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Antibiotic resistant bacteria are a fact of life for those of us in the medical profession. In my 25 years of practice this has gradually morphed from a very manageable problem to one that is increasingly difficult if not frightning. We are now at the point where previously healthy people can contact a lethal infection that we cannot cure with antibiotics. Many others have to be treated with courses of expensive, inconvenient and even toxic antibiotics because resistance has made much cheaper and safer old standards useless. MRSA has become a household 'brand' in the medical world.

Well, this scary situation is about to get a lot worse. Follow me if you dare.

We frankly do a pretty lousy job of managing antibiotic usage here in the United States. More than half of all yearly antibiotic production tonnage (yes, we're talking thousands upon thousands of pounds) goes into animal feed to permit BigAg to make a few more pennies per pound on hogs and cattle jammed together shoulder to shoulder on massive factory farms. That's just insane from a public health standpoint, and the Obama administration is finally taking some tentative steps to mitigate the stupidity.

The medical world is not a lot better. We are far, far too promiscuous in our use of antibiotics. Some of this is the result of harried, overworked primary care providers who find it easier to write a prescription for Amoxicillin than to spend the time required to explain to a patient why it won't help their head cold. Some is the crass overuse of very expensive broad-spectrum antibiotics for infections easily treated with something simpler and cheaper. Much of it is simply the result of far sicker people kept alive much longer on dialysis and with multiple surgical procedures or indwelling medical devices, where cascading infections and multiple rounds of antibiotics are the rule. And finally, we've become far too complaiscent about basic infection control procedures (like, for instance, simple handwashing) with antibiotics available.

This is all going to change, and probably quite soon. As you can read here, a new extremely resistant strain of bacteria is gaining headway, appearing initially among "medical tourists" returning from India after having surgical procedures. If you think antibiotic use and infection control procedures are lax here in the U.S., in the developing world it's a nightmare. There's virtually no surveillance for developing resistance patterns, no review or constraints on use of broad spectrum antibiotics, little systematic follow-up to ensure infections are eradicated. To put it bluntly, it's the ideal situation if your goal is to cultivate the development of extremely drug resistant bacteria.

This is really, really bad news. The resistance is mediated by genetic information that is easily transmitted to other strains, even completely different species, of bacteria. It is entirely possible that this resistance factor may leap to common strains of very virulent bacteria causing most serious infections here in America, making them overnight impmervious to virtually all antibiotics.

80 years ago, my grandfather began practicing pediatrics in the pre-antibiotic era. He once told me how diagnosing meningitis or a severe pneumonia was effectively a death sentence; all he could do was hold a child's hand as he or she died. When Penicillin arrived after 1941, suddenly he could cure these children. It was like magic.

My entire career to date has been in the era of antibiotics.

But I can see that in the coming years, I may be practicing in the post-antibiotic era. An era in medicine when antibiotics are largely worthless, and we're back to quaranteens and hand-holding.

Originally posted to Ralphdog on Wed Aug 11, 2010 at 09:59 AM PDT.

Poll

Last time I took antibiotics was:

4%4 votes
2%2 votes
10%9 votes
37%34 votes
43%39 votes
2%2 votes

| 90 votes | Vote | Results

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Comment Preferences

  •  Scary, but important! (12+ / 0-)

    Here in Germany it's a mixed bag. My personal experience has been that doctors are hesitant to prescribe antibiotics. And many people I know are reluctant to take them.

    As the mother of a child with a congenital heart defect which required open heart surgery, I never forget the vulnerability of little patients with lowered defenses and increased exposure to nasty bugs during long hospital stays - it's scary as hell.

    http://www.storyofstuff.com/ When it gets harder to love, love harder! - Van Jones

    by bluesheep on Wed Aug 11, 2010 at 10:06:00 AM PDT

  •  "quarantines" (12+ / 0-)

    What I don't understand is why people are so terrified of vaccines (so much so preventable diseases are seeing a comeback) and yet have such an unwavering faith in antibiotics.  

    C'mon people!  You will get over your cold.  Pertussis, mumps, and rubella can be life-threatening illnesses.

    FWIW, drug-resistant tuberculosis is my personal bugbear.

