Missing Microbes: How the Overuse of Antibiotics Is Fueling Our Modern Plagues (29 page)

Along with better training, pediatricians need better pay. Paradoxically, physicians involved in the primary care of our children—the doctors on the front lines who receive tens of thousands of visits every day from parents and their children—are among the lowest paid of all physicians in the United States. Something is wrong with our system when the doctor who performs a brief diagnostic procedure—some form of X-ray, for example, or a fifteen-minute operation—is paid many times more than the doctors making crucial decisions about our children’s health.

Pediatricians should be paid sufficiently to methodically evaluate the children brought to them and be rewarded for taking time to discuss each diagnosis with mothers and fathers. Since our current system markedly undervalues this kind of care, it’s no surprise that 70 percent of the kids coming in with what is considered an upper respiratory infection walk out with an antibiotic.

Many well-informed parents and good doctors and nurses are trying to change these attitudes and practices, but our system conspires against them. Unconscious biases are everywhere. We think that cutting routine office visits to twenty minutes, fifteen minutes, even ten minutes will save money when in fact, with less time for doctors to examine and less time to think, we are incurring far greater costs through excessive testing and needless treatment.

Physicians and patients also should be made aware of how local customs drive their prescription rates. Southerners swallow about 50 percent more antibiotic courses than people living in western states. I doubt there is a 50 percent difference in the incidence of bacterial diseases in those regions. Like rates for C-sections or episiotomies, such differences in usage reflect variations in the practice of medicine.

*   *   *

When I talk with colleagues about what has to happen to change attitudes about our health practices, they are downright pessimistic. Time horizons, they say, are distressingly long. Habits are engrained. People are terrified of germs. Doctors like to feel powerful and at the same time are afraid of being sued. Government regulators fear making difficult decisions that might invite political controversy or jeopardize their careers. Health systems are paid by insurers and by the government to act, not to withhold treatment. And pharmaceutical companies are content with a status quo that provides them hefty returns for little or no new investments.

But I am hopeful that change will come faster than the naysayers think. I believe that we are at a tipping point. As discussed in the previous chapter, the director of the Centers for Disease Control recently called a press conference to focus on resistance to antibiotics; magazines are full of stories about horrible cases of antibiotic-resistant infections; and many people are beginning to realize that “germophobia” has serious downsides. As we consider real costs and limited benefits, simple actions become more sensible.

Governments can do more to bring antibiotic use under control. The French provide a shining example. In 2001, France had the highest rate of antibiotic use among European countries, which prompted its public-health agencies to swing into action. In 2002, the French National Health Insurance launched “the national plan to preserve antibiotic efficacy,” which was solely aimed at preventing the spread of antibiotic-resistant organisms.

Of course, to reduce resistance they had to reduce use. While hospital patients received many antibiotics, more than 80 percent of the drugs were being prescribed to people in the community. That was the place to intervene. The major target: reduce the use of antibiotics given to children for viral infections of the respiratory tract. Health officials focused on the winter months, when most such infections occur.

Called Antibiotics Are Not Automatic, the campaign was aimed at simultaneously changing the mind-set of both patients and their health-care providers. Because France has a centralized database of pharmacy prescriptions, health officials were able to review a large sample, roughly between 2002 and 2006, during which 453 million antibiotic prescriptions—nearly 10 million per month—were written. For a country of 60 million people, that is a lot of antibiotics.

By the end of the intervention in 2006–2007, the prescription rate had declined by 26 percent. This reduction, which was repeated across all areas of France, affected nearly every class of antibiotics and worked across all ages, not just children as targeted. But it was particularly effective in kids under three whose annual prescription rates fell from about 2.5 courses per child to about 1.6, a drop of 36 percent.

