and moderately active (having a minimum inhibitory concentration for 90% of strains of 8 mg/L) against Haemophilus influenzae.[87][90] It has also been used to great effect as a second-line treatment for Capnocytophaga infections.[43][92]
Beyond that, it's no longer just MRSA. There's all manner of resistance mechanisms, for a very, very wide set of diseases, including some dirt common ones.
"Resistant" isn't an on/off switch. How resistant? Where are the resistant bugs? How many of them are there compared to non-resistant competitors, etc.
The article's cool though.
> bacteria will always change in order to survive.
Excellent article. Everyone should read it from top to bottom twice. Forward it to your entire network. This is a serious matter.
However. I really cringe when I see scientists get loose with language like this. I know he knows perfectly well how evolution works. This is an attempt to make it simpler to swallow for those who might not be up to speed and, perhaps, come to the discussion lacking a minimal scientific background to be able to rationalize it. I get it. Among that population the misrepresentation of the driving mechanisms behind evolution can actually do more harm than good.
Taken far enough you end up with? "Oh, so you mean to say that a monkey WANTED to survive and CHANGE in order to become a human". Which makes you sound like an insane lunatic, of course.
The mechanism is dead simple: Out of a pool of organisms exposed to an environment some die and some survive. This "environment" can be anything, from an antibiotic at the bacterial level to a flood in a canyon. Of those who survived some did so due to blind chance. Others because they might possess a characteristic that helped them survive the environment. Survivors mate and reproduce. Some mutations occur. The cycle repeats with the new population. If the environmental "attack" (antibiotics, the flood, whatever) remains the same, over time populations will develop that will have better and better resistance to their particular challenges. This is the brutally simple result of the demise of those who simply could not handle whatever was dished out. Over time either the entire population is killed off and game over or those who were resistant, for whatever reason, will --without intent, goals or knowledge-- help evolve populations equipped with increased resistance to what is trying to kill them.
In evolution there is no "wanting" to do anything. There isn't even the idea of wanting to survive. There is no struggle for survival. There is no conscious desire to change or to become something else. It is brutal and simple. Some die. Some don't. Those who survive repeat the cycle. Eventually either all die or you end-up with one or more new species/variants that got past the killing spree and emerge resistant to whatever ailed them. And it goes on. Challenge after challenge.
Part of me wishes people would have a better handle on this very simple scientific fact so we could move on to more important topics. We went to see Richard Dawkins at Caltech this weekend. He mentioned that in the US some 40% of the population think the earth is 6,000 years old and reject evolution. What they reject might very well be what ends-up killing them.
This issue of bacteria evolving past our ability to concoct antibiotics is a very serious one. I've always believed we are all going to be killed-off by something microscopic that nobody is going to see coming. The potential is there for hundreds of millions of people to die over a short period of time. Airplanes will contribute to that greatly, helping take bacteria all over the world before we even realize what's happening.
That's why I don't understand why we don't get behind this --as a planet, not just a nation-- with great force. I see virtually no use for our military and that of other nations. Can't we lobby for the elimination of the horrible waste that is the maintenance of massive military forces and, instead, devote those funds to more worthy causes? Imagine if we, as a nation, devoted half our current military budget to honest medical research. I am not one for huge government programs, but there would be ways to do such a thing without having government bureaucracies devolve the thing into a cash burning furnace.
The point isn't the details but rather the idea that something like this should be priority one. We are looking at the possibility that within the next 25 to 50 years there could be a massive antibiotic resistant bacteria outbreak that takes out a huge chunk of the human race. We need to be ahead of that event, not behind it. And it is far wiser to throw billions of dollars into medical research of almost any kind rather than into making the latest wiz-bank how-to-kill-more-people-per-round machine.
Utopia. I know. Sad.
EDIT: I neglected to add how I would explain evolution to a general audience without resorting to "want" and "desire" type analogies. In other words, don't be critical without offering a solution. Well, I think it's simple, I sort of did:
When faced with challenges organisms either excel or die. Those who excel go on to reproduce. In reproduction there is mutation. Small changes to each and every new organism. Reproduction does not produce clones. Reproduction results in a population of new and distinct individuals with some of the traits of their parents and some new ones. Their offsprings, if faced with the same challenges will, just the same, survive or die. If none survive the population goes extinct. Otherwise, over time, the only organisms who will continue to survive are those who continue to carry the traits that made their ancestors survive. This repeats over time and across challenges.
That's not the elevator pitch, of course. So here is that one, applied to bacteria in particular:
When attacked by antibiotics some bacteria survive. These reproduce and produce new bacteria that might carry-on some of the traits that allowed the parents to survive. Random mutations might also make some members of the new population even more resistant to the same antibiotics. The process repeats over many generations. Over time new populations emerge with immunity to the antibiotics that killed so many of their ancestors.
The more we expose bacterial populations to wide ranges of antibiotic challenges the greater the effect can be. Over time populations will evolve that will be resistant to anything we have on the shelves to throw at them.