Keeping the world safe from antibiotics

The Pediatric Insider

© 2015 Roy Benaroch, MD

Intellectually, we know it’s true. Antibiotics are becoming less able to protect us from infections, and it’s our fault. Exposing microorganisms to antibiotics “selects out” the ones best able to survive. Over generations of life the germs that are left become craftier and hardier – and they can even share their genetic material with other unrelated microorganisms, giving nearby pathogens a protective power boost.

This is no surprise. We’ve known this since the first early antibiotics started to lose their power in the 1950’s. But the hope had been that we would keep inventing new antibiotics, so we’d stay ahead of the evolutionary learning curve. We think we’re clever. But we’re now losing the war. The pipeline of genuinely new antibiotics has been running dry, and those persistent and patient bugs are quickly catching up.

To make matters worse, we continue to shoot ourselves in the foot with policies and attitudes that seem designed to make sure the bacteria win:

 

#1: We pump farm animals full of antibiotics they don’t even need

In the US, 80% of the total antibiotics sold go into farm animals, literally about 32.2 million pounds each year. The vast majority of this, about 94%, is added to animal feed or water to be given to healthy, non-infected animals. We’re not talking about animals that are sick with infections, examined by a vet, and prescribed a therapeutic course of medication to help them get healthy—we’re talking about tons of antibiotics, sold legally without a prescription or a veterinarian’s input, directly to farming companies to give to all of their animals. This is entirely legal, and is thought to promote faster growth of animals or allow them to be raised with less feed.

Antibiotics given to animals unquestionably changes the resistance pattern of bacteria on farms, in consumed meat, and in people. And active antimicrobial agents can be found in runoff and wastewater from farms, and in groundwater nearby. These are often the same antibiotics used to treat people with infections.

This problem has a relatively simple fix: we should ban the use of non-therapeutic antimicrobials for agricultural use. Antibiotics should only be given to animals who have infections, under the supervision of a veterinarian, similar to how antibiotics are used in people in the USA. Though, even then there’s still far too much antibiotic overuse, in part because….

 

#2: We expect antibiotics for viral infections

Ask any practicing physician—it’s a daily struggle. Our sloppy prescribing has led to an expectation from many patients that an antibiotic be given for almost any ailment. People think “bronchitis” needs antibiotics, and sore throats, and fevers, and upper respiratory infections. It’s quicker to just write a prescription than to fight about it. And if we don’t give them antibiotics, our “satisfaction scores” will suffer. (Which often means we’ll lose our bonus, or even lose our jobs.)

The fix, this time, has to come from a few different angles:

  • Patient and physician education should stress when antibiotics are and are not helpful.
  • Physicians need to be protected from patient complaints when their recommendations are appropriate.
  • At the same time, physicians need to have the time to evaluate and explain and develop rapport. If we’re expected to prescribe fewer antibiotics, we need the time to explain why.
  • Patients should speak up, too. Physicians often assume that patients “want” antibiotics—but, in truth, many really just want a good careful exam and recommendations. Start your visit with “Doc, I don’t really want antibiotics unless you really think they’re help.” Watch how that statement changes the tone of the encounter. Make yourself an ally in the decisions about your own medical care.

I don’t think these fixes are very difficult, but they’re both going to take some changes in the minds of regulators, doctors, and patients. We can do this, together, but time’s running short. We can still beat the bugs, but it’s not going to be quite as easy as we expected.

 

Alexander Fleming

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