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Comment by AaronFriel | Hacker News Reader

For the past half century, we should have been treating our antibiotics like weapons of mass destruction - tools of last resort only to be used in emergencies, with great hesitation, and only when absolutely necessary. The industry and the doctors responded: antibiotics were too profitable and the risk seemed too distant. Now we have no weapons; we're helpless and the world is again going to be a scary place where a cut or a scrape can land you in a hospital or in a mortuary.

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.

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> Now we have no weapons; we're helpless and the world is again going to be a scary place where a cut or a scrape can land you in a hospital or in a mortuary.

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.

The return of the sanitarium and things like leper colonies could be in our futures.

And they'll be absolutely necessary. The infrastructure exists now. As an example, if you contract XDR tuberculosis you will be quarantined under orders from the CDC, by force if necessary, until the infection is cleared, which can currently be done reliably only with surgery.

This, right here, is the biggest issue. Routine, minor surgery? No longer a risk free proposition. This sort of antibiotic resistance will have, and is having, enormously deleterious effects on the kind of basic health care and medical science we take for granted.

Fun fact: modern plastic surgery -- including purely cosmetic, non-normative surgery -- predates both antibiotics and anesthetics.

That's not too surprising. People sometimes have ugly face moles and stuff, and it's not too hard to cut it off.

> 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.

> This is one reason to avoid hospitals at all cost.

I think generally, everyone avoids hospitals at all costs.

Good point. And hospitals themselves are very costly. In case you need another reason.

I feel a lot less silly now for avoiding medical treatment unless absolutely necessary all my life.

The difficulty is avoiding treatment and not diagnostics. If your method of avoiding treatment is never going to the doctor, ie, never being diagnosed, you don't really know when your problems are life-threatening.

So this would be a bad time to start talking about rates of community acquisition of MRSA and C. difficile, wouldn't it?

This is what I don't completely understand. Why has no one developed a disinfectant spray that hospitals can apply ad-nauseum (pun intended, the smell ideally wouldn't make people nauseous) all over the hospital? Or, do I not understand the vectors properly?

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'.

Google for "mrsa aerosol transmission".

Yes yes make everyone wear gas masks and space suits the entire time, staff and patient alike...

> Why has no one developed a disinfectant spray that hospitals can apply ad-nauseum (pun intended, the smell ideally wouldn't make people nauseous) all over the hospital?

We have robots that do that now.

http://loyolamedicine.org/newswire/news/uv-light-robots-kill...

We do. We have disinfectant sprays, chlorhexidine, bleach, UV radiation shot by Cylon looking robots, and surfaces made of copper and patterned after shark skin.

Bacteria are just bloody durable, and people are shedding new bacteria into the environment at really absurd rates.

>We have disinfectant sprays, chlorhexidine, bleach, UV radiation shot by Cylon looking robots, and surfaces made of copper and patterned after shark skin.

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...

It actually looks like this: http://upload.wikimedia.org/wikipedia/commons/0/0f/Clostridi...

That kind of solution is part of the problem. Resistent bacteria are normaly outcompeted by non-resistant ones, except when there is antibiotics on the enviroment. As a consequence, the mere act of keeping something always sterilized (as well as possible) helps the resitent bacteria growth.

But, of course, you can't avoid keeping a hospital sterilized.

Maybe the solution is to have the procedure in a place that is a hospital. You'd want some environemnt that isn't shared by other sic people, and is only sporadically 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.

Like a surgery center? They do have those.

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.

> we're helpless and the world is again going to be a scary place

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.

I still worry about the profit motive getting in the way. You'll buy antibiotics for days or maybe weeks; you'll buy drugs for high cholesterol the rest of your life.

>you'll buy drugs for high cholesterol the rest of your life

Not if you get killed by an infection first.

Also many chronic diseases are autoimmune diseases, like asthma or type 1 diabetes. In such patients the immune system gets weaker when in crisis, leaving them vulnerable to infections.

This humorous observation does not affect the argument, it just derails it. It's easier to make money off drugs for chronic conditions than for one-off infections.

And it's sometimes easier to invent a chronic condition for a drug, than vice versa.

Remember, it takes 8-12 years and $1,000,000,000 on average to whittle 10,000 drug candidates into 1 fully tested FDA approved drug.

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.

Though one recent study of drug development costs had an antibiotic against C. difficile as one of the cheapest to develop.

I've actual found there's a fair amount of interest in antibiotic development among drug companies.

This is touched in the FRONTLINE documentary. See 33:40-40:00 here: http://www.pbs.org/wgbh/pages/frontline/hunting-the-nightmar...

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.

No we don't - this is just where we need to fund government laboratories to research drugs in areas which drug companies do not presently find profitable.

Having read this and the article on autonomous corporations, I suddenly understand that the future of capitalism is extinct humans and very financially well-off computers.

Keep in mind that Pfizer's strategy is in response to the incentives offered by the marketplace including regulations set forth by the FDA and patent office. It's not a free market that sense.

