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American Medical Practices: Providing the Quick-Fix or the Long Term Solution? | October 2014 Issue
what we don't want to catch
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Most of us have had an experience of going to the doctor’s office, describing symptoms that are typical of some type of infection, having the doctor examine us and then prescribe us an antibiotic. We go home, take our pills, and continue on with our lives. Most of us have probably also had an experience of going to a busy clinic with patients lining up out the door, coughing a bit in front of the doctor, and begging for relief. The physician quickly writes a prescription, assuming it’s a chest infection, and we again go on our way. Problem is, we don’t feel better this time, and we find ourselves back at the doctor’s office with symptoms consistent with a virus—something an antibiotic is incapable of curing.
It is the latter case which is now a huge concern for the medical field. What you might have viewed as a small mistake on your doctor’s part has actually been deemed by the Center for Disease Control as “the single most important factor leading to antibiotic resistance around the world,” when considered in the aggregate (Antibiotic, 11). Unfortunately, this is a case where the small mistakes add up. According to a study conducted by the CDC released in April 2014, among 19 of the acute care hospitals reporting antibiotic use in 266 patient care facilities that were monitored in the study, it was found that some hospitals prescribed up to three times more antibiotics than their counterparts, speaking to the great variance in use, and potential overuse, of antibiotics in American clinics and hospitals. More troubling is the finding that 40 out of the 111 patients in 36 hospitals who were treated for urinary tract infections with antibiotics were not properly evaluated prior to being prescribed those drugs (Vital). Moreover, the CDC now estimates that up to fifty percent of all antibiotics prescribed are prescribed unnecessarily (Vital). It appears that American doctors are turning to the supposedly reliable quick fix too quickly when it comes to curing their patients.
When prescribed correctly, antibiotics can treat bacterial infections—anything from acne to pneumonia, if you’re dealing with a non-resistant strains. In fact, after the first antibiotic, penicillin, was made available to the public in the 1940’s, it was pronounced a “wonder drug” for its ability to cure infections from war wounds and combat the effects of sexually transmitted diseases like syphilis (Bud). Over the next 70 years, antibiotics tetracylcine, erythromycin, methcillin, gentamicin, vancomycin, imipenem, ceftazidime, levofloxacin, linezolid, daptomycin, and ceftarolin were all developed and made available for the public’s use, and antibiotics became the drug most frequently prescribed by doctors (Antibiotic, 27). This increase in use marked a shift in the focus of medicine from prevention to treatment as the infections that for so long were a deadly threat could now be quickly and effectively cured.
However, the “wonder drug” label has led to massive overprescribing, and often inaccurate prescribing, of these drugs, as is evident from the recent CDC study. Why is this a problem? While mis-prescribing antibiotics for a single patient may not directly harm him, the huge and unnecessary increase in antibiotic use has contributed to the phenomenon of antibiotic resistance in bacteria. Bacteria, like all living things, evolve according to the principal of natural selection. They build up resistance to antibiotics by genetic mutation—spontaneous changes in their genetic material-- and they share that resistance to other bacteria through the transfer of their genetic material in a process known as conjugation (Alliance). Once resistant, these bacteria can withstand the antibiotics that other bacteria naturally produce—and the fittest survive.
So, as you can see, bacterial resistance to antibiotics has always been inevitable; it occurs naturally within bacteria over time, and the use of antibiotics by humans to combat infection will not ultimately change that. However, we have sped up the timeline dramatically by adding a massive selective pressure that results from human use of antibiotics to an existing selective pressure produced by antibiotic-secreting bacteria that is minor in comparison (Alliance). Every time we inject a person with antibiotics, we essentially thin the pack of bacteria and eliminate competition for the resistance strains. Multiply this times the hundreds of thousands of people to whom we prescribe antibiotics each year, and the problem is evident.
The CDC estimates that among Americans, antibiotic-resistant bacteria infects more than two million people each year and kills 23,000 (Antibiotic, 6). In particular, resistance to antibacterial drugs used to treat urinary tract infections caused by E. coli and resistance to the drugs used to treat Staphylococcus auras infections are widespread. There is also emerging resistance in tuberculosis in this nation and across the globe (WHO). These are just a few of the infections that now threaten to claim lives as resistant strains are spreading, not only on a national scale, but also on a global one.
However, researchers at MIT might have found a way to fight these resistant strains of bacteria. In a study recently published in the journal Nature Biotechnology, a team led by Timothy Lu described a mechanism they have developed for splitting bacteria’s genes at locations that code for antibiotic resistance, rendering them again susceptible (Popular Science). They use a protein called Cas9 to cut the genes at these specific locations, and they deliver the protein to bacterial cells using phages—viruses that attack bacteria. In addition, they engineer these bacteria to carry their new antibiotic-susceptible genes in their plasmids, such that they can be passed on to other bacteria in horizontal gene transfer. The success of this study has been limited to test tubes and waxworms, though Lu and his team are soon extending testing to mice and then plan to begin human trials (Popular Science).
