Antibiotic resistant infections and society

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Antibiotic Resistant Infections and Society

The indiscriminant and imprudent use of antibiotics has led to a new era of disease. Nobel Prize winner Joshua Lederberg describes the problem of antibiotic resistance in this manner: "Antibiotic worrying because it is accumulating and accelerating while the world’s tools for combating it decrease in power and number" (FDA’s "Performance Plan and Report" 2) Pre-eminent health establishments including the World Health Organization (WHO), The New England Journal of Medicine (NEJM), the U.S. Food and Drug Administration (FDA), and the U.S. Center for Disease Control (CDC) have all acknowledged that drug resistant microbes pose a genuine threat to humanity. These institutions assert that complacency on the part of consumers and health professionals, combined with the strong propensity of pathogenic bacteria to adapt in order to survive in antagonistic environments has led to the current dilemma concerning microbial resistance to antibiotics. The over-prescription and negligent usage of antibiotics has helped to create an ideal environment for microbes to acquire resistance. In order to appreciate the severity of antibiotic resistance, one must understand how antibiotics work, the potential repercussions that could result if we remain indifferent to the dilemma, the processes by which bacteria become resistant, why they are rampant in contemporary America, and who is responsible for perpetuating their existence.
Antibiotics have been the foundation of infectious disease treatment since the first penicillin became available in the early 1940s. Since then numerous other antibiotics have been developed. Antibiotics possess remarkable healing powers against bacterial infections. They work by either killing bacteria (bacteriocidal) or by inhibiting their
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growth (bacteriostatic). Soon after penicillin and other antibiotics were discovered, antibiotic resistant bacteria began to appear. Today many pathogenic bacteria, including those that cause pneumonia, ear infections, urinary tract infections, gonorrhea, acne, salmonella, and tuberculosis often circumvent some of the most established antibiotics. The World Health Organization (WHO) warns that the level of resistance to drugs used to treat common infectious diseases is reaching a crisis point. In a recent report on infectious diseases "Overcoming Antimicrobial Resistance," the WHO states that if governments around the world do not increase their efforts to control disease and quell the spread of resistance there will be a return to the pre-antibiotic era and entire populations could be decimated by "superbugs" for which no effective treatment exists.
The increased prevalence of antibiotic resistant bacteria is a consequence of evolution. "The pathogenic bacteria have changed their genetic constitution millions of times during the aeons in which they coexisted with other organisms" (Mann 74). Any population of organisms, bacteria included, naturally includes constituents that deviate from the multitudes in regard to certain traits (aberrant bacteria are referred to as "mutants"). In certain instances, bacteria can experience mutational changes that are conducive to acquiring resistance to antibiotics: "Occasionally a mutation may help the bacterium resist a particular drug" (Radetsky 5). When antibiotics are administered they are only effective in exterminating the susceptible bacteria. The residual bacteria then inhabit a vacant environment where competition is diminished. These remaining bacteria are able to flourish without bound. What further exacerbates the situation is that once a microbe is exposed to a particular antibiotic, it naturally encodes data regarding the antibiotic into its
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DNA. Unfortunately for humans, this encoded information gives the microbe the ability to elude the antibiotic’s killing mechanism if encountered in the future. These newly resistant bacteria will then procreate, thereby passing on the DNA-encoded resistance gene to their progeny (Callahan 4). Because of the distinct advantages resulting from inherent resistance genes, these mutant bacteria soon become the predominant strain in the surrounding environment.
Another distinguishable characteristic of bacteria that promotes an increased rate of resistance is their unique ability to share genetic information through a process called horizontal gene transfer. The horizontal gene transfer process facilitates the spread of microbial resistance because it creates an environment where: "bacteria can gain a defense against an antibiotic by taking up resistance genes from other bacterial cells in the vicinity" (Levy 4). The most alarming aspect of horizontal gene transfer is that entirely divergent strains of bacteria possess the capability to exchange genetic information. This implies that pathogenic bacteria that are devoid of inherent resistance can acquire resistance from other bacteria with relative ease. Horizontal gene transfer between bacteria is ubiquitous to the point where: "the entire bacterial world can be thought of as one huge mulitcellular organism in which the cells interchange their genes with ease" (Levy 4).
Hospital-acquired infections are another problem associated with antibiotic resistance. Hospitals serve as an ideal environment for drug resistant microbes to flourish. "The combination of highly susceptible patients, intensive and prolonged antimicrobial use, and cross-infection among patients has resulted in nosocomial [hospital derived]
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infections that are highly resistant to available therapeutics" ("Issues of Resistance: Microbes, Vectors, and the Host" 2). According to a recent study performed by the CDC "approximately 70 percent of infections that people get while hospitalized are now resistant to at least one antibiotic" ("Antimicrobial Resistance: A Growing Threat to Public Health" 1). The CDC’s findings are substantiated by the recent dilemma concerning the intravenous antibiotic vancomycin. Vancomycin is one of the most potent antibiotics used today. It is often regarded as the last line of defense against the most formidable hospital–borne pathogens. Last year, the fear of many physicians became real: "In three geographically separate patients, an often deadly bacterium, Staphylococcus aureus, responded poorly to a once reliable antidote—the antibiotic vancomycin" (Levy 1). These isolated but portentous instances of vancomycin resistance coincide with a current trend in antibiotic resistance encountered at the University of Arizona Medical Center (UMC). In the results of its July 2001 Microbiology Susceptibility Data Chart, the University of Arizona Microbiology Lab revealed (using bacterial samples taken from the UMC hospital) that vancomycin’s rate of effectiveness against the pathogenic bacterium enterococcus (responsible for causing urinary tract infections, blood poisoning, and wound infections) and streptococcus (responsible for ear and throat infections, meningitis, and blood poisonings) are diminishing at an alarming rate. A representative from the group of microbiologists who perform cultures at the UMC interprets the decline in microbial susceptibility to vancomycin in this manner: "The results of our susceptibility lab cultures reveal just how resilient the bacteria have become. I believe

