Illustrations by Erin Erskine
Antibiotics & Superbugs: The Future of Health?
When most people think of germs, they typically think of organisms we need to avoid and extinguish, mainly through the use of antibiotics. We probably focus on harmful bacteria because they have killed millions of people across history. For example, the Spanish Flu epidemic of 1918-1919 infected one fifth of the world?s population and killed between 20 and 50 million people. It was not the flu that killed so many people; rather, the bacterial infections that attacked flu victims? lungs wer responsible for the high mortality rates. After the discovery of antibiotics in the early 1900s, death rates from bacterial infections like these plummeted, and millions of lives have been saved. The term antibiotic? was first used as a noun in 1941 by Selmon Walksin to describe a class of molecules that directly antagonized the growth of microorganisms (Walsh). Early antibiotics attacked only one kind of bacteria, but drug companies have now developed broad-spectrum antibiotics that kill a variety of microbes with one fell swoop. Jack Gilbert, Professor of Surgery at the University of Chicago and Director of the Microbiome Institute; and Rob Knight, Professor of pediatrics at the University of California, San Diego, describe these new antibiotic drugs as a kind of scorched-earth approach? to bacterial infections (68). Similarly, B. Brett Finlay, Professor of Microbiology at the University of British Columbia, and Marie-Claire Arrieta, Assistant Professor of Microbiology and Immunology at the University of Calgary, describe the use of these broad-spectrum antibiotics as carpet bombing the microbiota? (101). Unfortunately, bacteria are smart and hearty. If you are a microbe that has been bombarded by these drugs, what would you do? Like all living organisms, you would evolve. What has emerged from this evolution are bacteria called superbugs,? which are resistant to most if not all antibiotics that we have today (Finlay and Arrieta 104).
In the United States, these superbugs are killing thousands of people every year, and making thousands more ill, yet most people are not even aware of them. However, if you have recently been in a hospital, it is almost impossible not to be terrified. My father was admitted to Christiana Hospital on December 16, 2016 with a diagnosis of idiopathic pancreatitis. The treatment for this disease was to stop all fluid and food intake except for IV fluids and to provide pain relief. Ten days later, he was on a ventilator in the surgical Intensive Care Unit because he had been infected through his pic line by MRSA, a superbug, which quickly spread through his entire body. My dad was eventually taken off the ventilator, but he never made it out of the ICU. Another antibiotic resistant infection attacked his lungs, and he died on March 5, 2017. Like thousands of people in the United States, my dad did not die from the illness that put him in the hospital. He died from a superbug, just one of several that now lurk in virtually every hospital in the U.S. waiting to find a new host. It is this personal tragedy that inspired me to investigate why superbugs have emerged and how to prevent more from developing.
To understand the factors that have facilitated the rise of these superbugs, it is first important to highlight the nature of bacteria. Bacteria are part of the microbiome? family, which also includes viruses, protozoa, and other very small organisms. Finlay and Arrietta note that these microbes are the oldest and most successful forms of life on the planet, having evolved long before plants and animals ?. Although invisible to the naked eye, they play a major role in life on Earth? (Finlay and Arrietta 3). In fact, only a few bacteria are truly dangerous and cause illnesses. The majority of bacteria play important roles in both our environment and in our bodies (Finlay and Arrietta 5). Recent research has demonstrated that the microbiome is essential for human development, immunity, and nutrition. Gilbert and Knight specifically note that There are at least one hundred microbial genes for every human gene, and they are responsible for many of the biochemical activities associated with your body, ranging from digesting carbohydrates in your food to making some of your vitamins? (8).
Unfortunately, we have spent more time and energy trying to kill the harmful bacteria than investigating the important roles the beneficial bacteria play in keeping us healthy. It is easy to understand why this has occurred: antibiotics have improved quality of life provided by treating bacterial infections. After the discovery of antibiotics, the prevalence of infectious diseases declined and many infections that would have once killed many thousands of people can now usually be treated. For example, before antibiotics, 90 percent of children would die if they contracted bacterial meningitis; now most cases fully recover if treated early? (Finlay and Arrietta 7). Since the discovery of antibiotics along with other medical advancements like vaccines, life expectancy rates in developed countries including the United States have significantly increased.