Other public-health authorities in France have gone further. A pilot campaign in the French Alps called Antibiotics Only When Necessary is a logical next step from “not automatic” to “only when necessary.” If the United States adopted a similar program, we might also slowly wean ourselves of our addiction. Already antibiotic use in children is off from its peak, perhaps by 20 percent, based on programs originally intended to decrease antibiotic resistance. The programs mostly involve the education of doctors and other health practitioners on the front lines about why they should avoid the reflexive urge to pull out their prescription pads. And in Sweden, a highly developed medically sophisticated country, the outpatient prescription rate is “only” 388 per thousand persons versus our 833. That antibiotic prescribing rates in Sweden are less than half of ours shows that it can be done without excessive health hazard.

*   *   *

There’s one more thing the government can do to reduce overuse of antibiotics: prevent farmers from giving them to animals whose products—meat, milk, cheese, eggs—we eat. The carryover of antibiotics into our food and water is completely avoidable. We must set a date, which can be a series of dates with increasingly stringent requirements, to ban the practice.

For consumers, it means that the prices of meat, eggs, milk, and fish will all go up at the supermarket cash register by a small percentage. In comparison, we are already paying the price of antibiotics in food through the spread of resistant organisms and the diminishing utility of our antibiotics, and we are probably contributing to our costly epidemics of allergy and autoimmunity and metabolic problems. In the future, we can pay at the supermarket or we can pay at the clinic through our insurance premiums, taxes, and compromised personal health.

In late 2013, the Food and Drug Administration announced that it will take the first steps to removing growth-promoting antibiotics from our livestock. The change is based on the threat of antibiotic-resistant bacteria traveling from animals to humans, but a collateral benefit would be to reduce antibiotic residues in our food and drinking water. Although this is an important move in the right direction, we must hold the FDA’s (and the industry’s) feet to the fire, because without enforcement the producers could use similar amounts of antibiotics to “treat illness” in the livestock.

And let’s not stop at antibiotics. Food producers are allowed to sell foods that have detectable levels of antiworm agents, insecticides, and hormones. Interestingly, for certain hormones like testosterone and estrogen, there are no set limits, because of the following wording in the World Health Organization regulations: “Residues resulting from the use of this substance as a growth promoter in accordance with good animal husbandry practice are unlikely to pose a hazard to human health.” Is this now an appropriate standard for us?

*   *   *

The way new antibiotics are developed also needs overhauling. For inspiration, we can go back about a century, when Paul Ehrlich, the early germ-theory pioneer, experimented with hundreds of compounds until he found Salvarsan, a safer derivative of arsenic, which was his “magic bullet” for treating syphilis. It was good for only that, nothing else. When you get a skin abscess, you may have been exposed to many bacteria, but almost always just a single microbe dominates the infection. If your therapy were directed narrowly at that one bug, you’d get better.

But for more than seventy years, pharmaceutical firms have sought “broad-spectrum” agents that kill many types of microbes. There are plenty of advantages to this approach. When someone is sick—with pneumonia, a urinary infection, or an infected wound—the doctor can immediately start treatment with a drug that kills all of the expected bad actors. And if occasionally one medication won’t cover everything, then a second, and rarely a third, can be added. This works most of the time. But the broader the antibiotics and the more they are used, the bigger the collateral effects on our resident bacteria.

There are two problems with narrow-spectrum drugs. First, very few exist. We need to create and test them. If we want an antibiotic that is specific for
Streptococcus pneumoniae
, we have to identify a target in that organism that is shared by few if any other bacteria. Same for
Staph aureus
.

Second, even if we had one antibiotic for each of the thirty or forty species that cause most bacterial infections in humans, we wouldn’t know which one to use in any individual case. The coughing patient does not come in with a sign that reads “I am infected with
Streptococcus pneumoniae
.” Right now our diagnostic tests are slow, taking days or longer. Doctors need rapid tests, enabling them to sample blood, sputum, exhaled air, or urine to look for the chemical signature of particular organisms. With that information, your doctor could reach into a formulary and take out the best narrow-spectrum agent for your condition.

