Today, ear infections, strep throat, and UTIs are typically mild infections. But that hasn’t always been true- before antibiotics, these illnesses made people severely ill, and could even be deadly. With the discovery of the first antibiotic in 1928, we developed the ability to kill bacteria selectively. They’ve become an integral part of surgery, made cancer treatment and organ transplants survivable, and helped ensure most children reach adulthood. They’ve helped to extend our lifespan by almost 25 years in the last century alone1. But they have also become an abused and poorly utilized treatment that we take for granted, which has led to the development of “superbugs”, or bacteria that are resistant to antibiotic treatment.
Superbugs sound apocalyptic and doomsday-ish. But in reality, there are a very modern issue, created by bacteria’s determination to win its own version of Survivor. The first antibiotic-resistant strain of bacteria was discovered in 1940. And since then, it has become a major public health threat, with the CDC, NIH, World Bank, and WHO all declaring it an emergent crisis. But while many people are peripherally aware that it’s an issue, we don’t often discuss why it’s happening. Let’s talk about how it occurs and what we can do to slow it down.
A quick biology lesson- at least it’s not chemistry?
I’ll try to keep the science portion of this brief, but it’s important to understand how this happens to put the rest of the picture together. If you want to geek out a little bit more, this video is a good source as well.
Bacteria, like all living organisms, use DNA to make proteins that help them survive. Their whole M.O. is to live to pass on genes, but they have to compete with all of the other bacteria that naturally live in your body for nutrients. Small accidental mutations in DNA can be harmful, not make a difference, or help with survival. Some of the changes can cause resistance to antibiotics. If they aren’t exposed to antibiotics, these genes aren’t helpful; in fact, sometimes they are harmful in other ways, by either slowing down protein synthesis or unnecessarily spending energy. But when you take antibiotics, the other bacteria that don’t have these genes are killed off, so the bacteria with these special resistance genes can live on. Some of these genes are not completely protective, they just make it harder for the antibiotic to treat them. When you start antibiotic treatment but don’t finish it, they work to express these genes even more for better protection the next time. They then grow exponentially, and can even be spread to other people.
Here’s the scary thing- once one bacterium has developed a gene to resist an antibiotic, they can pass it to other ones through a variety of mechanisms they have to share genetic material. So it doesn’t take long from the first development of resistance to an antibiotic being almost unusable.
In 2010, an average of 22 doses of antibiotics were prescribed per person in the US2. That would be all well and good if they were needed; but studies have shown that 30-50% of antibiotic courses are incorrectly prescribed in some way3. And this came back to bite us- the CDC estimates that 2 million Americans are infected with antibiotic-resistant bacteria every year, and 23,000 of these people die as a direct result of their infection4. If the increase of superbug infections keeps up at this rate, an estimated 10 million people will die annually by 2050, around the same number of people who die from cancer every year!
The map on the left shows number of antibiotic prescriptions, the right shows antibiotic resistance prevalence. They look very similar… coincidence? I think not.
Source: Ventola, CL. The antibiotic resistance crisis. PT. 2015: 277-283.
There are a few diseases where resistance has become a significant issue- gonorrhea being the most concerning for young Americans. In a WHO study of 77 countries that report antibiotic susceptibility, 97% reported resistant strains, with 50 countries reporting cases that were unresponsive to treatment. This has progressed to the point that gonorrhea treatment requires 2 antibiotics in case of resistance. Tuberculosis has been developing resistance, as well; extensively drug resistant TB is defined as a strain that can survive at least 4 drugs, and increases the cost of treatment from $18,000 to $494,000. The most commonly known superbug is MRSA; 2% of the US population carries this in their body, and it has become a commonplace infection nationwide.
Dollar dollar bills, y’all
A very logical thought would be that we should just make new antibiotics. So why don’t we? Very little drug development is being done, because it’s not profitable for pharmaceutical companies. You take most antibiotics for 7-10 days, and then you’re better, and you won’t need it again for another few years, if ever. Compared to drugs that people need to take every day for the rest of their lives, there’s not a lot of room for financial gain, or even to pay off the hundreds of millions of dollars it takes to invent a new drug. By the time that superbugs become prevalent enough for there to be a financial incentive to develop more drugs, we will have to wait years while drugs are researched, as it takes an average of 12 years for new drugs to go through the entire development process. (This would be a good time to call your government representatives to let them know this should be a priority.)
Only YOU can stop antibiotic resistance!
It may seem like there’s nothing we can do, and we should all just go screaming for the hills to avoid being anywhere near a potentially infected person, or perhaps all start sporting face masks in public. We aren’t quite there yet thankfully (because who looks good with a face mask) but there are some things we can do to help prevent further resistance.
First, you have to take responsibility for how often and how well you take antibiotics. You may think you need antibiotics for your cold- you don’t. Colds are caused by viruses, which are a completely separate organism than bacteria, and so aren’t affected by antibiotics. It’s not just that you don’t need them- it’s that it will do nothing for your viral infection. If you’re not sure if it’s caused by a virus, here’s a couple of general principles.
These are general rules of thumb, however if you feel ill enough to talk to your doctor, don’t hesitate to call.
