Posts Tagged ‘antibiotic resistance’
physical examination photo copyright istockphoto
Ear infections (otitis media) are serious business, whether you’re a parent or practitioner. Approximately 75% percent of children have one by the age of three and almost half of them have 3 or more ear infections by that age. By the age of 7, 93% of children have experienced an ear infection. This led to a total of 8.8 million ear infections in children during the year 2006, and most of those were in children 7 and under. These infections cost those of us in the US approx $5 billion dollars annually to address, and are the primary cause for childhood antibiotic prescription.
In fact, the typical situation involves an upper respiratory infection, which leads to a visit to the primary care provider. This in turn results in a peek into the ears and, quite often, a diagnosis of an ear infection as well. In some cases, the ear infection causes pain, and the child’s complaints spur the visit to the care provider. Regardless, this diagnosis usually results in a prescription for an antibiotic, and in many cases, the antibiotic of choice is stronger than the drug used to treat the previous infection. The prescription begins and within a few days, the symptoms subside and parents once again are increasingly grateful for the benefits of modern medicine.
While this scene plays out all across our country, many parents don’t realize that this standard practice is in direct conflict with evidence-based medicine, AAP guidelines, and the standard of care for ear infections across the world. Even fewer parents realize that this standard practice may be causing our children more harm than benefit.
Here’s the catch. Actually, there are a couple:
1. Ear infections are not always correctly diagnosed. According to the AAP, “The diagnosis of AOM, particularly in infants and young children, is often made with a degree of uncertainty.” (AOM = acute otitis media) Each year, thousands of prescriptions for antibiotics are written for conditions that never were ear infections.
2. Studies show that antibiotics don’t have a benefit in most ear infections. The vast majority of ear infections resolve on their own without antibiotic treatment. This takes a couple of days in many cases, and can coincide with antibiotic treatments, leading many parents to believe the antibiotic is actually curing the infection, furthering the belief that they won’t go away on their own.
3. Because antibiotics are overused in ear infections, we’re now having to use stronger drugs than we could have used in previous generations. This means more side effects and more resistance. According to the AAP, “Greater resistance among many of the pathogens that cause AOM has fueled an increase in the use of broader-spectrum and generally more expensive antibacterial agents.” For more info about the very real risks of antibiotic overuse, see here.
4. Antibiotics don’t relieve pain or distress. They will not make our little ones feel better sooner. Pain relief treatments are responsible for that. Reducing the inflammation and the accumulation of fluid will make our little ones feel better; an antibiotic does neither of those things. However, a study published in Pediatrics in 2003 does show that an herbal ear oil treatment can help to relieve the inflammation, reduce pain, and reduce the duration of the illness, faring much better than the antibiotic test group.
5. The AAP has clearly recommended since 2004 that practitioners use the “wait and see” approach for most children. Given that 61% of children naturally have decreased symptoms within 24 hours, with or without antibiotics, and that 75% of children have a decrease in symptoms within 7 days, the official recommendation is that antibiotic use be delayed for the first 48-72 hours in most children. This will dramatically reduce the use of needless antibiotics, reserving them for the small percentage of children that would receive the most benefit. Additionally, studies show that immediate antibiotic treatment does little to reduce the duration of the infection and does nothing to reduce pain or distress in the child.
So here’s the crux of the problem – why does this matter? So what if antibiotics don’t work on most ear infections and we’re using stronger antibiotics than ever before? Parents need to feel like they’re doing something and this gives the parent comfort. And after all, some ear infections do need antibiotics.
The problem is – antibiotics have risks. In fact, the risks of antibiotic treatment, according to several studies, outweighs the potential benefit. According to the studies, initiating antibiotic use at the first visit may reduce the symptoms by 1 day in between 5% and 14% of children. However, it will cause adverse effects in 5% – 10% of children, it can cause infrequent but serious side effects, and it increases the risks of antibiotic resistance. These side effects are numerous and can lead to chronic health concerns. When it takes between 7 and 20 prescriptions for 1 child to benefit, and each of those prescriptions have clear risks, the overall situation just isn’t worth it. That, coupled with the success of wait and see approaches in European countries, played a role in prompting the AAP to make those recommendations years ago.