It is clear that antibiotics have helped save millions of lives, but this reliance on them has come with a cost that is getting higher.
It is clear that antibiotics have helped save millions of lives, but this reliance on them has come with a cost that is getting higher. Over the past several decades, antibiotics have been indiscriminately prescribed and misused. Finlay and Arrieta note that Between the years 200 and 2010 alone there was a 36 percent increase in the use of antibiotics worldwide ?. One troubling thing about these numbers is that the use of antibiotics peaks during influenza virus infections, even though they are not effective against viral infections? (7). Other researchers have confirmed that many antibiotic prescriptions in the United States are being prescribed for all types of illnesses such as viral infections (e.g. flus and colds), which cannot be treated with antibiotics (Finlay and Arrieta).
How do we know that this increase is really the misuse of antibiotics? A recent study published by the Journal of the American Medical Association analyzed two survey data sets collected by the Centers for Disease Control (Fleming-Dutra et al.). These two surveys collected information on the diagnosis and treatment for patient visits to two types of facilities. One survey collected information from a random sample of non-federally-employed, office-based physicians, and the other survey collected information from a random sample of non-federal emergency and outpatient departments and non-federal short-stay hospitals across the United States. Results indicate that in the United States in 2010-2011, there was an estimated annual antibiotic prescription rate per 1000 population of 506, but only an estimated 353 antibiotic prescriptions were likely appropriate? (Fleming-Dutra et al. 1866). In total, about half of antibiotic prescriptions for respiratory conditions, and 30% of all outpatient antibiotic prescriptions were deemed to be inappropriately prescribed (Fleming-Dutra, et al. 1869). Finlay and Arrieta more directly state, Antibiotics have gone from being miracle drugs that could bring a dying person back to life to being used indiscriminately for every fever in a child? (113).
The overuse and misuse of antibiotics has two consequences: not only are these unnecessary antibiotic prescriptions ineffective in treating patients? illnesses, but the bacteria that reside in the bodies of these patients, which are either beneficial or not harmful, are still going to be attacked. This is where the term carpet bombing? has been applied. Finlay and Arrieta, who used this military metaphor, explain that This indiscriminate killing of many bystander microbes, in addition to the desired infectious agent, has had unintended consequences. We?re starting to realize that we may be wiping out microbes from our society before we even realize that they?re beneficial ?. Our quest to kill them all may have serious consequences for future generations? (110). In fact, it is having serious consequences now.
This overuse of antibiotics is compounded by the misuse of them by patients once they are prescribed. Every prescription has instructions for using a medication, that is, how many pills should be taken and how often. However, many people will stop taking their prescriptions when they start to feel better, thinking that they have been cured, but the bacterial infection is usually still alive and well. Compounding this problem is that many of these same people will save their unused antibiotics and take them when symptoms reappear and/or give them to friends and relatives to take. These people will also get a reduced dosage, thereby increasing the likelihood that more attacked bacteria will live. Because these bacteria have been attacked but not killed, they have an increased likelihood of becoming resistant the next time they encounter the same antibiotic (Gallagher).
Because they can evolve relatively quickly, bacteria that are resistant to a particular antibiotic are also likely to emerge relatively quickly.
