Antibiotic Resistance – It’s Complicated!

Big words, yes, but we can still figure this out. I’ve learned a lot about this topic as a patient advocate on antibacterial drug development committees with the Clinical Trials Transformation Initiative (CTTI) and the Brookings Institution. It’s really about the bug in the laboratory (lab), not in humans. That has to change if we want better solutions for patients.

First, Some Basics

Bacteria are small single cells whose whole purpose in life is to replicate.

Some bacteria are good. We’re only talking about the ones that infect people and make them sick. There are lots of words to describe different kinds of ‘bad’ bacteria – we’ll call them ‘bugs.’

Antibiotics: Drugs used to treat bacterial infections

Alexander Fleming discovered penicillin in 1928. Clinical trials, run by Edward Chain and Howard Florey, followed and they all shared the Nobel Prize in 1945 for antibiotics. More antibiotics are listed here. BTW, antibiotics are also called “antimicrobial” just to confuse things further.

cdc - plate testing Img26_sm

‘Superbug’ Hype Misses the Point

Have you heard about superbugs? They are definitely a problem. Some bugs resist some antibiotic drugs, due mostly to their overuse by doctors and hospitals (and in animals, but that’s another story). The situation, however, is not critical yet. This is not explained very well, nor is the fact that drug development must change if we are to have new drugs that truly work in people (also another story… soon, I promise!).

The resistance that doomsayers actually talk about pertains to resistant bugs in lab plates. This is different from what happens inside people.

“Disease is as much about the host as it is the infectious agent — the focus on microbes is hindering research into treatments, say Arturo Casadevall and Liise-anne Pirofski.”

Microbiology: Ditch the term pathogen – Comment

Lab plates don’t have immune systems to protect them – people do. Infections also work differently in people who are otherwise healthy (they usually get better), compared to people who are sicker to begin with (this is where most problems occur).

In fact, the PATIENT matters MORE than the bug when you consider other important factors. For instance, Yaw et al wrote a paper which looked at death rates and hospital re-admissions from MRSA compared to Staph infections. They found similar results after matching factors like age, co-morbidities (other health conditions), the severity of illness, metastatic infections, and long-term care status.

Doctors & Hospitals Overuse

cdc - antibiotic prescription useDoctors commonly prescribe antibiotics “just in case” for patients before being diagnosed with a specific illness. This is called “empirical” practice and is not appropriate in many cases. This is especially true when there is no bacterial infection, or for diseases that resolve on their own. So patients get a general antibiotic first instead of getting what they actually need once they have a clear diagnosis. Research and medical systems have not focused on better diagnostics because they’ve been able to use antibiotics this way. Until recently…

What does Resistance Mean?

The system classifies bugs in labs as “susceptible,” “intermediate” or “resistant.” FDA sets criteria for these when it approves a drug label after reviewing patient outcomes from clinical trials.

The University of Pennsylvania explains the standards this way: “Note that this definition says nothing about the chances of clinical success; in fact predicting clinical outcome based on susceptibility testing and the use of drugs shown to be in the susceptible category is very imprecise. This imprecision is due to the effect of host responses, site of infection, toxin production by bacteria that is independent of antimicrobial susceptibility, the presence of biofilm, drug pharmacodynamics and other factors.”

Older Antibiotics Still Work!

cdc - antibiotic-resistance numbersResistant microbes or “pathogens” are commonly called superbugs now. Important point: antibiotics still work for most people in most situations, even when they have superbugs.

Resistance reflects how many drugs the bug can resist on a lab plate. It doesn’t show how many drugs still work for patients. Multi-Drug Resistance (MDR) means the bug is resistant to at least 3 drugs. This still leaves effective drugs that are available for patients, and most patients get better.

The fact is, only 1% (1 in 100) people die when they get a resistant bacterial infection. This is still too many, but compared to other diseases, this is an amazing success story. Patients who run out of antibiotic options are usually sick people whose immune systems don’t work well.

So, What is the Problem?

The Atlantic’s article called Antibiotic Resistance is Everyone’s Problem  summed it up nicely:

“You could get an infection that was drug-resistant even if you’d never taken antibiotics in the past.”

Ramanan Laxminarayan, Director, Center for Disease Dynamics, Economics and Policy

The more doctors prescribe antibiotics before knowing what disease to treat, the more superbugs are produced which affects everyone. This is especially true for patients who are sicker or have other illnesses. Doomsayers often hint at more “bloodstream infections” but when you look at the real numbers, there are more sick patients, not more resistant bugs.cdc - dr hospital solutions pdf_cover_as-factsheet

Another problem, as STAT News reports – people don’t understand when antibiotics should be used and when they shouldn’t. The World Health Organization (WHO) surveyed people in 14 countries, and found that 2 out of 3 are confused. “For example, 64% believe antibiotics can be used to treat colds and flu, despite the fact that antibiotics have no impact on viruses. Close to one-third (32%) of people surveyed believe they should stop taking antibiotics when they feel better, rather than completing the prescribed course of treatment.”

ALERT: These actions increase antibacterial resistance! Don’t do them!

The WHO Global Burden of Disease Project shows that deaths actually went down in all infectious diseases from 1990-2013. These real numbers sounds different from numbers that are often bandied about. Remember, there is a big difference between the absolute risk a person faces vs. the relative risk between rates or groups of people.

If You Missed Antibiotics Week, No Worries

Even though the WHO “World Antibiotic Awareness Week” and US “Get Smart About Antibiotics Week” (both Nov. 16-22nd) passed us by, we can use the tools all year, thanks to the Center for Disease Control and Prevention (CDC), WHO and the Food & Drug Administration (FDA). They track antibiotic usage and have tools for doctors, hospitals and states.

How YOU Can Help

cdc - 6 facts abt bacteriaThe CDC also has information for patients and the Public. Here are a few steps everyone can take:

  1. Learn which illnesses need antibiotics, and which ones don’t.
  2. Ask your doctor why they are prescribing antibiotics and if they are necessary for your illness.
  3. If you need antibiotics, take ALL of them. You don’t get personal resistance from antibiotics – you create resistant bugs if you don’t finish them as prescribed!
  4. Take this Antibiotics Quiz.
  5. Share this information with everyone you know.

All content © 2015 by Deborah Collyar unless otherwise specified. All rights reserved. Permission is granted to use short quotes provided a link back to this page and proper attribution is given to me as the original author.

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