The post-antibiotics era

[CharonY]

In various threads we have (albeit briefly) touched on the fact that resistant bacteria are starting to overwhelm our ability to treat them. Now the CDC has issued a new antibiotic resistance threat report, Basically every 4 hours a new resistant strain is detected and about 35k people die every year due to resistant strains. Countermeasures that have started since the last report came out (2013) were less effective than hoped. Among the biggest threats currently are resistant Acinetobacter, Candida auris, Clostridioides difficile (formerly Clostridium), carbapenem resistant Enterobacteriaceae, and resistant Neisseria gonorrhoeae.

There are a lot of issues that have to solved outside the clinical environment, such as reducing or stopping the massive use of antibiotics in agriculture. There, antibiotics are routinely used to fatten animals which results in massive amounts of antibiotics released into the environment and enter the human food chain. Another aspects are procedures in health care (including elderly care) which are often not up to par to limit microbe spread. The challenge is that a single failure can lead to spread through the health care services.

There are folks still hoping that we will find an alternative treatment that will be as useful as antibiotics (which we messed up badly) but so far not alternative golden bullet is really in sight (yes there are some developments which can be useful but for the most part they have potential and/or have not shown to be effective in vivo). As a result, it seems that we are indeed moving straight toward the projected post-antibiotic era. 

Personally (and of course biased by my own research), I think we need to accelerate our understanding of bacterial physiology in order to develop effective countermeasures from the bottom up, as in most cases we only have a very rough understanding how antimicrobial substances actually kill bacteria (which to some extent is also true for antifungals and fungi).

 

[CurrentSci]

Interesting post, I have even heard some stories of hospitals blocking the public from knowing there true numbers for superbugs because they do not want the public to be frightened of their hospital. These strains truly are one of the biggest potential problems on the horizon of humanity. The fecundity of these bacteria is quite frightening, yet I think it is starting to be more realized my government entities.

I think the only way we can get more funding into these matters is to put our effort into educating the public and pushing for communities to show interest in supporting the research of bacteria physiology. Perhaps making clear how our lack of knowledge is crippling us, and how studying these basic mechanics in the past has given us breakthroughs. 

Appreciate your work on the front lines!😉

Edited November 17, 2019 by CurrentSci
clearity

[StringJunky]

A first step would be to statutorily prohibit the use of antibiotics for purposes they weren't intended for and condemn animals that have them from the  human food chain to discourage further use. Easier said than done I imagine.

[John Cuthber]

Higher beef prices are not a vote winner.

It is, in principle possible to split

antibiotics into two groups- those used in humans and those used for animals, but it's an imperfect solution.

On 11/15/2019 at 4:55 PM, CharonY said:

but so far not alternative golden bullet is really in sight

If we found it, there would be immense pressure on doctors pressure to screw it up in the same way we did with penicillin etc.

 

I'm intrigued by the idea of using phages, though I recognise that they suffer from essentially the same issues.

One thing that would help would be if doctors had the freedom to prescribe placebos or to be more honest to their patients.
 

Mr Smith "Dr I have a cough and I'd like something to treat it.
Dr "Sure, here's a prescription for some cough syrup " (while writing out Rx for "simple linctus" which works just as well as anything else and costs  the NHS about a pound per gallon).
Mr Smith "is it an antibiotic?"
Dr "No, but there's a nine out of ten chance that your cough is viral and so an antibiotic would be useless. On the other hand, there's about a 1 in 3 chance that the antibiotics will upset the natural balance of bacteria in your guts. So, overall, an antibiotic is about 3 times more likely to give you the s*Its than to do any good."

 

[Dagl1]

One thing regarding (some forms of) phage therapy is that they negatively effect the immune system in research studies. While a phage may combat a specific bacterium, the bodies reaction to the increased viral load (if I remember correctly) leads to either overreaction of the immune system or increased infection risk to new pathogens.
(I currently don't have the papers in front of me, if someone wants them I'll look them or similar ones up).

