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Wednesday, April 23rd, 2014

Antibiotic Armageddon: Modern Medicine on the Edge of the Abyss

By Sarah Carlson


Photo: sparktography
Close-up picture of antibiotics.

Imagine a world in which antibiotics fail to effectively treat diseases and turn organisms that naturally reside in your body against you. After decades of over-prescribing and rapid bacterial evolution, this is a reality that most of the developed world may soon face, as bacteria are becoming increasingly resistant to the healing powers of prescription drugs. As bacteria develop stronger resistance, the popular sense of invincibility that modern medicine has may be over. In fact, Britain’s Chief Medical Officer, Dame Sally Davies, describes the quickly developing resistance an “apocalyptic scenario.”

Penicillin was discovered in the 1940s, fulfilling immunologist Paul Ehrlich’s idea of a “magic bullet” that targets only disease-causing microbes without targeting the host, to treat bacterial infections.

From 1940 through 1970, substantial advances within the field of medicine were made, with the discovery of several new classes of antibiotics. More than 20 classes of antibiotics were produced in an antibiotic boom between 1940-1962. Antibiotic classes are different types of antibiotics that are bacteria specific, like Penicillan and Methicillin. Since then, research and development has slowed with the discovery of only two more classes within the last fifty years. This is problematic as there are fewer antibiotics to effectively combat bacterial evolution, exacerbating the resistance problems.

Dr. Laura Piddock, from the University of Birmingham, explains, “The emergence of antibiotic resistance is the perfect example of evolution.” As the bacteria evolve, they build a resistance to the antibiotics available, making them essentially ineffective.

Too Much of a Good Thing?

As antibiotic discoveries flourished, their use became popularized to an extreme. Dr. Anders Hakansson, a researcher at the University at Buffalo, states, “In the past, there has been too much antibiotic use,” explaining that antibiotics, which are specifically designed for bacteria, were prescribed to patients with viral infections. If antibiotics are unnecessarily prescribed to viral infections, “they can do more harm than good,” advises the National Institute of Health. Between 1995 and 2003, the National Hospital Ambulatory Medical Care Survey found that at least fifty-four percent of children with sore throats were prescribed unnecessary antibiotics for A beta-hemolytic streptococci bacteria (strep throat), while only fifteen to thirty-six percent actually had the bacterial infection.

Every time antibiotics are introduced to the body, they attack specified microbes, killing the weak. The use of antibiotics creates a medically induced process of natural selection for the bacteria, encouraging the strong surviving microbes to multiply. Prescribing and using more antibiotics than needed accelerates the microbes’ evolution, decreasing the effectiveness of available treatments. In many cases, when weak organisms are killed by antibiotics, the strong survivors create a new strain that is resistant to the antibiotic that was used previously. This is where the idea of “super bugs” comes from.

Doctors have been accused of over-prescribing antibiotics due to pressure from large pharmaceutical companies, from which they receive compensation. Heavy marketing campaigns by pharmaceuticals, via a “wining and dining” process, persuade medical practitioners to do the bidding of the industry. AstraZeneca spent over $250,000 compensating U.S. physicians just for speaking on their behalf. Several thousand more dollars were paid to doctors for “consulting fees, speaker compensation, research payments, meals, travel, educational items, royalties, license fees and ownership or investment interest.”

Upon going in for routine illnesses like the common cold, which is a viral infection, patients have been known to specifically request antibiotics, under the impression that antibiotics will cure any and all illnesses. However, this antibiotic-dependent mindset can be attributed to the cultural of over-prescription created and nurtured by physicians. Adding to the accessibility of antibiotics is the development and popularization of “e-visits” where patients submit their symptoms to doctors via an online forum and receive treatment advice within a few hours. While it is seen as more convenient, and insurance companies like the potential for less expensive medical visits, patients receiving online care are prescribed more antibiotics than those having in-person visits. Furthermore, virtual patients run the risk of misdiagnosis as a result of incorrectly describing symptoms, increasing the likelihood of being prescribed and using inappropriate antibiotics.

