In the twentieth century, one of the greatest weapons in the war against infectious diseases was created: antibiotics. With this powerful scythe of medicine, bacteria were decimated and humanity slowly gained control over the battlefield. Bacteria lost its killing power and humans lived to older ages. In fact, bacteria’s virulent characteristics were suppressed and they could no longer achieve their intended purpose: causing lethal illness. While it appeared that humanity would wipe out its microscopic enemy, they grew lax in their battle.
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Seeing the healing power of these medications, people assumed that it would be good to use them for any illness, not just those that they could actually cure. People wanted a simple pill to cure their ill, and many doctors provided it to make them happy. What was not expected was that antibiotics would use this laziness to develop resistance against this lethal weapon. And as they grew stronger deflecting the arrows aimed at them, superbugs arose. Humans are now confronted with infections that they’ve never seen before, and many bacterial infections that used to be cured with single antibiotics are no longer succumbing to their effects.
In the US every year, the Pew Charitable Trusts estimate that doctors prescribe approximately 7.7 million pounds of antibiotics. In 2013, the Mayo clinic estimated that 17% of all prescriptions were antibiotics. One superbug, methicillin-resistance staphylococcus aureus (MRSA) is now listed as one of the 12 most dangerous superbugs by the World Health Organization (WHO). The WHO estimates that at least 700,000 deaths annually are due to antibiotic resistance. They predict this number to rise to 10 million by the year of 2050. Approximately 1 out of every 25 patients in a healthcare facility will develop an infection and about half of these will exhibit some resistance.
How does antibiotic resistance happen?
Bacteria, like other organisms possess DNA which can change or mutate. When various agents from the outside world interact with these agents, survival of the fittest ensues and only the strongest organisms survive. When humans use antibiotics to kill these bacteria, they mutate their DNA in order to survive. The surviving bacteria pass on their genes through a process called conjugation to future generations of bacteria. Additionally, these bacteria can share genes across bacterial species. There are trillions of different types of bacteria existing in the human body and resistance genes can be spread through the different species of bacteria. In fact, even one course of antibiotics in a lifetime can lead to the spread of resistant bacteria throughout the body. As we use more antibiotics, this gives bacteria more chances to mutate DNA and spread resistance. The CDC estimates that there are approximately 23,000 people who die every year due to antibiotic resistance.
In a shocking study in 2015 from China, researchers found E. coli resistance to an antibiotic called Colistin in humans as well as other animals. What is shocking about this is that Colistin is an antibiotic of last resort that is rarely used because it can cause kidney failure. In China, because it is so cheap, it has been used commonly in farming. Approximately 70% of the global use of antibiotics is for the purpose of farming and getting animals ready for market more quickly. The results of this study showing antibiotic resistance in animals could be spread to humans was published in Lancet Infectious Diseases. China has now banned the use of this antibiotic in farm animals.
With the rise in the number of antibiotic resistant infections there has also come a halt in innovation of new medications. Over the past two decades, the number of antibiotics coming to market has stalled. In fact, Pfizer, long a leader in development of antibiotics, closed its antibiotic research branch in 2011. Currently, smaller biotech companies account for 80% of antibiotic development. A big reason pharmaceutical companies do not want to develop new antibiotics is strictly due to the amount of profits they can expect to earn. Unlike diabetic or anti-hypertensive medication which a person needs to take all the time, antibiotics are taken only in short one-time courses. While there are several new antibiotics being investigated now, most are second or third line medications and some may not pass FDA approvals.
Despite what we now know about antibiotic resistance and the rise of superbugs, antibiotics are still being prescribed at alarming rates. It is estimated that approximately 1/3 of antibiotics currently prescribed are not appropriate for the conditions that are being treated. It was found that 506 prescriptions for antibiotics were written for every 1000 persons. The CDC estimates that every year 4 out of every 5 Americans receive a prescription for an antibiotic.
While many experts are calling this one of the most threatening crises of the twenty-first century, not much progress seems to be happening in this war against pathogens. Doctors are still over-prescribing these arms against the invisible, patients still request them for any conceived infection, and pharmaceutical companies have dropped off the battlefield and took up seats in the bleachers to watch. More people are dying from these superbugs and antibiotic resistant bacteria and scientists all over the globe predict this to continue to rise.
Who is the blame for this impending global infectious disease crisis?
Many people point fingers as to who is to blame. Yes, doctors have been over-prescribing these medications and for inappropriate reasons. But, why do they do this? Because they are trained to cure diseases and when they have a sick patient in front of them in the exam room and that patient is begging for that antibiotic it is hard to resist. By this time, most people are aware of the problem of antibiotic resistance yet they ask for them anyway. I know very well when I tell a patient no to a prescription for antibiotics that they may very well go to the local urgent care center and find another doctor to prescribe it for them. I have seen this happen many times. And I am the bad guy for saying no? No one wants to be the bad guy. But, that is what is needed from doctors. We need to say no when we think an antibiotic is not warranted and stick to it. We need to remind ourselves that we are indeed causing harm to our patients by prescribing antibiotics when they are not needed by increasing antibiotic resistance in that patient. When they truly have a bacterial infection that requires antibiotics for treatment in the future, those antibiotics may no longer work and that patient may actually die (as 23,000 Americans do every year). While the patient may be satisfied in the short-term, in the long run they have received a great disservice.
Patients need to understand that we do not refuse antibiotic prescriptions to be argumentative. We are not doing it to let you suffer needlessly. We are doing it because this is the right medical decision. Unless doctors and patients reach an agreement about prescribing habits in the exam room, this problem will never be addressed.
While some blame falls on doctors and patients, there is still some left for pharmaceutical companies. Much money goes into research and development but profits should not be the only factor going into what is being researched. Medications need to be developed for the health of the public and while they stand idly by, this crisis flourishes. They have been a big factor in convincing doctors to prescribe certain antibiotics and now must step up and take some responsibility for their role in the rise of superbugs. They are not immune to the attacks of resistant, virulent organisms.
So who is to blame? We all are. And unless we all own up to our responsibility, the bacteria will win this war. While we stand divided and don’t know where to strike next, our unseen adversaries do not share this same problem. They stand united; in fact they share their very DNA, mutated and all, with all other species of bacteria without discrimination. And they know where they will battle next: they will give rise to superbugs whom will maime and kill us, while we continue to point fingers and spin our political agendas. They will neutralize our weapons and we will cower in fear. They are winning this war and unless we face this crisis head-on, this war will be won by the microscopic world.
About the Author
Linda Girgis MD, FAAFP is a family physician practicing in South River, New Jersey and Clinical Assistant Professor at Rutgers Robert Wood Johnson Medical School. She was voted one of the top 5 healthcare bloggers in 2016. Follow her on twitter @DrLindaMD.