    "Right wing freak machine" General Wes Clark

    by Tracker on Wed Aug 11, 2010 at 10:11:47 AM PDT

  •  I am on immune system supression medication (9+ / 0-)

    Remicade
    Antibiotics are a life saver for me. Last year a cold turned into bacterial pneumonia in three days. No immune system means stay away from sick people!

    I am very cautious. It is a calculated risk. Without the medication I am disabled. With it I can walk and work and provide income and health insurance for my family.

    These new bugs scare the hell  out of me, and I am certain one would kill me. Calculated risk, as I said.  

    I've got an unfinished short story about Schrodinger's Dog; it was mostly moaning about all the attention the cat was getting~Terry Pratchett

    by debbieleft on Wed Aug 11, 2010 at 10:19:17 AM PDT

  •  In 2003, I had a problematic and scary (2+ / 0-)
    Recommended by:
    NY brit expat, QuestionAuthority

    infection in my outer ear canal (outside the ear drum), likely caused by my use of earplugs at night. I woke up one morning with the ear unaccountably sore. "Slept on it wrong," I thought. Over the course of 4 days, the problem worsened to where the ear was throbbing, full-time, and swelled to the point where I looked on one side like Alfred E. Newman on the front of Mad Magazine. It was all just too weird and too creepy. So, I went to the doctor and got on antibiotics and painkiller (paid for out-of-pocket). Within a day or so, whatever-it-was in my ear canal ruptured, and started to exude pus. Lots and lots of it. I was trickling for hours, in fact. And the ear healed. I could sleep on that side for the first time in days.

    Stuff like this is just gonna keep getting more common, is the point.

    Thanks for the diary.

  •  I've mentioned this before (14+ / 0-)

    When I was in high school in the late 60's I had an after school job as a lab assistant to a Molecular Biologist studying "Infectious Drug Resistance": The ability of a resistant bacterium to pass the resistance to another bacterium via the exchange of a small piece of genetic material called a plasmid. Once this happens, the resistance becomes part of the genetic makeup of the second bacterium, and so is passed on every time it multiplies.

    At that time -- and we're talking 40+ years ago -- it was obvious to everyone in the field that over-utilization of antibiotics, in particular the addition of antibiotics to animal feed, was a disaster waiting to happen.

    Of course no one listened, and so here we are...

    •  Sadly it's all in the financial incentives. (8+ / 0-)

      Capitalism is a great way to find the correct price for a bushel of wheat or a pound of nails.

      It's a truly horrible way to determine the proper utilization of potent antibiotics.

      •  doubly true for antibiotics (2+ / 0-)
        Recommended by:
        elfling, Ralphdog

        If you are going to lose your patent on an antibiotic in a few years anyway, there's every financial incentive to sell as much as possible ASAP, and little financial incentive to keep it useful after it goes generic. For a long time there was little financial incentive to come up with new antibiotics to treat superbugs either: such drugs  would be binned as drugs of last resort (last and least likely to be prescribed = low sales volume).

  •  was raised by a mother who only approved of (4+ / 0-)

    antibiotics in cases when they were truly necessary.  i've always been resistant to them and the last time i can remember using them was back in '07 when i had an abscess.

  •  Timely post (4+ / 0-)

    I just got this in

    (UKPA) – 8 hours ago

    International travel and medical tourism helped the spread of drug-resistant bacteria that could lead to the end of antibiotics, scientists have warned.

    A new gene, NDM-1, emerged which allows bacteria to be highly resistant to almost all antibiotics, the scientists said.

    NDM-1 spread in India, Pakistan, and Bangladesh. But it was also found in 37 patients from the UK, who travelled to India or Pakistan for medical procedures including cosmetic surgery, according to an article published in The Lancet.

    . . .

    The gene was mostly found in E Coli, a common cause of urinary tract infections and pneumonia, which is highly resistant to antibiotics. The authors said it could be easily copied and transferred between different bacteria, suggesting "an alarming potential to spread and diversify among bacterial populations".

    . . .

    "This is important because carbapenems were often the last 'good' antibiotics active against bacteria that already were resistant to more standard drugs. We have now also identified bacteria with this type of resistance - NDM - in around 50 patients in the UK.

    Copyright © 2010 The Press Association. All rights reserved.