The good news is that it should be relatively simple to develop narrow-spectrum agents. We may have to target just one organism at a time and experiment with chemicals or even bacteriophages (viruses that eat bacteria). Bacteriophages that can be produced by the trillions do the same work as antibiotics and have been battling (and living with) bacteria for billions of years. I’m currently advising a company that is developing a type of medicine similar to phages because I believe it will lead to a new armory of narrow agents.

We also can tap into more than a decade of genomics. We have deciphered the genetic sequence of all of the major human bacterial pathogens. We know which genes are found in each organism and the potential structure of the products they make as if we had a map guiding us to the buried treasure. We can look for genes that are unique to
S. pneumoniae
. We might find specific inhibitors for particular enzymes and be able to create a “designer” antibiotic.

The bad news is that these new drugs will be expensive. For manufacturers to recoup their outlays, each five- to ten-day course of narrow-range antibiotics used in relatively few people would have to be priced at thousands of dollars, compared with the tens of dollars today for broad-spectrum drugs. Given our current economic model, this is not feasible. The pharmaceutical industry is focused on developing drugs that millions of people take every day for years—like pills for high blood pressure, diabetes, heart disease and its prevention—or ultraexpensive drugs for patients with cancer.

On the diagnostic side, there has been significant improvement of late. Currently under development are new panels of diagnostic tests that can distinguish between viral and bacterial infections much better by identifying specific agents. And a new class of diagnostics is being brought to market that use the host’s immune responses as the indicator of which organism is causing the trouble. Both of these are in their early stages, but the path to their widespread use is clear. The only issue is money.

But in the long run it may be more expensive to ignore the need for better diagnostics and narrow-spectrum antibiotics. If taking antibiotics early in life is leading to some portion of the cases of obesity, juvenile diabetes, asthma, and other disorders, what is the lifetime cost of those illnesses in dollars, not to mention suffering and years of life lost?

We can pay now to prevent or we can pay later to treat. The drugs and diagnostics that I propose would be public goods, with value for practically everyone well into the future. It’s a little like road building. Let’s say we needed a highway between Los Angeles and Phoenix. No one can afford to construct it alone, but if we build it collectively through taxes we have Interstate 10. The quality of life has improved a lot for those who live there and perhaps a little for the rest of us who might one day like to travel at high speed across the desert. Similarly, we need a national or international initiative to create the diagnostics and the therapies we need. We live in a highly interconnected world. I was shocked to learn that antibiotic use in China is even higher than it is in the United States.

C-sections are another overused medical practice that can benefit from personal and institutional changes. If you are a woman of childbearing age, carefully question the need for elective C-sections. Is it best for your baby? Ask your doctor if it is absolutely necessary. Obviously, if your doctor tells you that you need an emergency C-section to save your baby’s life or your own life, then don’t hesitate.

Recently, I spoke with a friend whose daughter was about to give birth. She knew my stance. “And remember, no C-section…” I said at the end of our conversation.

“Only if absolutely necessary,” she agreed. “If she does have a C-section, either she or I will use the gauze-in-the-vagina technique and inoculate the baby ourselves.”

The gauze-in-the-vagina technique is a practice that my wife Gloria is studying in Puerto Rico. The idea is simple. Because a baby born via C-section misses picking up microbes from the mother’s vagina, the deed can be done artificially. The mom or a helper places a gauze pad in the vagina so it collects bacteria-laden secretions and then, right after birth, gently swabs the baby’s skin and mouth. It’s not exactly the same as a vaginal birth, but microbiologically it’s a step in the right direction.

I believe that Gloria’s technique or some variants of it will become the standard practice within a few years. This is not to say that it’s perfect or won’t cause new problems. A few babies might get infections from their mothers. These might have happened in any case, but there will always be suspicion that the swabbing technique caused them. We must screen mothers for potential pathogens, and if we begin to routinely swab newborns delivered by C-section, then we’ll need to monitor outcomes across all of the relevant time frames, including the long term. Maybe one day we will understand which of the mom’s organisms are crucial and just give those to the baby, but I doubt it. In my opinion, most of them, in their diversity and plurality, may be useful.