How does overuse and misuse of antibiotics actually create superbugs? We know that all species develop based on principles of evolution, which involves competition and cooperation. Bacteria also reproduce quickly, which means they evolve quickly. In fact, some bacteria can double in numbers every 20 minutes (Gallagher). Unlike many species, microbes are masters at cooperation? (Gilbert and Knight 3). Bacteria not only share genetic information with their offspring, they share their genetic material with other microbes that just happen to be nearby. Every time bacteria are exposed to an antibiotic, their evolutionary instinct is to evolve to resist being killed. Combined with random mutations that naturally occur, this provides a lot of opportunities for bacteria to become resistant to antibiotics. Because they can evolve relatively quickly, bacteria that are resistant to a particular antibiotic are also likely to emerge relatively quickly. When this happens, the genetic information that allows for this resistance is passed along not just to their progeny, but to all neighboring bacteria as well. This process is called conjugation. James Gallagher, Heath Editor for the BBC News, states that conjugation is a bit like going for a walk and swapping genes for hair color with the neighbor?s dog.? Ironically, Sir Alexander Fleming, the Scottish physician who discovered one of the first antibiotics called Penicillin, noted the problem of bacteria?s ability to become resistant in the lecture he gave after winning the Nobel Prize for his discovery. He stated that the time may come when Penicillin can be bought by anyone in the shops. Then there is the danger that the ignorant man may easily underdose himself and by exposing his microbes to non-lethal quantities of the drug make them resistant? (qtd. in Gallagher). It is unfortunate that nobody appeared to listen to him back in 1945.
The use of antibiotics in livestock populations is another factor that has contributed to the emergence of superbugs. In fact, about 70% of all antibiotics produced in the U.S. are given to livestock including chickens, pigs, cows, and pigs (Moyer). A large percentage of this use is not for illnesses that require treatment, but to increase animal growth. In addition, livestock housed in tight quarters in feed lots are also given sub-therapeutic doses of antibiotics to prevent them from getting sick. A reporter from Scientific Americaninvestigating the use of antibiotics on pig feed lots describes this use: Beard [the pig farmer] planned to give them feed containing antibiotics ? a necessity if they were to stay healthy in their crowded, manure-gilded home. Antibiotics also help farm animals grow faster on less food, so their [antibiotic] use has long been a staple of industrial farming? (Moyer).
Empirical evidence, like that for humans, has documented the relationship between the overuse of antibiotics in livestock populations and the emergence of superbugs. Based on this evidence, the European Union banned the use of antibiotics for livestock growth promotion in 2006. In the United States, however, lobbying groups for pharmaceutical companies and for the livestock industry have fought against such legislation. Moreover, these same groups continue to wage a media campaign attempting to convince the public that antibiotic use in livestock populations does not pose any threats to the public safety of humans. In fact, the International Business Times reports that U.S. farmers are still allowed to use many antibiotics in livestock with few restrictions despite the toll on public health partly because two of the nation?s most influential lobbies?the pharmaceutical industry and the meat production industry?have bankrolled a long fight to retain their freedom to use, as they see fit, antibiotics in animals? (Nordrum and Whitman). Combined, these lobbying groups spent 23.5 million dollars lobbying against legislation aimed at eliminating antibiotic use for growth, and against another bill that would require drug manufacturers to report data on how antibiotics are used on farms (Nordrum and Whitman). Needless to say, this federal legislation to ban nontherapeutic use of antibiotics for livestock has not even made it out of a U.S. Congressional committee.
The U.S. Food and Drug Administration (FDA) did establish guidelines that discourage the use antibiotics in animal feed and/or water to promote growth, and these guidelines were implemented on January 1, 2017. However, following these guidelines is only voluntary. That is, livestock producers are asked to comply with these guidelines of their own accord. Still, the FDA strongly claims that the public will be much safer once these voluntary? guidelines are followed. On their website, it states, By law, drugs administered through feed must be used according to the approved labeling ?. Therefore, once manufacturers voluntarily [emphasis added] make these changes, medically important antimicrobial drugs can no longer be used for production purposes, and their continued use to treat, control, or prevent disease in food animals will require an order or prescription from a licensed veterinarian? (U.S. FDA).