    If you think you're too small to be effective, you've never been in the dark with a mosquito.

    by marykk on Wed Aug 11, 2010 at 10:53:22 AM PDT

  •  Your poll does not include (6+ / 0-)

    'many decades' or 'never'.

    My answer: 34 years ago, my hand got infected after an injury. That was the last time I had antibiotics.

    Pissing away our advantage over the bugs is just nuts.

  •  Last year. (0+ / 0-)

    I had a kidney infection and my doctor, an excellent one, prescribed a combination of medications potent enough to down a horse. Unfortunately, we started chatting (the late doctor was a family friend) and he forgot to tell me not to take them before driving (I was planning to go to our weekend house because I'm grouchy when I'm ill). Fortunately, I didn't.

    When I took them, the room started spinning in short order. Had I been on the highway... Anyway, after that first dose the side effects went away, but it was one bad trip.

    Iuris praecepta sunt haec: Honeste vivere, alterum non laedere, suum cuique tribuere. - Ulpian, Digestae 1, 3

    by Dauphin on Wed Aug 11, 2010 at 11:45:12 AM PDT

  •  Incredibly timely, I was watching the news (2+ / 0-)

    earlier and heard this about a new superbug in the UK.
    I actually blinked when I saw your diary which I have tipped and rec'd:

    http://www.bbc.co.uk/...

    No society can surely be flourishing and happy, of which the far greater part of the members are poor and miserable (Adam Smith, 1776, I, p. 96).

    by NY brit expat on Wed Aug 11, 2010 at 12:04:24 PM PDT

  •  As someone who has had a resistant (3+ / 0-)

    C. Diff infection, it's important that people realize that the risks of antibiotics aren't just theoretical and population-based, but that there are real risks to the patient him/herself.

    When people were taking Cipro like water because they were freaking out about anthrax, I was just dumbfounded by how little respect they had for these drugs.

    Fry, don't be a hero! It's not covered by our health plan!

    by elfling on Wed Aug 11, 2010 at 12:14:28 PM PDT

    •  Just a year ago (0+ / 0-)

      My mom died from a C. diff infection. Healthy 85 years old needed antibiotic for a UTI 6 weeks of hell later she died. Found out the long term care facility she lived in accepted residents with active c. diff infections but did not tell the staff or train them because they didn't want the staff upset. Just gave them hand gel and told them to use it between residents. Even when she had symptoms the RNs in charge   did nothing. BTW hand gel does nothing against c. diff only hot water and soap. C diff is an opportunistic bacteria and can take a spore form. It can wait months on clothing or hard surfaces and spring to life when given opportunity. It is also one of the bacteriums that reside in your intestines. There is no problem until you take antibiotics that kill off all the rest them it takes over. I have found this link "http://www.cdiffdiscuss.org/phpBB3" to have lots of good information. No one should take an antibiotic or enter the hospital without reading about it and MRSA.

      •  C. diff is back, big time. So sorry for your loss (0+ / 0-)

        I was head of infection control about 15 years ago, when nosocomial spread (transmission within the hospital or nursing home) was a real problem. We solved it quickly with a rigorous regimen of training for the housekeeping staff, who scoured and scrubbed patient rooms from floor to ceiling, and aggressive policing of handwashing for staff.

        We had a long stretch of quiet...but over the last year C. diff is back with a vengeance, and it has become quite widespread out in the community among healthy people. It's also a very different bug now; it's a lot more aggressive, tougher to get rid of and more likely to cause a life-threatening infection.

        This is our future.

        •  It kicked my butt (0+ / 0-)

          I was in the hospital for 4 days with dangerously low potassium levels and a fever above 104. I was 31 and with a new baby.

          Even after I was released, I was so sick and weak that for a couple of months I could not sit in a noisy room (like a restaurant), or in a bouncy car without experiencing intense physical pain.

          It took about a year to recover. Oh, and it also made me uninsurable.

          Fry, don't be a hero! It's not covered by our health plan!

          by elfling on Wed Aug 11, 2010 at 10:28:08 PM PDT

          [ Parent ]

  •  I fear this more than global warming, nuclear (1+ / 0-)
    Recommended by:
    Flaming Liberal for Jesus

    war and losing the House in November -- combined.

    And, it looks like there isn't anything to be done about it.