So the keys for ear infection management include: prevention (breastfeeding!), obtaining an accurate diagnosis or having clear conversations about the degree of certainty with a diagnosis, focusing treatment measures on comfort and the natural options that have clear records of success (many natural options do not have clear records of success and some are risky), and keeping an eye on the infection for the first few days to seek advanced help if indicated. Not only does this benefit our own children, it helps to reduce the overall antibiotic load, reducing our community risks of antibiotic resistance.
Sources:
NIH Pub. No. 97-4216 July 2002
Gates GA. Cost-effectiveness considerations in otitis media treatment. Otolaryngol Head Neck Sur. April 1996. 114 (4): 525-530
Soni, A. Ear Infections (Otitis Media) in Children (0-17): Use and Expenditures, 2006. Statistical Brief #228. December 2008. Agency for Healthcare Research and Quality, Rockville, MD
Rosenfeld RM, Vertrees JE, Carr J, et al. Clinical efficacy of antimicrobial drugs for acute otitis media: metaanalysis of 5400 children from thirty-three randomized trials. J Pediatr.1994;124 :355– 367
Del Mar C, Glasziou P, Hayem M. Are antibiotics indicated as initial treatment for children with acute otitis media? A meta-analysis. BMJ.1997;314 :1526– 1529
Glasziou PP, Del Mar CB, Hayem M, Sanders SL. Antibiotics for acute otitis media in children. Cochrane Database Syst Rev.2000;4 :CD000219
Rosenfeld RM, Kay D. Natural history of untreated otitis media. In: Rosenfeld RM, Bluestone CD, eds. Evidence-Based Otitis Media. 2nd ed. Hamilton, ON, Canada: BC Decker Inc; 2003:180–198
Subcommittee on Management of Acute Otitis Media Diagnosis and Management of Acute Otitis Media Pediatrics Vol. 113 No. 5 May 1, 2004; 1451 -1465
(intro note: If you haven’t read part 1 and part 2, you’ll want to read though those to get the full background of the situation and why resistance is such a growing concern.)
So, it’s easy to talk about antibiotic resistance and antibiotic overuse without clearly defining the situation. Does anybody really think they overuse anything? We all generally feel that we only use medication when necessary, I’ve never met with a parent that believed he or she overuses antibiotics, even if their family uses them once a month. After all, if we didn’t use antibiotics, what would we do instead? And that’s exactly why so many of the campaigns by the World Health Organization and other medical professionals appear to be falling short.
What are we doing that could be changed to lessen the trend of antibiotic resistance? And what can we do in place of those habits? We’ll look at our current habits first, then cover the solutions in the next installment.
Before we dig into specifics that cause antibiotic resistance, I want to make it absolutely clear that these habits are learned and have been taught–even by medical professionals at times. They are not indicators of bad parenting or uneducated individuals–they are habits that were passed down from generation to generation, based on the initial excitement about the new wonder drug that would end all disease. So, there’s no judgement here – but we can’t save antibiotics without looking at the habits that are risking this valuable drug’s future.
1. Viral Infections - Many Americans believe that even though antibiotics are ineffective against viruses, they may still help fight a viral infection. However, studies show that not only are they ineffective, they worsen viral infections! So, in addition to contributing to antibiotic resistance, antibiotic use for a viral infection does more immediate harm than good.
2. Just in case – Many parents want an antibiotic “just in case” for an infection. Yet, (again) studies show that antibiotics can actually make viral infections worse… longer lasting and with stronger effects. If the infection is not determined to be bacterial–and even if it is–antibiotics may not be the best treatment option. Many infections are best treated without antibiotics. This again ensures better health now, and the longevity of antibiotic options for our children.
3. Ear infections – Professional organizations have been saying for over a decade that the wait and see approach to treating ear infections is medically superior to treating with antibiotics. Not because they shouldn’t be treated, but because antibiotics can actually cause recurring ear infections! Clinical trials show that antibiotics rarely do any good, and some alternatives have fared better than standard antibiotic treatment. (Additionally, many ear infections are not bacterial; most are viral.)