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.

They could patent it and charge $5000 a course to people who are suffering from resistant bacteria. It's the American way.

If that's what's necessary for the company to develop such an antibiotic, why not? State-of-the-art cancer drugs can cost that ore more. I'd rather pay $5k and live, to not being able to do anything.

I worked for Pfizer, for 2 years in clinical trials to get Linezolid on the market. This was for treating MRSA infections. I was in close contact with nurses & doctors who seemed to think it worked well. Back then (around 10 yrs ago), there was almost no MRSA resistance, unheard of from what I remember.

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.

This is not at all how drug development works.

I suppose that's true, but it seems like a perverse incentive to me. Drug companies have a financial incentive to wait for people to die rather than taking action that will prevent people from dying.

Really? The most profitable drug ever is Lipitor which is entirely based on reducing the threat of future health problems. High cholesterol does nothing to you in a short timeframe, but will greatly increase your likelihood of death 20-30 years from now.

It's not an impossible scenario but have the decency not to wrap this 'End of the world fantasy' as a fact or certainty.

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.

Well, none of those (if you replace Y2K with Y2038!) are down for the count yet.

Tne real threat of a Dr. Strangelovian nuclear apocalypse certainly died with the Soviet Union, which isn't to say that such conditions could never arise again. And of course the risk of a smaller scale nuclear war is still very real.

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.

"Tne real threat of a Dr. Strangelovian nuclear apocalypse certainly died with the Soviet Union"

Why? Did the weapons magically disappear? That outcome is much more likely in the 2010s than the 1980s, for example.

Of those, though, two of the threats were real and mitigated before the impact could be realized (nuclear war and Y2K), and one of them is a fairly recent scientific theory that is still trying to be understood (climate change).

In the 80s we acted faster on freon/CFCs than we have on climate change in the ensuing 30 years, with less danger to human life and less evidence. The only thing that's new about climate change as a scientific theory is the annual increase in the pile of evidence that it's happening and we're the cause of it.

Absolutely horrible example because .com owns .gov and the primary patent for CFC production expired in 1979, obviously lots of money is going to be poured into encouraging the use of patented CFC replacements, such as making the use of CFCs illegal. I'm not questioning the science of it, I'm explaining why .com and .gov worked together really hard on banning CFCs in the early/mid 80s, because HCFCs and HFCs are more profitable. The historical about-face is documented and hilarious how .com strongly denied CFCs could have any effect therefore .gov wouldn't ban them until the patent expired, then suddenly everyone agrees we need to use the more expensive HFCs and HCFCs.

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...

This is nonsense. Some large portion of industry would be happy enough to not pay royalties.

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.

Freon and CFC's were easier to replace.

Exactly. Those are two specific things that needed to be eliminated. Climate change deals with a lot of bad actors, and a very broad category of changes.

> tools of last resort only to be used in emergencies, with great hesitation, and only when absolutely necessary.

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."

How about the animals and hand-soap aficionados? Perhaps they could hold off for a bit?

Maybe GP didn't have the best wording, but I would classify those both as emergencies appropriate for antibiotic use -- you may only think them not because antibiotics are seen as so commonplace.

Non-emergencies:

* sore throat * lots of chickens packed in one place

Those examples both qualify as necessary and emergent.

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).

Exactly. And not even for more severe colds either, like when having fever or a red throat, but rather for freaking runny noses.

I'm not sure how prevalent your example is these days.

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.

Doctors are getting better about it because of better awareness of the problem. My kids' pediatrician is similarly good about it.

Last year NY state started putting out "when does my child need antibiotics?" pamphlets that they have in the exam rooms.

What I'm saying is that we should have treated antibiotics, as a worldwide community, like a stockpile with a finite lifespan and only a limited availability. As few uses as possible, with the goal of saving lives, not making people "feel better".

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.

I think it's too easy to say that overuse of antibiotics is what brought us here. In the article it says that companies stopped developing new antibiotics when development costs became too high to justify given the narrow market.

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.

Kinda brings the free market idea into a different light, isn't it?

At least we have Viagra!

I think you're going a bit too far there.

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).

People use antibiotics to treat things that are not helped by antibiotics.

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.

Obviously unnecessary use of antibiotics is unnecessary (a fact I alluded to), but that's not what I was responding to. You're putting words in my mouth there. I said the call for "emergencies only!" antibiotics was overkill. If I took your point differently than you intended, maybe you would like to rephrase.

Being somewhat pessimistic here. As someone who actively hacks DNA, I believe that we can address this problem responsibly with the development of new and novel antibiotics for antibiotic-resistant bacteria. There are significant challenges in the biology but there is technology being developed that will significantly reduce the cost and time needed to develop new antibodies.

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.

> tools of last resort only to be used in emergencies, with great hesitation, and only when absolutely necessary

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?

I think it would be more accurate to characterize antibiotics as effective, not just profitable. You are completely ignoring the actual benefit of antibiotics and acting like they created profits without actually benefiting the patient

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