Despite the lack of action at the Federal level to curb antibiotic use in livestock populations, public pressure is beginning to have an effect on changing the policies of some companies. For example, in 2015, McDonald?s, one of the largest buyers of chicken in the U.S., announced that they would begin using only chickens not given antibiotics. The National Chicken Council responded by stating, A vast majority of antibiotics used for disease prevention in the industry were never given to humans. Chicken producers have a vested interest in protecting the effectiveness of antibiotics for the welfare of their animals. As such, we?ve proactively and voluntarily taken steps toward finding alternative ways to control disease while reducing antibiotic use? (qtd. in Strom).
Other fast food chains have also taken similar steps. Before a petition with hundreds of thousands of signatures was to be delivered to the main headquarters of the fast food chain Subway, it too announced that it would adopt stronger antibiotic-free policies for their chicken and turkey (Nordrum and Witman). However, critics say that making these policies for poultry is relatively easy because the three major poultry producers (Tyson?s, Pilgrim?s, and Sanderson Farms) have already taken measures to reduce their use of antibiotics for non-medical purposes. Lena Brook, of the National Resources Defense Council (NRDC) explains, Chicken is the low-hanging fruit in this scenario. For restaurants, making the switch to antibiotic-free beef and pork is where the real difficulty lies, because there?s so much less [antibiotic free beef and pork] available? (qtd. in Hackett). Supporting this contention is the fact that Subway does not plan to make the switch to antibiotic-free beef until 2025.
States are also taking action on their own to limit non-medical use of antibiotics in livestock populations. In October of 2015, California became the first state in the U.S. to ban farmers and ranchers from using low doses of antibiotics in healthy animals to prevent illness or to accelerate growth, but the legislation does not go into effect until January 2018 (Calefati). Other states, including Maryland, Minnesota, New Jersey and New York, are also considering similar legislation.
Today, there is a consensus in the medical and scientific community that the world?s widespread antibiotic use has led to the emergence of so-called superbugs,? which are resistant to most of if not all of the antibiotics available to fight them. The World Health Organization contends that the rise of resistant bacteria is one of the world?s most serious health crises, which is estimated to kill more people by 2050 than currently die from cancer (Walsh). Timothy Walsh, Professor of Medicine at Cardiff University, states, Antibiotic resistance in some parts of the world is like a slow tsunami, we?ve known it?s coming for years and we?re going to get wet? (qtd. in Gallagher). Despite this consensus, the medical community continues to prescribe unnecessary antibiotics for humans, most operators in the livestock industry still deny their responsibility and continue to use antibiotics for non-illness related reasons, and the U.S. federal government has still not taken serious steps to address the crisis or even monitor it.
Making this crisis even more urgent is the fact that only 2 new classes of antibiotics have been approved since 1998. Moreover, the antibiotics now under development are part of existing classes and are broad spectrum in nature, which increases the likelihood that these new drugs will only further promote resistance strains of bacteria. Why are pharmaceutical companies not being more aggressive in developing new classes of antibiotics? Medical doctors from the Mayo Clinic, Shira Doron and Lisa Davidson, explain: The reasons for this are simple: drug development is risky and expensive, and drugs to treat infections are not as profitable as those that treat chronic disease? (1113).
Like those for livestock, medical policies directed at humans to prevent the emergence of more superbugs remain voluntary and are termed antibiotic stewardship? (Doron and Davidson). Antibiotic stewardship has been defined as the optimal selection, dosage, and duration of antimicrobial treatment that results in the best clinical outcome for the treatment or prevention of infection, with minimal toxicity to the patient and minimal impact on subsequent resistance? (Doron and Davidson 1114). The first goal of this stewardship is to encourage heath care practitioners to prescribe the correct and properly dosed antibiotic that has the least collateral damage on other bacteria. This will hopefully serve to prevent overuse, misuse, and abuse. Overuse and misuse have been discussed above, but abuse is somewhat different. Doron and Davidson note that abuse is hard to define, but generally speaking, it is the use of one particular antibiotic preferentially over others by a physician as a result of aggressive detailing by the pharmaceutical representative or worse because of financial interest? (1114). Unfortunately, despite the push by CDC for health care organizations to implement these stewardship programs, a national survey of hospitals found that only about half of them (51%) reported that they had a formal Antibiotic Stewardship Program in place (Doron and Davidson).