You may think you always get better when you take antibiotics- that has more to do with timing, you were going to get better anyway. Colds generally resolve within 1-2 weeks; if you went to the doctor after being sick for 4 days, then started the antibiotic and got better 3 days later, that’s just because that’s how the virus ran its course. If you think you may have a sinus infection, wait 7-10 days before asking for antibiotics (and yes, that will feel like years), because most of them are viral. If you feel like you need to see a doctor, by all means go, but if they say you don’t need antibiotics, don’t push. I know it’s hard, and I’ve been guilty of this before, because when you’re sick you feel like you’d do anything to feel better; but just remember, it will only hurt you and possibly those around you. While it may seem harmless, the more bacteria are exposed to antibiotics, the more likely it is that the resistant bacteria will grow and spread.
If your provider decides that you do need antibiotics, take them appropriately. Even if you feel better and you’re only halfway through, finish the course (unless you’re having weird side effects, then call your doctor). The bacteria are taking a beating from the antibiotics and most of them are dead, but not all of them yet. Some are injured or avoided exposure through new genes they’ve developed, but they’re on their way out because those genes are new and not “well expressed” (meaning they aren’t making much of those proteins yet). Then, you stop the antibiotics early. This gives the bacteria time to recover, express that protective gene stronger, and come back better than ever. Kelly Clarkson was right- what doesn’t kill you makes you stronger.
Don’t ever save antibiotics for another illness or take those prescribed to someone else. Not only could this be a safety issue, they may no longer be completely effective. And not all antibiotics are the same- what you took for a sinus infection will probably not work for a UTI, because they are caused by different bacteria. And again, the more times bacteria are exposed to antibiotics, the more possibilities for resistance. If you have old antibiotics, don’t flush them!! They become part of our water system; take them to a pharmacy, where they can correctly dispose of them.
If you have the resources, buy meat products from producers that don’t use antibiotics. 80% of the antibiotics used in the US are used in feed for livestock, to prevent them from getting sick as well as to help them grow faster. But there have been studies that have shown development of resistant bacteria in animals that then spread to humans5,6,7. By investing in companies that don’t use antibiotics, you can help provide market pressure, and financially reward public health awareness.
Do you ever use antimicrobial soap thinking it will make you healthier? It won’t. Studies have shown no link between using antimicrobial (vs. plain) soap and infection rates. You can’t completely decontaminate yourself or your home- sorry germaphobes, it’s just not possible. While there’s currently no data that triclosan, the main antimicrobial in soap, has caused resistance in humans, there is some laboratory evidence to suggest that it could. So next time you’re at the store, maybe skip the extra antimicrobial additives.
And finally, you can prevent needing antibiotics by doing what you can to prevent getting infections. Make sure you have all of your vaccinations, like pneumonia and meningitis, to prevent yourself and others from needing antibiotics. Use condoms to protect yourself and your partners from STIs- if you want to read more about STIs, I know about a super helpful post here ;).
Okay, maybe there are other people who can stop it too
Trust me, you’re not alone if you’re worried about this. Providers and hospitals have become much more aware of the threat of antibiotic resistance, and have developed antimicrobial stewardship programs. This means that we have specific drugs we can’t use without talking to infectious disease specialists, to ensure we are using the correct medications. We also track drug resistance, to figure out which drugs will most likely be effective, and have “time-outs” to make sure we regularly address which antibiotics to use and how long.
The FDA has cracked down on livestock antibiotic use, and outlawed use of human antibiotics for growth purposes, however they are still allowed for illness prevention and treatment. The NIH is also trying to invest in antibiotic development, and recently allocated more money for new, innovative antibiotic ideas.
This is a scary topic, but there’s a lot we can do to make it better. Let’s all be super heroes and defeat these mutating superbugs together.
- Congressional Research Service Report Life expectancy in the United States. Mar, 2005. Available at: http://www.cnie.org/nle/crsreports/05mar/RL32792.pdf
- Global antibiotic consumption 2000 to 2010: an analysis of national pharmaceutical sales data. Van Boeckel TP, Gandra S, Ashok A, Caudron Q, Grenfell BT, Levin SA, Laxminarayan R Lancet Infect Dis. 2014 Aug; 14(8):742-750.
- Centers for Disease Control and Prevention, Office of Infectious Disease Antibiotic resistance threats in the United States, 2013. Apr, 2013. Available at: http://www.cdc.gov/drugresistance/threat-report-2013.
- Detection of Airborne Methicillin-Resistant Staphylococcus aureusInside and Downwind of a Swine Building, and in Animal Feed: Potential Occupational, Animal Health, and Environmental Implications.Dwight D. Ferguson et al. in Journal of Agromedicine, Vol. 21, No. 2, pages 149–153; 2016.
- Multidrug-Resistant and Methicillin-Resistant Staphylococcus aureus(MRSA) in Hog Slaughter and Processing Plant Workers and Their Community in North Carolina (USA).Ricardo Castillo Neyra et al. in Environmental Health Perspectives, Vol. 122, No. 5, pages 471–477; May 2014.
- Vinayananda CO, et al. Studies on occurence, characterization, and decontamination of emerging pathogenic Escherichia coli in table eggs. Br Poult Sci-Fi. 2017.