In light of this issue, legislation in some states in the US, such as the Pharmaceutical and Device Manufacturer Code of Conduct in Massachusetts, has made it difficult for pharmaceutical companies to persuade doctors to use their drugs by prohibiting unnecessary “gifts” to doctors. Additionally, a federal law, the Physician Payment Sunshine Act, stipulates that pharmaceutical companies must disclose gifts of more than US$10 that are made to physicians or hospitals in order to ensure full transparency and discourage overly generous gifts.

Increasing criticism of over-prescribing has resulted in a heightened sense of antibiotic dependency. “There is definitely a problem, but it’s getting better,” says Hakansson about over-prescribing.

After several decades of over-prescribing, many doctors are attempting to reverse the antibiotic dependency. Efforts to reverse this trend are manifested in clinics and hospitals. In doctor’s offices, there are posters and reminders that antibiotics will not cure every illness.

Dr. Ralph Gonzales from the University of California, San Francisco conducted a study in Pennsylvania investigating the effect that posters and reminders had on prescriptions for patients complaining of a cough, commonly known as bronchitis (a viral infection). Patients typically receive antibiotics, which are useless against viruses. Yet, when both practitioners and patients were exposed to reminders that antibiotics are not right for every infection, fewer antibiotics were unnecessarily prescribed.

While Decreasing Dependency, New Effective Drugs Still Crucial

While there is a push to decrease the use of antibiotics, and subsequently reduce resistant strains, there is still a necessity for effective drugs when it comes to bacteria like methicillin-resistant Staphylococcus aureus (MRSA) and multi-drug-resistant Mycobacterium tuberculosis (MDR-TB).

In the last few decades, there has been a dwindling interest in antibiotic research and development. Pharmaceutical companies earn more money in daily, lifetime drugs like antiretrovirals for the treatment of HIV, as opposed to antibiotics that are used for only several days, such as those that treat Streptococcal pharyngitis (strep throat). Antibiotics do not create substantial revenue. It seems discordant then that the industry would try enticing physicians to prescribe their antibiotics. However, since antibiotics are still widely used, companies need to distribute as many as they can in an attempt to earn some profit. Yet these profits, despite zealous encouragement, are dwindling. Over twenty pharmaceutical companies were involved in antibiotic research in 1990. As of 2011, only two pharmaceutical companies, GlaxoSmithKline and AstraZeneca, are working on antibiotic development.

Despite the pharmaceutical industry’s dwindling interest, there are several new antibiotics in the pipeline. However, “most are modifications of what is already on the market, and many will only be used as a last resort,” says Dr. Hakansson. Modifications made to already marketed antibiotics in an effort to fight new resistant strains is significantly less expensive than developing entirely new drugs.

Beyond new drugs and antibiotic modifications, researchers at the University at Buffalo are looking at antibiotic complements that could strengthen the effectiveness of existing drugs to combat infections. One innovation showing promise is HAMLET (human alpha-lactalbumin made lethal to tumor cells), which is a protein-lipid in breast milk that has antibiotic abilities on its own. However, combining the protein with existing antibiotics creates a synergistic drug that makes bacteria more sensitive and vulnerable. So far, this research is a successful step forward in combating antibiotic-resistant strains of bacteria. Hakansson expresses optimism in the research thus far, stating, “we have not found any resistant organisms.”

Anticipating the Apocalypse

While Dr. Hakansson assures that “we aren’t there yet,” the much alluded to antibiotic apocalypse is still “definitely a problem.” When it comes to organisms that naturally reside in the body, the situation is getting worse, he explains. Although these common bodily microbes are generally harmless while they lie dormant, when we use antibiotics and they strengthen their resistance; so when they do attack, the infections are significantly more dangerous.

When it comes to how long we have until this “apocalypse,” Dr. Piddock states, “There are no accurate estimates for how long this will be,” but so far “most people think within the next 10 or 20 years.”

If the antibiotic apocalypse occurs, as many health care professionals anticipate, health care costs could potentially soar as antibiotics become ineffective for treating bacterial infections and hospitalization becomes the norm, putting a severe strain on the existing system. An issue that once seemed a problem of the future is very much a problem for the present that needs rapid solutions, and fast. However, it is the research of doctors like Dr. Hakasson, who are looking for solutions to antibiotic resistant bacterial strains that provide optimism for the future and perhaps even a way to keep modern medicine firmly anchored to this side of the abyss.