The reality of superbugs must be acknowledged and taken seriously by all nations if we are going to prevent a health crisis. What can be done about this looming health crisis and how many people will have to die unnecessarily before our federal government takes the threat of superbugs more seriously? The scenarios that are predicted by scientists are not just doomsday exaggerations, but they are already happening. Dame Sally Davies, Professor of Medicine and the chief medical officer for England, stated, The soaring number of antibiotic-resistant infections poses such a great threat to society that in 20 years? time we could be taken back to a 19th century environment where everyday infections kill us as a result of routine operations? (qtd. in Whiteman). By not taking more serious action to combat antibiotic resistance, the question is not if we will return to living in a pre-antibiotic world, but when.
Author: John Bachman-Paternoster
During my first year of college, my dad went into the emergency room with what we thought was a bad case of food poisoning. I remember vividly because it was during finals week. He was diagnosed with idiopathic pancreatitis, which we were told goes away in about 10 days in about 90% of cases.? He caught a superbug? in the hospital that went septic throughout his body and ended up in the ICU on a ventilator. Of course, the doctors didn?t use the term superbug?; they simply said that he was not responding to the antibiotics. After being on a ventilator, and after several surgeries, he began to recover, but he was infected again with another antibiotic resistant bacterial infection that killed him on March 5, 2017. How could someone go into the hospital with one thing and die from a bacteria caught in the hospital while trying to recover? I wanted to answer this question. The 110 essay gave me the opportunity to investigate the issue of antibiotic resistant infections, and I was horrified by what I uncovered. I started first in the medical literature, but found the articles focused on very specific questions not related to the big picture. Although they were helpful, they didn?t answer the larger question of how thousands of people can die from these infections every year and nobody seems to be aware of it. I then found 3 books that provided good overviews of the issue, each with different perspectives. These books led me down other research paths. For example, a chapter in one book highlighted the problem of antibiotic use in the livestock industry, so I went to the U.S. Food and Drug Administration (FDA) to see what they were doing about it. As you can see in the essay, virtually every scientific and governmental agency acknowledges that antibiotic resistance infections will kill an increasing number of people annually, but very little is being done about it. While this research provided the answers I sought, I hope it can be used to educate people about this tragic reality and compel them to get involved and demand action.
Instructor: Professor Frank Hillson
My research project provides the inquisitive and motivated student an opportunity to investigate any topic which strikes his or her fancy, as long as it is approved by the instructor. The topic generally emerges from a personal interest or perhaps a desire to investigate an intriguing concern, but it must satisfy four basic requirements: is it researchable, is it arguable, is it significant, and is it likable. This last query highlights the large amount of time and effort (approximately two months) the writer will spend on composing, drafting, and editing a researched argument of approximately 10 pages. Hopefully, it should be a pleasurable, albeit challenging, writing experience. Daniel Scanlon picked an educational issue concerning African-Americans, which impacts our entire nation. His idea grew out of material in our Honors E110 course: The Slave Narrative: Past and Present.? He found a problematic area?the current educational discrepancies between black and white student achievement?which, he argues, stems from educational practices (or lack thereof) in the antebellum South. John Bachman-Paternoster was piqued by a medical issue based on a poignant personal example. He further researched this topic and built his research paperAntibiotics and Superbugson keen data and examples of the potential catastrophe, which the over prescription and misuse of antibiotics could cause to humanity. Both authors wrote insightful and significant pieces in an engaging and convincing voice.
Works Cited
Calefati, Jessica. Antibiotics Ban: California First state to Outlaw Routine Use of Bacateria-Fight Drugs in Livestock.? The Mercury News, 10, Oct., 2015. http://www.mercurynews.com/2015/10/10/antibiotics-ban-california-first-state-to-outlaw-routine-use-of-bacteria-fighting-drugs-in-livestock/.