    •  Ironically, they're related. (1+ / 0-)
      Recommended by:
      Flaming Liberal for Jesus

      With global warming, we're starting to see more 'tropical' organisms showing up here in the States. Dengue fever has returned to Florida with multiple confirmed cases after decades without one. No doubt in my mind, other diseases associated with tropical climates, like Malaria, are going to march northward into the United States as things get hotter and more disorganized.

  •  And, help is not coming soon. (0+ / 0-)

    The requirements for testing antimicrobials during clinical trials for efficacy as well as their licensing has engendered hot and heavy arguments between the FDA and Industry.

    Previously one only needed to demonstrate equivalence for efficacy, the FDA is demanding demonstration for superiority and so results that were previously considered as Acceptable Quality are being assessed for Rejectable Quality.  The number of samples (patients in the test groups) to overcome such a hurdle can increase by two to three orders of magnitude.  The tremendous expense is creating a de-facto barrier for new antibiotic development.

    Yes, I expect the FDA to demand good science-based development, but that must also consider the costs for commercialization.  It is hard to find something that workd in-vitro, even harder to run the gauntlet of IND clinicals, and that is not even a guarantee that after commercialization the product will have uniform efficacy and safety in the general population.  There has got to be some better way that promotes development and minimizes the errors that will occur.  But, unless the impass is broken quickly the pipeline for new licensed antibiotics is going to dry up.

    Distrust of authority should be the first civic duty. - Norman Douglas

    by Fossil on Wed Aug 11, 2010 at 12:44:07 PM PDT

    •  This applies mostly to "me too" drugs. (0+ / 0-)

      For a long time the most profitable strategy for a pharmaceutical company has been to 'clone' another ocmpany's spiffy new wonder drug, producing a very similar competitor offering no therapeautic advantages at all, yet soaking up lots of FDA manpower to review for approval.

      I don't have a problem with the FDA demanding that a new drug be better than existing cheap generics, rather than "no worse".

      •  Not really (0+ / 0-)

        If you have seen the arguments between innovators and CDER (Center for Drug Evaluation and Research) the "me too" impression is provided if a proposed antimicrobial is tested within a population having current levels of resistance.  The point at which improved efficacy would be determined with respect to a population of increasingly resistant infections would leave a significant gap (years) between phase III INDs and commercialization.  This precludes predictive development.  Further, do you understand the difference between sampling for acceptable and rejectable quality?  The cost of entry is high.

        All of this is having a chilling effect for the development of innovative antimicrobials.

        Distrust of authority should be the first civic duty. - Norman Douglas

        by Fossil on Wed Aug 11, 2010 at 04:02:39 PM PDT

        [ Parent ]

  •  there are natural anitbiotics (0+ / 0-)

    oil of Oregano, bioavailable silver, MMS (chlorine dioxide), Chinese herbal preparations, jackass bitters, grapefruit seed extract, and more. There are preparations available that are very effective - Resistant Microbes by Herbs of Light - proven in war when pharma antibiotics weren't working, Chuan Xin Lian, for example. I've treated Lyme and staph myself. Also teasel root for Lyme. We should all reduce the opportunity for infection by cleaning up our "terrain" - conventional naturopathy. Get rid of the waste matter in your body. Stop using sugar; stop consuming flesh foods; forget the refined white stuff; if it isn't food, don't eat it; become whole. We are human; our destiny is divine; we will overcome.

    •  Gotta disagree there; this is voodoo territory. (1+ / 0-)
      Recommended by:
      The Werewolf Prophet

      Certainly there are some herbal remedies with genuine pharmaceutical or medical effects. But they should be held to exactly the same standards of safety and effectiveness as prescription medications. That is simply not the case for what you're advocating. These things are unregulated, un-standardized, with huge variations in actual contents and purity.

      Our craven Congressional "leaders", especially the despicable Orin Hatch (who has received millions from Vitamin and supplement makers) explicitly exempted supplements and herbals from FDA authority, until they start killing so many people it can't be ignored anymore, like Ephedra. Even then it takes years for any action because of the handcuffs applied to the FDA.

      Consumption of bioavailable silver is, in a word, poison.

