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Antibiotic Apocalypse

The beginning of the antibiotic apocalypse may be nigh. Woman dies from the ultimate superbug – carbapenem-resistant Enterobacteriaceae (CRE) with New Delhi metallo-beta-lactamase (NDM). The bacterium is resistant to 26 different antibiotics. There were no antibiotics left to treat the infection – it was resistant to everything. Word on the street was that she was taking a Z-Pack for her cold before she got sick. Kidding about the Z-Pak thing, but this is no laughing matter. I thought it before and I still think it now – antibiotics should be treated like Norco and other controlled substances. Tracked. Patients who take too many of them should require special paperwork before they can fill prescriptions. All these unnecessary prescriptions for coughs and colds are just making the bugs stronger. We’re doing this to ourselves.

Then again, scientists just announced that they have discovered a molecule that reverses antibiotic resistance in multiple strains of bacteria at once. The bad news is that some jerkoff investor will probably purchase the patent, jack the price for the molecule to about $17,000 per dose and will make sure that the molecule won’t be covered under Obamacare or any other insurance plans. The molecule is called a peptide-conjugated phosphorodiamidate morpholino oligomer or PPMO and works to disable the NDM-1 found in the most resistant bacteria. Powerful weapon to beat resistant organisms, but if we don’t change our prescribing habits and demands for antibiotics, it’s only a matter of time before the bugs learn how to beat the PPMO in this high-stakes game of cat and mouse.

Is a post-antibiotic world approaching? This NY Times article again notes how the number of effective antibiotics in our arsenals is diminishing and that there isn’t much of an incentive for pharmaceutical companies to produce new antibiotics. The article states that

Medicare has moved to require hospitals and nursing homes to adopt plans to prevent the spread of drug-resistant infections and to assure the proper use of antibiotics

However, note that under the “Hospital Compare” program – created by the same government that wants to “assure the proper use of antibiotics” – hospitals are deemed substandard if they don’t throw strong antibiotics at every pneumonia within six hours of a patient’s presentation to the emergency department. Have those policies decreased pneumonia deaths since they were initiated?
According to CDC data (.pdf file), deaths from influenza and pneumonia decreased from 18.4 per 100,000 population in 2006 to 15.1 per 100,000 population in 2014 – an 18% decrease (see page 37). During that same timeframe, the rate of death from all causes decreased from 791 per 100,000 to 724 per 100,000 – a 9% decrease (see page 35). I picked the cutoff date of 2006 because the Hospital Compare website started comparing hospitals in 2005. There are multiple confounding variables such as inability to separate influenza (viral-related and unaffected by antibiotics) from bacterial pneumonia that would be affected by antibiotics, the fact that pneumonia is a subjective diagnosis in many cases (was it pneumonia, CHF, or chronic interstitial changes?), that many deaths have more than one cause, and that financial incentives may make it more likely that pneumonias are underreported (readmissions for same diseases may not be paid by Medicare). Draw your own conclusions.

A somewhat dated article, but one that shows the potential seriousness of a world in which we don’t have readily available effective antibiotics. In Venezuela, the imploding/imploded economy has made antibiotics largely unavailable and turned simple injuries such as a scraped knee into major health threats.

One more infection-related article for the day. If you want to be ahead of the curve at medical dinner parties, learn about MERS, Lassa fever and the Nipah virus. Those three are the ones that the Coalition for Epidemic Preparedness believes are most likely to become epidemics in the future – and none of them have vaccines or treatments. Even the mighty Z-pak won’t help you.

 

6 comments

  1. Equally frustrating are the patients who think it is a game to have multiple allergies to perfectly good antibiotics. Penicilins AND sulfas AND doxy AND macrolides.

    Anyone with more than a couple antibiotic allergies should see an ID or Allergy specialists for desensitization.

    Or, when the patient told me last month “I’m allergic to all antibiotics…” I looked at her and said, “Well, that means that you’re going to die from this foot cellulitis. Or we have to take your leg off at mid-shin.”

    The tune she sang changed quickly.

  2. Don’t get me started on the allergy thing.
    Now I’m going to have to dig up an old post about bizarre patient allergies. Here’s one from my old blog on EP Monthly
    http://epmonthly.com/blog/my-newest-medical-problem/

  3. Might be true?
    Silver Makes Antibiotics Thousands of Times More Effective
    “Collins and his team found that silver — in the form of dissolved ions — attacks bacterial cells in two main ways: it makes the cell membrane more permeable, and it interferes with the cell’s metabolism, leading to the overproduction of reactive, and often toxic, oxygen compounds. Both mechanisms could potentially be harnessed to make today’s antibiotics more effective against resistant bacteria, Collins says.”

    Link to study HERE: http://stm.sciencemag.org/content/5/190/190ra81

  4. And Iodine. Why forget about iodine? The antiseptic benefits are undeniable and the problems wiht delayed healing are overstated:

    J Hosp Infect. 2010 Nov;76(3):191-9. doi: 10.1016/j.jhin.2010.04.026. Epub 2010 Aug 12

  5. There are multiple potential non-antibiotic treatments for resistant infections – including manuka honey. The idea is that we need to stop treating every cough and sniffle with a course of antibiotics and that we need to think outside the box regarding infection management before there isn’t anything left to use when we really need it.

  6. The PPMO molecule have a sequence of bases that bind to the RNA bases of their target transcript. If a bug does become resistant to a particular PPMO, the target can be sequenced to uncover the change and a new PPMO synthesized. Unfortunately, as easy as that is, the FDA would require full clinical trials before the modified sequence can be used to treat a human.

    Here are some citations to PPMO work in bacteria.

    http://www.gene-tools.com/bacteria

    and an introduction to the antisense molecules:

    http://www.gene-tools.com/sites/default/files/Guide_to_using.pdf

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