Antibiotics – In the Garden of Good and Evil
There have been many “miracle” advances in medicine. Pasteur realized sterility decreased infections, and medicine did an immediate about-face (up until that time, a dirtied and bloodied physician was deemed to be a good one!), changing forever the way we think about infectious disease, and extending human lifespan in the process. Local and General Anesthesia added surgery as a brand new branch of modern medicine. Vaccines dropped infant mortality in ways that cannot be adequately described with numbers alone. Adding to these achievements, and perhaps doing more to change the average lifespan of human beings: Antibiotics.
Up until the advent of Penicillin, during World War 2 (and first commercially made in Peoria, Illinois!), we only had poor versions of sulfa antibiotics that often did more harm than good. With Penicillin (and it worked on EVERYTHING when it first came out, even in tiny doses), many lethal infectious diseases were conquered with a simple injection. Pneumonia was the #1 killer of human beings in 1900, followed quickly by Tuberculosis. Syphilis ran rampant. With the advent of Penicillin, and other antibiotics, these killers dropped completely from the Top 10 (David Letterman would be so proud!).
The average lifespan of human beings increased from about age 45 in the pre-antibiotic era, to almost 60 after the emergence of antibiotics.
So where is the evil?
It sure does sound all pretty when you look at those numbers, and antibiotics are still amongst the most important medications we have to combat disease.
The “evil” in this case, is the overuse of antibiotics. You see, those little bacteria are very quick to adapt to changing conditions. We call this Natural Selection. If you put a bacteria into an environment where it is surrounded by antibiotics, you can be sure the ones that actually survive to reproduce themselves are the ones which are most resistant to the antibiotics!
So why are they surrounded by antibiotics?
Because we, as physicians, have overused them prodigiously.
It is not entirely our fault. Patients often demand them, for every little viral cold and sniffle (something antibiotics clearly do not cure). Sometimes doctors feel obligated to give the patient “something” for their office visit. Patients often feel like they somehow got ripped off, if all they get from us is advice on how to deal with the common cold. Sometimes, physicians are just lazy and it is easier and quicker to give out a prescription for an antibiotic than spending 5 or 10 minutes explaining that the antibiotic is not going to help fight off their cold, and may in fact do them real harm (e.g. allergic reactions, side effects or causing future bacterial resistance to the antibiotic).
Patients are also sometimes to blame when they only take a portion of the antibiotics which are prescribed because they feel better! It doesn’t sound like such a bad thing to stop an antibiotic when the symptoms go away. After all, the less medicine, the better, right? Unfortunately, what has actually occurred in these cases is that the antibiotic killed 99% of the bacteria causing the infection, bringing the patient to a point where he no longer has symptoms, but still harbors a small amount of bacteria. Unfortunately, the 1% of bacteria which have survived are the ones which are most resistant to the antibiotic. These survivors get to live on, reproduce, and pass on their resistant genes. We have, as humans, caused a natural selection to occur towards antibiotic resistance.
Most of the time though, it is our fault, as physicians. If we spent more time educating our patients and less time writing prescriptions, we might not be in the pickle we are in now.
What pickle is that? I’m so glad i asked!
Bacteria are rapidly becoming resistant to antibiotics. Up until recently, we have been able to stay ahead of them by inventing new classes of antibiotics to take the place of the older ones which no longer work. As these bacteria evolve (yes, there really is evolution due to natural selection, and if you don’t agree, I will be happy to prescribe the older medications which do not work anymore! See the comic strip below), several have done so enough that we are down to the last arrow in our quiver to fight them with! The famous MRSA (Methicillin-Resistant Staphylococcus Aureus), VRE (Vancomycin Resistant Enterococcus) and Multiply Drug Resistant TB are just a few of the most highly evolved bacteria which are getting very smart! I commonly see antibiotic resistance panels which show bacteria are becoming resistant to more and more of the antibiotics in our holster!
So what is the take-home message?
1 – Don’t be upset if your physician tells you an antibiotic is not going to help cure your infection. One day we will create antibiotics that cure viruses (and someone will win a Nobel Prize for Medicine when it happens!) but for now, be happy that your doctor has the good sense not to expose you to unneeded antibiotics.
2 – If you are prescribed an antibiotic, be sure you take it exactly as directed. Complete the entire course.
I believe you can click on the Doonesbury comic strip below to see it in a larger format!