While their research offers a solution to the problem of bacterial resistance, and potentially bacterial infection altogether, Lu admits that their method might not be effective for acute infection because the slicing proteins take time to work (Popular Science). Moreover, even if the human trials are successful, their solution is still likely several years away from being available for widespread public use. Thus, even with this promising solution on the horizon, there is still incentive for doctors and patients alike to combat the threat of bacterial infection today and reverse the shift we’ve seen in medical focus from treatment to prevention. Doctors need to place as much importance on keeping infection from spreading as they do in treating patients, especially in hospital settings where bacteria can easily infect patients with weakened immune systems. In addition, doctors should document the cases they see and utilize the CDC’s National Healthcare Safety Network (NHSN) (Vital). This network is a means of electronically cataloguing infections, which the CDC can then analyze in order to track the spread of bacterial infections on a national scale. Sharing this type of data can help us develop better practices for containing outbreaks and reducing the spread of resistant strains; it might also help researchers like Lu modify and update gene recombination therapies as bacteria mutate and adapt to these new advances in treatment. Even in the next phase of fighting bacteria, we should maintain a focus on prevention. Lu himself said in an interview with Loren Grush for Popular Science magazine, “Instead of taking an antibiotic when you’re sick, you might take these probiotics when you’re healthy, removing bad bacteria before you get ill” (Popular Science). The most success we will see in fighting off illness will always be by trying to ensure that we don’t become sick in the first place, regardless of the treatment options available.
It is the latter case which is now a huge concern for the medical field. What you might have viewed as a small mistake on your doctor’s part has actually been deemed by the Center for Disease Control as “the single most important factor leading to antibiotic resistance around the world,” when considered in the aggregate (Antibiotic, 11). Unfortunately, this is a case where the small mistakes add up. According to a study conducted by the CDC released in April 2014, among 19 of the acute care hospitals reporting antibiotic use in 266 patient care facilities that were monitored in the study, it was found that some hospitals prescribed up to three times more antibiotics than their counterparts, speaking to the great variance in use, and potential overuse, of antibiotics in American clinics and hospitals. More troubling is the finding that 40 out of the 111 patients in 36 hospitals who were treated for urinary tract infections with antibiotics were not properly evaluated prior to being prescribed those drugs (Vital). Moreover, the CDC now estimates that up to fifty percent of all antibiotics prescribed are prescribed unnecessarily (Vital). It appears that American doctors are turning to the supposedly reliable quick fix too quickly when it comes to curing their patients.
When prescribed correctly, antibiotics can treat bacterial infections—anything from acne to pneumonia, if you’re dealing with a non-resistant strains. In fact, after the first antibiotic, penicillin, was made available to the public in the 1940’s, it was pronounced a “wonder drug” for its ability to cure infections from war wounds and combat the effects of sexually transmitted diseases like syphilis (Bud). Over the next 70 years, antibiotics tetracylcine, erythromycin, methcillin, gentamicin, vancomycin, imipenem, ceftazidime, levofloxacin, linezolid, daptomycin, and ceftarolin were all developed and made available for the public’s use, and antibiotics became the drug most frequently prescribed by doctors (Antibiotic, 27). This increase in use marked a shift in the focus of medicine from prevention to treatment as the infections that for so long were a deadly threat could now be quickly and effectively cured.
However, the “wonder drug” label has led to massive overprescribing, and often inaccurate prescribing, of these drugs, as is evident from the recent CDC study. Why is this a problem? While mis-prescribing antibiotics for a single patient may not directly harm him, the huge and unnecessary increase in antibiotic use has contributed to the phenomenon of antibiotic resistance in bacteria. Bacteria, like all living things, evolve according to the principal of natural selection. They build up resistance to antibiotics by genetic mutation—spontaneous changes in their genetic material-- and they share that resistance to other bacteria through the transfer of their genetic material in a process known as conjugation (Alliance). Once resistant, these bacteria can withstand the antibiotics that other bacteria naturally produce—and the fittest survive.
So, as you can see, bacterial resistance to antibiotics has always been inevitable; it occurs naturally within bacteria over time, and the use of antibiotics by humans to combat infection will not ultimately change that. However, we have sped up the timeline dramatically by adding a massive selective pressure that results from human use of antibiotics to an existing selective pressure produced by antibiotic-secreting bacteria that is minor in comparison (Alliance). Every time we inject a person with antibiotics, we essentially thin the pack of bacteria and eliminate competition for the resistance strains. Multiply this times the hundreds of thousands of people to whom we prescribe antibiotics each year, and the problem is evident.