      •  you are hysterical (0+ / 0-)

        Some of these have been in use for thousands of years. Ever since drugs have been patentable, drug companies have fought tooth and nail against the use of natural  medicines. Ephedra is just one example, it hardly makes a case. I used to use it for sinus congestion. It's the best; now I can't it. Water will kill you if you don't take it right! The body has metabolic pathways to handle most natural substances. Pharmaceuticals kill more people than all illegal substances combined. Synthetic drugs are all toxic. Most death by kidney failure is caused by acetaminophen - Tylenol! If it isn't patentable, you can't get rich on it. You are arguing against nature to protect corporate predators. I agree there should be safety standards, but a rational discussion is not possible with Pharma at - in fact controlling, the table.

    •  While I am not categorically opposed to ... (0+ / 0-)

      ... every alternative healing method, I'm vigorously opposed to those which have no foundation whatsoever in fact or experience, such as colloidal silver.

      I like your Christ. I do not like your Christians. They are so unlike your Christ.
      ~ Mohandas K. Gandhi

      by The Werewolf Prophet on Wed Aug 11, 2010 at 02:06:28 PM PDT

      [ Parent ]

  •  I am allergic to penicillin and sulfa drugs (0+ / 0-)

    and don't take antibiotic unless I am deathly ill to avoid my system becoming immune to them.  The only thing that really works for me is Cipro,  It scares the living shit out of me too...

    It is horrifying that we have to fight our own government to save the environment. Ansel Adams -6.5 -6.75

    by Statusquomustgo on Wed Aug 11, 2010 at 02:08:17 PM PDT

    •  Your system won't become immune. (1+ / 0-)
      Recommended by:
      Statusquomustgo

      it's the bacteria living on you that develop immunity.

      Antibiotics and bacteria interact in a way that perfectly demonstrates evolution, right before our very eyes.

      Take an antibiotic, and it will exterminate the 99.99% of bacteria on/in your person that are susceptible. That's enough to give your immune system the upper hand, ending the infection, in the vast majority of cases. In the process, however, that antibiotic applies a selection pressure. The 0.001% of organisms that are less susceptible (or frankly resistant) are the progenitors of your future normal flora. Now you're carrying some resistant bugs.

      Over time, away from that antibiotic selection pressure, your normal flora will gradually revert to more sensitive critters, because there's often a small fitness penalty for bacteria that are drug resistant. There was an elegant study from Finland a couple of years ago, demonstrating that restricting the use of macrolide (erythromycin-type) antibiotics resulted in a steady rise in the percentage of bacteria in the community that were once again susceptible to these drugs.

      The problem is that we're constantly using more antibiotics throughout the biopshere, form animal feed to therapeautic use, applying ever more selection pressure that's pushing bacteria to become more resistant.

      •  thanks for the explanation... I am not a medical (0+ / 0-)

        professional, just going by what a doctor told me a few years ago.  I hope and pray they take the antibiotics out of the animal feed soon.  It's one of the reasons I am not eating as much meat these days.

        It is horrifying that we have to fight our own government to save the environment. Ansel Adams -6.5 -6.75

        by Statusquomustgo on Wed Aug 11, 2010 at 03:01:02 PM PDT

        [ Parent ]

  •  Question for the Medical Geeks ... (0+ / 0-)

    How effective are topical iodine preparations against bacterial spores (like C. diff) & viruses?

    I like your Christ. I do not like your Christians. They are so unlike your Christ.
    ~ Mohandas K. Gandhi

    by The Werewolf Prophet on Wed Aug 11, 2010 at 02:14:10 PM PDT

    •  They're quite effective with some qualifications. (0+ / 0-)
      1. They become much more effective as they dry; the typical yellow/purple Povidone 'paint job' in the operating room won't work nearly as well if it's not given enough time to dry out.
      1. Most viruses are actually very fragile. The vast majority become inactive within minutes simply by drying out and reaching room temperature.That's why direct contact is required for transmission in the vast majority. Hep B is an exception, and it can remain viable in a blood splash for many hours.
      1. There is surprisingly little data about cleansers/disinfectants for Clostridium difficile; hypochlorite-containing cleaning solutions appear to be the most effective, but you can't put them on people. Soap and water are still the standard.
      1. Pseudomonas aeruginosa has actually been found growing in betadyne Iodine solution! That'll give you nightmares. Oddly enough, Pseudomonas has become a much less problematic bug over the last two decades, compared with newer villains like MRSA or VRE.

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