Doron, Shira, and Lisa E. Davidson. Antimicrobial Stewardship.? Mayo Clinic Proceedings,vol. 86, no. 11, November 2011, pp. 1113-1123.
Finlay, Brett B., and Marie-Claire Arrieta. Let Them Eat Dirt: Saving Your Child from an Oversanitized World. Algonquin Books of Chapel Hill, 2016.
Fleming-Dutra, Katherine E. et al. Prevalence of Inappropriate Antibiotic Prescriptions Among US Ambulatory Care Visits, 2010-2011. JAMA, vol. 315, 2016, pp. 1864-1873.
Gallagher, James. Analysis: Antibiotic Apocalypse.? BBC News. 19 Nov., 2017.http://www.bbc.com/news/health-21702647.
Gilbert, Jack, and Rob Knight, with Sandra Blackeslee. Dirt is Good: The Advantage of Germs for Your Child?s Developing Immune System. St. Martin?s Press, 2017.
Hackett, Jennifer. Antibiotics: Fast-Food Chains are Leading the Charge Against Antibiotic Overuse in Food Production. Scientific American. 28 Oct., 2015. https://www.scientificamerican.com/article/subway-joins-other-fast-food-giants-to-cut-back-on-antibiotics/.
Moyer, Melinda Wenner. How Drug-Resistant Bacteria Travel from the Farm to Your Table.Scientific American, 1 Dec., 2016. https://www.scientificamerican.com/article/how-drug-resistant-bacteria-travel-from-the-farm-to-your-table/.
Nordrum, Amy, and Elizabeth Whitman. Antibiotic Resistance: How Livestock Lobbyists and Drug Companies Hinder the US fight Against Superbugs.? International Business Times. 29 April, 2015. http://www.ibtimes.com/antibiotic-resistance-how-livestock-lobbyists-drug-companies-hinder-us-fight-against-1901499.
Strom, Stephanie. McDonald?s Moving to Limit Antibiotic Use in Chickens.? The New York Times, 4 March, 2015. https://www.nytimes.com/2015/03/05/business/mcdonalds-moving-to-antibiotic-free-chicken.html.
U.S. Food and Drug Administration. FDA?s Strategy on Antimicrobial Resistance: Questions and Answers.? https://www.fda.gov/AnimalVeterinary/GuidanceComplianceEnforcement/GuidanceforIndustry/ucm216939.htm.
Walsh, Fergus. Superbugs to Kill More Than Cancer by 2050.? BBC News. 11 Dec. 2014. http://www.bbc.com/news/health-30416844. Accessed 30 Nov., 2017.
Whiteman, Honor. Antibiotic Resistance: How Has it Become a Global Threat to Public Health Medical News Today. 10 Sept., 2014. https://www.medicalnewstoday.com/articles/282357.php.
Paper Prompt
My research project provides the inquisitive and motivated student an opportunity to investigate
any topic which strikes his or her fancy, as long as it is approved by the instructor. The topic
generally emerges from a personal interest or perhaps a desire to investigate an intriguing
concern, but it must satisfy four basic requirements: is it researchable, is it arguable, is it
significant, and is it likable. This last query highlights the large amount of time and effort
(approximately two months) the writer will spend on composing, drafting, and editing a
researched argument of approximately 10 pages. Hopefully, it should be a pleasurable, albeit
challenging, writing experience. Daniel Scanlon picked an educational issue concerning
African-Americans, which impacts our entire nation. His idea grew out of material in our
Honors E110 course: The Slave Narrative: Past and Present.? He found a problematic area?
the current educational discrepancies between black and white student achievement?which, he
argues, stems from educational practices (or lack thereof) in the antebellum South. John
Bachman-Paternoster was piqued by a medical issue based on a poignant personal example. He
further researched this topic and built his research paperAntibiotics and Superbugson
keen data and examples of the potential catastrophe, which the over prescription and misuse of
antibiotics could cause to humanity. Both authors wrote insightful and significant pieces in an
engaging and convincing voice.