The CDC estimates that among Americans, antibiotic-resistant bacteria infects more than two million people each year and kills 23,000 (Antibiotic, 6). In particular, resistance to antibacterial drugs used to treat urinary tract infections caused by E. coli and resistance to the drugs used to treat Staphylococcus auras infections are widespread. There is also emerging resistance in tuberculosis in this nation and across the globe (WHO). These are just a few of the infections that now threaten to claim lives as resistant strains are spreading, not only on a national scale, but also on a global one.
However, researchers at MIT might have found a way to fight these resistant strains of bacteria. In a study recently published in the journal Nature Biotechnology, a team led by Timothy Lu described a mechanism they have developed for splitting bacteria’s genes at locations that code for antibiotic resistance, rendering them again susceptible (Popular Science). They use a protein called Cas9 to cut the genes at these specific locations, and they deliver the protein to bacterial cells using phages—viruses that attack bacteria. In addition, they engineer these bacteria to carry their new antibiotic-susceptible genes in their plasmids, such that they can be passed on to other bacteria in horizontal gene transfer. The success of this study has been limited to test tubes and waxworms, though Lu and his team are soon extending testing to mice and then plan to begin human trials (Popular Science).
While their research offers a solution to the problem of bacterial resistance, and potentially bacterial infection altogether, Lu admits that their method might not be effective for acute infection because the slicing proteins take time to work (Popular Science). Moreover, even if the human trials are successful, their solution is still likely several years away from being available for widespread public use. Thus, even with this promising solution on the horizon, there is still incentive for doctors and patients alike to combat the threat of bacterial infection today and reverse the shift we’ve seen in medical focus from treatment to prevention. Doctors need to place as much importance on keeping infection from spreading as they do in treating patients, especially in hospital settings where bacteria can easily infect patients with weakened immune systems. In addition, doctors should document the cases they see and utilize the CDC’s National Healthcare Safety Network (NHSN) (Vital). This network is a means of electronically cataloguing infections, which the CDC can then analyze in order to track the spread of bacterial infections on a national scale. Sharing this type of data can help us develop better practices for containing outbreaks and reducing the spread of resistant strains; it might also help researchers like Lu modify and update gene recombination therapies as bacteria mutate and adapt to these new advances in treatment. Even in the next phase of fighting bacteria, we should maintain a focus on prevention. Lu himself said in an interview with Loren Grush for Popular Science magazine, “Instead of taking an antibiotic when you’re sick, you might take these probiotics when you’re healthy, removing bad bacteria before you get ill” (Popular Science). The most success we will see in fighting off illness will always be by trying to ensure that we don’t become sick in the first place, regardless of the treatment options available.
Alliance for Prudent Use of Antibiotics. “General Background: About Antibiotic Resistance.” Accessed October 19, 2014. http://www.tufts.edu/med/apua/about_issue/about_antibioticres.shtml.
Bud, Robert. “Antibiotics: The Epitome of a Wonder Drug.” BMJ 334 (2007): 6. Accessed October 29, 2014. doi: http://dx.doi.org/10.1136/bmj.39021.640255.94.
CDC. Antibiotic Resistant Threats in the United States, 2013. Atlanta, GA: US Department of Health and Human Services, 2013.
CDC. Vital Signs: Improving Antibiotic Use Among Hospitalized Patients. Atlanta, GA: MMWR, CDC; 2014.
Popular Science. “Editing The Genes Of Superbugs To Turn Off Antibiotic Resistance.” Accessed October 19, 2014. http://www.popsci.com/article/science/editing-genes-superbugs-turn-antibiotic-resistance?dom=PSC&loc=recent&lnk=1&con=editing-the-genes-of-superbugs-to-turn-off-antibiotic-resistance.
WHO. “Antimicrobial Resistance.” Accessed October 19, 2014. http://www.who.int/mediacentre/factsheets/fs194/en/.
Bud, Robert. “Antibiotics: The Epitome of a Wonder Drug.” BMJ 334 (2007): 6. Accessed October 29, 2014. doi: http://dx.doi.org/10.1136/bmj.39021.640255.94.
CDC. Antibiotic Resistant Threats in the United States, 2013. Atlanta, GA: US Department of Health and Human Services, 2013.
CDC. Vital Signs: Improving Antibiotic Use Among Hospitalized Patients. Atlanta, GA: MMWR, CDC; 2014.
Popular Science. “Editing The Genes Of Superbugs To Turn Off Antibiotic Resistance.” Accessed October 19, 2014. http://www.popsci.com/article/science/editing-genes-superbugs-turn-antibiotic-resistance?dom=PSC&loc=recent&lnk=1&con=editing-the-genes-of-superbugs-to-turn-off-antibiotic-resistance.
WHO. “Antimicrobial Resistance.” Accessed October 19, 2014. http://www.who.int/mediacentre/factsheets/fs194/en/.