Charon, some time ago I read these 2 papers (and some of their references) regarding acquisition of antibiotic resistance, which I believe goes counter to consensus, but I am not very read in this field except for papers from this "group", so I have a very biased view of this at the moment. I was wondering if you can comment on these papers, specifically on any statements related to: 
"Most of us were taught that terminating antibiotics prematurely can lead to the development of bacterial resistance. This has proven to be a myth as mounting evidence supports the opposite. In fact, it is prolonged exposure to antibiotics that provides the selective pressure to drive antimicrobial resistance; hence, longer courses are more likely to result in the emergence of resistant bacteria.^14,15 "
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5661683/#bibr14-1715163517735549

This article is the main driving point as far as I remember when reading about these papers, but can't access it at the moment. I really like their comment/peer review section, interesting to hear about the opinions of many in different fields. 

https://www.bmj.com/content/358/bmj.j3418 

[QuantumT]

In Denmark, hand sanitizers with ethanol, are being used with great effect in all areas of health care.
I was recently in a Danish hospital, and the sanitizer gel was everywhere, with instructions to use before touching anything.

Patients with 'super bugs' had sanitizers at their beds, and cleaning after them was done with chlorine. It works!

Now we just need to address the usage of antibiotics in agriculture.

[CharonY]

10 hours ago, John Cuthber said:

It is, in principle possible to split

antibiotics into two groups- those used in humans and those used for animals, but it's an imperfect solution.

Indeed, and it would probably achieve fairly little. Selective pressure on a given antibiotics often also increase resistance for others. Most obviously, there are unspecific resistance mechanisms, such as efflux pumps, which are also one of the big issues with regard to multiple resistances.

 

9 hours ago, Dagl1 said:

One thing regarding (some forms of) phage therapy is that they negatively effect the immune system in research studies.

There are a number of additional uncertainties and issues. Unknown interactions with the immune system is one, resistance to viruses is a real concern, viruses have very specific activity, so applying therapies are going to be more complicated and more limited, pharmaceutical development is tricky, phages can contribute to the further spread of AB resistance (via transduction) and so on. It is likely going to have a place, but its scope is probably going to remain more limited than traditional ABs.

 

9 hours ago, Dagl1 said:

Charon, some time ago I read these 2 papers (and some of their references) regarding acquisition of antibiotic resistance, which I believe goes counter to consensus, but I am not very read in this field except for papers from this "group", so I have a very biased view of this at the moment. I was wondering if you can comment on these papers, specifically on any statements related to: 

I think it is not necessarily an either or situation. The critical point is that ideally the treatment has a sufficiently high concentration and lasts just long enough to clear the infection, but does not provide a continuous selective environment. Medical guidelines provide estimates, but realistically, each infection is different. 

 

4 hours ago, QuantumT said:

In Denmark, hand sanitizers with ethanol, are being used with great effect in all areas of health care.

Actually, in North America that is widely used in public buildings. In many universities you will see them everywhere near doors, for example. While it helps, there are also other measures that hospitals need to take into account. One important bit is proper isolation of stations (e.g. that folks do not freely move from high to low risk environments and spread bugs). Often, clothes are underappreciated as a source of carrying bugs for example. Another now common source are cell phones (it is actually also an issue in our labs and part of an ongoing culture fight).

[Endy0816]

On 11/17/2019 at 12:15 PM, CharonY said:

Actually, in North America that is widely used in public buildings. In many universities you will see them everywhere near doors, for example. While it helps, there are also other measures that hospitals need to take into account. One important bit is proper isolation of stations (e.g. that folks do not freely move from high to low risk environments and spread bugs). Often, clothes are underappreciated as a source of carrying bugs for example. Another now common source are cell phones (it is actually also an issue in our labs and part of an ongoing culture fight).

I was really surprised by this my last visit. A number of doctors, nurses and staff ended up passing through my hospital room.

2-4 doctors, 6 nurses, 2 payment processors, various cleaners and workers transporting patients for surgeries and tests.

You would think at least some of that could be minimized.

Would be nice if companies would supply hands-free options to help combat inevitable boredom. You wouldn't be handling a pair of voice controlled glasses or headphones anywhere near as much as your cell.

Edited November 18, 2019 by Endy0816