4. Patient Demand - When polled, physicians listed “patient demand” as the #1 cause of prescribing antibiotics. Physicians know that parents will turn around and find another provider to prescribe these drugs if they don’t. And in their short 15 minutes of visit time–or even less on a phone call–they don’t have the time necessary to educate the parent on the misuse of antibiotics. So, many have admittedly just given in. This is one key reason that public health agencies such as the CDC and WHO have initiated awareness campaigns that attempt to educate the public about the antibiotic crisis. However, many parents still consider a physician to be a “good” physician if they’ll prescribe an antibiotic over the phone without an office visit. This has also contributed to care providers prescribing antibiotics when they’re not needed under the assumption that the patient is requesting one.
5. The Wrong Antibiotic – Antibiotics are not all the same. Most individuals now know some are stronger than others, but they differ in many different ways. Initially, they were designed to be effective against single diseases. Bacteria can be classified as gram positive or negative, and antibiotics are often more effective against one or the other. Some antibiotics are broad spectrum antibiotics or effective against a lot of bacteria, both gram positive and negative. These antibiotics should be reserved for extreme life saving situations when there is not time to properly identify the offending bacteria, but are often used as a short cut to save time.
6. Incorrect Prophylactic Use – This is the idea that a constant dose of antibiotics will prevent infection. In other words, instead of waiting for the infection to begin, this means treating it before it begins–assuming that it will. Not only is that usually based on bad science, it greatly contributes to resistance and often results in lasting harm to the individual. I’ve worked directly with numerous individuals that are experiencing the negative results of previous prophylactic use. Acne, infection prevention and other common causes of long term prophylactic use are generally better treated with other safer and more effective measures.
7. Animal Husbandry – Animals are among the most common recipients of prophylactic antibiotics. Constant treatment with antibiotics will often result in a faster growing animal and are thought to prevent infections (see #6) However, in reality, this habit is not good for the animal or the individuals that consume the animals–and it contributes significantly to resistance.
8. Antibiotics in the Home / Hand Sanitizers – These habits are directly related to the notion that we can sanitize our lives, eliminating disease. We can’t–and don’t want to–sanitize our lives. Bacteria are our friends in most cases, and experts have determined that the use of antibiotics in the home and in portable sanitizers actually acts as a stimulant for the mutation of bacteria and the development of resistance. It actually hastens the cycle exponentially. With the information we now have about the benefits of routine bacteria exposure, these habits are doubly harmful to children.
WHY are these habits bad? In addition to the situations where the treatment is worse than the disease–or worsens the disease–they contribute to antibiotic resistance. Resistance–if not halted–will result an a post antibiotic era, thrusting us back to a time in which we don’t have the option of antibiotics to treat disease. Imagine yourself 10 years from now. What routine but life saving procedures would not be available to you without antibiotics? What diseases would you fear without antibiotics? The fear parents experienced decades ago with the looming threat of diphtheria and other pre-antibiotic era diseases can and will return unless something changes.
Fortunately, we do have evidence that this cycle can be not only halted but reversed. Countries that have banned routine animal antibiotic use, restricted the availability of antibiotics and implemented public awareness campaigns (like the CDC has with the Get Smart campaign) find that older antibiotics are once again useful; the trend has been halted in places.
In the next installment, we’ll look at practical ways to respond to each of the situations listed above. There are simple and effortless tools available for each of the issues–things that result in wellness without risking one of our most valuable tools!
Antibiotic overuse and the risk of losing antibiotics is a tough concept to understand without reviewing some basic information about bacteria and how it reacts to antibiotics. We have a misconception in our society that antibiotic use is without risks, and there is nothing wrong with taking a dose – or a series of doses – just in case. Yet, nothing could be further from the truth. For this installment, we’ll take a peek into the inner workings of bacteria and see what actually happens when bacteria change.
