Even if this scenario doesn’t describe your life today, you are no doubt familiar with the feeling: your child is sick and uncomfortable, has a fever, can’t go to school or day care, and needs to go to the doctor to get some antibiotics to get well. Or so we think.
Unfortunately, our mastery of the microbial world is less complete than even the most common of our behaviors would suggest, and more and more of this is playing out to our extreme disadvantage. Our weapons aren’t working far too much of the time. While incidents of antibiotic misuse may be harmless to us as individuals in the short term, when we add them all up, they literally tilt the world in the wrong direction.
If we are, truly, to master the tiniest of organisms so they don’t kill us, we first have to take stock of how they operate in the environments we’ve created. If that means war, then we can’t rely on only the conventions of the past. Along with developing more sophisticated pharmaceutical weapons and refining our diagnostic intelligence gathering information, we also have to learn to support our allies and change the conditions that breed our attackers.
According to researchers at the Centers for Disease Control, about one third, or 50 million of the 150 million annual outpatient prescriptions for antibiotics are unneeded. The harm in using these antibiotics is that they create the conditions for the emergence of strains of bacteria that are drug-resistant. When medicines attack disease-causing bacteria, they also hit “collateral” targets, eliminating harmless but drug-susceptible bacteria that would otherwise create some sort of natural boundaries for the pathogens. Instead, the resistant pathogens persevere, as do the bystanders that aren’t affected by the drug. And even these bystanders, while harmless themselves, can pass along the traits of resistance to other pathogens.
If this sounds like a sci-fi war movie, it’s one that’s playing in a kindergarten or hospital near you. What we are facing is both a medical and a public health crisis. And it will take both medical and public health solutions to work our way out.
Diagnostic developments are key to winning at least the battles, and perhaps the war. Faster assessment of a causative pathogen and its resistance— whether by rapid latex test (page 1), improved susceptibility or “real-time” molecular methods (page 18)—means quicker administration of the correct antibiotic. This may not only save the life of the individual being treated, it also means more targeted antibiotic use and a shrinking reservoir of deadly-resistant bacteria.
The News Digest synopsis (page 8) of the first report on an outbreak of macrolide-resistant group A streptococcus to reach the U.S. provides a good example of how quickly resistance can spread to a wider community. It also points the way to methods that can reverse the trend. Physician knowledge of the prevalence of antibiotic resistance in a community is an important part of appropriately selecting a treatment. And, prescribing a broad spectrum antibiotic without testing the susceptibility of a pathogen can lead to treatment failure. Perhaps we in the U.S. may have felt immune to the erythromycin-resistance that spread through parts of Europe and Japan. Now, we can learn the lesson that it is not more, but rather more judicious use of antibiotics that will stop the uprising.
This may mean examining not only prescription medication, but some other aspects of our ordinary lives as well. Bacteria are everywhere, and as we struggle to control them everywhere, we create resistance that comes back to us when we are most vulnerable. Nearly half the antibiotics we manufacture in the U.S. are mixed into the feed we give to the animals that become our food. And though it might be tempting for that reason alone to put down your fork and pick up an apple, remember that we also spray antibiotics onto our fruit trees. While the apple may not fall far from the tree, the antibiotics are aerosolized and airborne. No, this is not a public health crisis, but there are available alternatives that can be encouraged in the interest of the long-term public health. So, wash your fruits and vegetables, but reserve the antimicrobial soap for the bad bacteria. As for the rest of the microbial world, maybe a little more live and let live thinking won’t kill us—unfortunately, if we continue to overprescribe antibiotics, even the best of our best will not be able to stop the bugs that can.
The National Center for Infectious Disease maintains an antimicrobial resistance home page, accessed at www.cdc.gov/drugresistance. A new addition to the site details the Campaign to Prevent Antimicrobial Resistance in Healthcare Settings, launched, according to the CDC, because each year nearly 2 million patients in the U.S. get an infection in a hospital, and 90,000 die as a result. More than 70 percent of the bacteria that cause hospital-acquired infections are resistant to at least one of the drugs most commonly used to treat them, making hospital stays longer and necessitating treatment with second- or third-choice drugs that may be less effective, more toxic, and/or more expensive. To see the 12-step program to prevent resistance, headlined as tools for clinicians but crucial for laboratorians as well, click on the link from the CDC Division of Healthcare Quality Promotion.
Antibiotic resistance is not only a local hospital or community problem—it is a growing global threat. But we also have the research tools, diagnostic achievements and epidemiological capabilities to reverse resistance, and protect the fragile ecosystem of our microbial world. Now, we have to put the sum of our knowledge into our medical and public health practice—and into our own thinking.
In the April 2002 issue of Clinical Lab Products, our Disease Management feature on cardiac markers incorrectly identified Dr. Robert Jesse as Robert Cook. Our apologies to Dr. Jesse, and also for any confusion this may have caused.