Doctors have been warned about it for decades. If we did not stop over-prescribing antibiotics the day would come when antibiotics would not work anymore. Some of us listened, many of us didn’t and society is about to pay the price. There has been an outbreak of a nearly unkillable bacteria at UCLA Medical Center.
The long tubes called endoscopes that are threaded down the throat and into the upper intestinal tract for certain procedures became contaminated with a particularly nasty strain of a common bacteria, one that is resistant to the most potent antibiotics. As a result of the contamination over 150 patients were exposed and a number have died. Even if this were the first outbreak of a resistant strain of bacteria there would a cause for worry.
It is not the first outbreak and there is reason to be seriously concerned. Common infections have been growing increasingly resistant to antibiotics for decades.
Staphylococcus Aureus is a common bacteria that can be found on the skin of 25-50% of healthy individuals. It is the most common cause of skin infections and can cause severe illness when it enters the blood stream. Originally sensitive to penicillin, resistant strains were discovered within just years of the antibiotic's first use in World War II. By the 1970’s penicillin was no longer effective at all.
As newer forms of antibiotics were effective against Staph there was not widespread concern. Methicillin was a readily available and relatively inexpensive alternative, and it was effective. Resistance to Methicillin was known but it was rare. Methicillin Resistant Staph Aureus (MRSA), was found in only 5-10% of hospital and nursing home infections and was almost never seen in the community. Things changed in the late 1990’s. The incidence of MRSA exploded, up to 50% of Staph infections were resistant in many hospitals.
Within just a few years MRSA was no longer just a hospital problem. It spread into the community and healthy people began to develop severe skin infections and abscesses. I witnessed the epidemic in my practice. Prior to 2001 I treated 1-2 skin abscesses a year in the office. By 2010 I was treating 1-2 abscesses a week. The bacteria had not only become widely resistant it had become much more aggressive! Hospitals have now been forced to develop new screening and isolation procedures to prevent staff members from inadvertently spreading the disease. The world has changed forever.
The problem of resistance is not limited to rare infections. E. Coli is the bacteria responsible for the majority of urinary infections. When I was an intern in 1990, in the hospital in which I worked ampicillin was effective against E.Coli 72% of the time and cefazolin was effective 90% of the time. Just 23 years later, UCLA (just a few miles away from where I trained), reported that ampicillin was effective only 32% of the time and cefazolin in only 68% of cases. The trend is discouraging. If something doesn’t change we may run out of effective antibiotics in our lifetimes! How does this happen?
A study I read several years ago helped answer the question. Researchers in Israel cultured all of the children in a daycare. None of them tested positive for resistant strep bacteria. One child was treated with antibiotics for strep. A few weeks later the researchers tested all of the children again. 40% of the children tested positive for resistant bacteria! Antibiotic resistance was contagious!
When a person takes an antibiotic all of the bacteria sensitive to the antibiotic die. The only bacteria left are the resistant ones. Through a variety of mechanisms one bacteria can pass its resistance on to another one, so harmless resistant bacteria can pass resistance on to harmful ones. When these resistant bacteria are passed from one person to the next the resistance spreads through the community.
In smaller “communities” such as hospitals where antibiotics are widespread the danger of passing resistance is much greater, which is why this is where outbreaks often begin. The MRSA story reminds us that hospital resistance may not stay in the hospital, and the E. Coli story reminds us that resistance is not just a hospital problem.
Since the problem of resistance and overprescribing antibiotics is well known the question arises, “Why do doctors keep writing needless antibiotic prescriptions?” The answer is simple. Patients want them and doctors are afraid to say “No.”
I deal with this issue almost every day. Patients come in with an obvious viral illness and argue when I say antibiotics are not indicated. Science, studies, statistics and the stories of antibiotic resistance do not matter to these patients. They “know their body”, “just can’t afford to be sick right now”, “want to nip this in the bud before it gets worse” or “have a friend who had this and he took antibiotics and was better in 2 days.” I often am left with a choice. Do the right thing and have them leave disappointed or angry (and maybe not come back) or do the wrong thing and have them leave happy.
The choice is difficult enough to begin with but is compounded by the reality that doctors today are judged according to patient satisfaction surveys and are reviewed on Yelp. One unhappy patient with a grudge can cost a doctor thousands of dollars in bonuses and business. Because of this the problem will never be corrected by doctors alone. Patients need to get involved.
Patients need to educate themselves and others about the dangers of antibiotic overuse. (They can start by sharing this post!) We all need to learn to allow minor illnesses to run their course and to reserve antibiotics for those rare circumstances when there is no other choice. The world is changing and we are faced with a harsh choice. Do we want to treat our sinus congestion today, or do we want to survive our pneumonia tomorrow? It appears we cannot do both.
- Bart
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References-
http://www.pathnet.medsch.ucla.edu/department/cliniclab/microbio/amic.pdf http://newswise.com/articles/day-care-centers-spread-antibiotic-resistant-bacteria http://wwwnc.cdc.gov/eid/article/7/2/70-0178_article