Bacteria are single celled organisms. There are countless types of bacteria throughout our environment. Don’t get grossed out. This is actually a really good thing! Bacteria can be found in the depths of an ocean, in the intestines of animals and humans, in the frozen tundra and miles deep into the earth. They are everywhere. It has been estimated that we have more bacterial cells in our bodies than human cells. This is a good thing! It really is!
We live in a symbiotic relationship with bacteria. They help us to digest our food. They protect our skin from infection. They protect our bodies from infection. Bacteria protect us. These single celled organisms are our friends.
We’ve all heard of pathogenic bacteria with frightening abilities to cause meningitis, pneumonia, ear infections and countless other infections. (As seen in the cartoon drawing of a mean, nasty bug at the beginning of this post!) Yet, we rarely discuss the fact that the vast majority of bacteria are actually good for us. They protect us from these pathogenic bacteria. Researchers are now finding that a variety of conditions from obesity to autoimmune disorders can be linked to bacteria. The beneficial bacteria on our skin protect us from infections. The beneficial bacteria in our gut make sure that we can use the nutrients we consume. A goal of eradicating bacteria from our environment is the frightening concept because we’d quickly perish without the valuable benefits of bacteria.
As living beings, bacteria are also constantly adapting to their environment. They mutate over time and develop new traits, just like humans. And, like humans, they also have the ability to reproduce, creating bacteria with new abilities. Unlike humans, bacteria are asexual. Yet, they have a gene swapping ability that enables them to provide other bacteria with super traits. In some cases, this may mean more bacteria have the ability to resist penicillin or another antibiotic. It may mean that these bacteria have the ability to stay in a dormant state for a longer period of time. It may mean that certain bacteria have the ability to emit toxins within the body. In some cases, this has caused previously friendly bacteria to become pathogenic, thanks to the passing of new traits and abilities.
In humans, this means that a specific strain of bacteria becomes resistant to previous antibiotics and becomes more dangerous at the same time. Not only is it now more difficult to wipe out, it is more likely to be deadly in a faster time span. It means that individuals can now acquire MRSA (a specific type of resistant bacterial infection) from their communities, not just hospitals. It means that individuals are now dying from bacterial infections – something thought to be impossible decades ago. It means that surgical procedures are more dangerous than they were previously because of the potential for incurable infections and it means that today’s children are requiring stronger, second and third generation antibiotics to cure infections that were treated in our childhood with much milder drugs.
What causes this to happen? Some of it is natural. It happens just because it is going to happen. However, research has shown us that the vast majority of the danger currently taking place with certain pathogenic bacteria can be directly linked to human behavior. The overuse of antibiotics is a critical factor in this occurrence, and we have complete control over this factor.
In the next installment, we’ll look at the things that we are doing that are causing it and what it will mean to humankind if this trend continues. Stay tuned…
How it all began…
To understand the issue of microbial resistance, it is best to understand this history of antibiotics and their use. So, like anything I write, we’ll start at the beginning… In 1928, a Scottish biologist by the name of Alexander Fleming (pictured above) was conducting research in a laboratory. Having accidentally contaminated one of his bacterial cultures with a fungus, he returned to work one day to find that the fungus had destroyed all of the bacteria surrounding it in the culture. “That’s funny,” he remarked, not realizing that this funny incident would soon become legendary. Alexander Fleming had discovered the source of the first modern antibiotic, penicillin. In 1929, his work was published in medical journals and the course of medicine would be changed dramatically. Over the next two decades, researchers refined his discovery, working with the chain of fungus to isolate the active principles and make it suitable for human use. By the mid 1940s, antibiotics were ready to be used in modern medicine, sparking a revolution in medicine as it was known at the time.
Suddenly, diphtheria, typhoid, pneumonia, meningitis and other horrific diseases were curable. No longer did parents have to dread the word diphtheria from their physicians – this new miracle drug could cure it. It could cure everything! When the public discovered the drug, they rushed to purchase it, and manufacturers made sure that it was readily available. It was included in cough drops, lotions, cough remedies – over the counter medicines for just about any ailment… no prescription needed!
Alexander Fleming had a problem with this. He advised that the drug should be only made available through iv administration so that it could be regulated in a hospital. If it was made available to the public, he warned, bacterial resistance would emerge. While scoffers abounded, the first documented antibiotic resistant bacterial infection occurred only a year later. Within a decade, 59% of bacterial strains isolated from sick patients were resistant to penicillin – over half!
Not to worry though! The war on infection was now won. New antibiotics began to pour out from researchers and manufacturers. With every resistant strain was a new, stronger and more harsh antibiotic. The days of dangerous life threatening infections were something of the past. Physicians began using this new tool for everything that came along – bacterial infections, viral infections, fevers, colds, anything… just in case.
So, you may wonder… where exactly is the problem? How is this a bad thing? It’s not… it’s a great advancement of modern medicine. However, it’s an advancement we may lose very soon, if things don’t change dramatically.
As Fleming warned, resistance can occur with bacteria – quickly. Bacteria have the ability to swap genes with other bacteria and they can mutate to form resistance to attackers in their environment. What this means is that when antibiotics are used widely, bacteria will learn how to thrive in spite of it – it adapts to its environment so that it is not wiped out. This can take place in a matter of minutes, but it takes researchers decades to release new antibiotics. We take far longer to come up with new ammo than it takes bacteria to come up with new resistance abilities. When this happens, if we don’t create new antibiotics that keep up with the resistance, bacterial infections cannot be cured. Global health professionals are telling us that if things don’t change, we will be thrown back to a pre-antibiotic era of medicine, where we don’t have the ability to cure bacterial infections and lives that could have easily been saved will be lost.
Consider these facts:
- For decades, an incurable bacterial infection was unheard of… it didn’t exist. Now, 19,000 individuals die annually in the United States due to antibiotic resistant infections. (25,000 in the EU)
- In the 1990s, 20 pharmaceutical companies were researching new antibiotics. Currently, there are two.
- The World Health Organization has declared that the single greatest threat to worldwide health today is antibiotic resistance … not AIDS, not famine, not malaria… antibiotic resistance.
- New stains of resistant bacteria are being discovered frequently – many worse than the previous discovery.
- Antibiotic resistant strains can be acquired from the community, not just the hospital, which means they are spreading throughout society becoming more and more prominent.
- Roughly 440,000 new cases of drug resistant tuberculosis arise annually worldwide … resulting in approximately 150,000 deaths.
- Without reliable antibiotics, routine procedures such as surgery, chemotherapy, organ transplants and similar procedures would become dangerous and risky – if possible at all.
- Almost half (49%) of our beef in the US contains drug resistant bacteria. Our poultry also contains a significant amount of antibiotic resistant bacteria.
The problem is not isolated to any specific country; it is an issue the entire world shares and the entire world will lose the benefits of antibiotics if action is not taken. The World Health Organization assures us, “No action today = no cure tomorrow.” In this series, I’m going to cover how exactly this happens, what is causing it, how it affects each of us, what we can do about it, and what happens on a large scale when we each take action. The good news is that we do have time to act… antibiotics can be saved. But now is the time to do so… not after we’ve lost the benefit of one of the greatest advancements in modern medicine.
Antibiotic resistance is a hot topic right now. We’re finding that new superbugs exist – more dangerous than the last. And we’re finding that resistant bacteria is everywhere – including our food supply! This issue isn’t a new one… far from it. We’ve been warned for years that this is a big concern – Alexander Fleming even predicted it decades ago! We teach about responsible antibiotic use and prevention of resistance in our courses – and have since the formation of the school in 2007.
So, I’m prepping a series about resistance. Just the facts… how this happens, why it’s a concern and what we can do to protect our children and their children from entering a pre-antibiotic era soon. We also have some fabulous guest posts from Elizabeth Battle, a Clinical Master Herbalist student with Vintage Remedies on some antibiotic herbs that make great options. Interested? Stay tuned… and if you have specific questions, I’m still tweaking the posts and would love to fit those answers in for you. Just leave your thoughts or questions in the comments below.