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that drug companies have a real predicament on their hands when it comes to creating new specialized drugs to combat these bugs" (interview 3-25-02).
Methicillin-Resistant Staphylococcus aureus (MRSA) is a frequently encountered hospital room infection which derives a significant amount of notoriety from its high lethality rate in hospital patients. "Today one of the most dangerous features of a stay in the hospital is the risk of infection with a strain of MRSA" (Mann 73). Dr. Robert Lowe, a vascular surgeon in Albuquerque, New Mexico, recently performed surgery on a patient who subsequently contracted MRSA post-operatively. "The day before she was scheduled to be released she began displaying symptoms that were indicative of a MRSA infection [e.g. fever, muscle pain]. I immediately consulted an Infectious Disease Specialist" (Lowe). The patient was administered premonaxin and vancomycin but the antibiotics were ineffectual and the infection eventually spread to the patients’ heart and ultimately to the brain. After two weeks of intensive treatment and observation the patient eventually expired. "It is unfortunate that even with the best therapy some people still die from nosocomial infections" (Lowe). Hospital acquired infections are more pervasive than most people recognize. "Hospital records suggest that...over 2 million people fall prey to microbes while in the hospital in this country...Some 90,000 of those die" (Radetsky 2).
The increasing levels of drug resistant bacteria in humans can in some cases be traced to the practice of administering antibiotics to livestock. "More than 40 percent of the antibiotics manufactured in the U.S. are given to animals" (Levy 7). The practice of giving livestock antibiotics is, in itself, not necessarily imprudent. What can be
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problematic is that farmers systematically administer antibiotics to their animals in incorrect dosages and in circumstances where antibiotics are unnecessary. The antibiotics "are administered in subtherapeutic [below the levels used to treat disease] doses to promote weight gain in healthy livestock" (Raloff 1). The farmers’ indiscriminate implementation of antibiotics to animals in order to maximize profits promotes bacterial resistance within the animals. These same animals are then slaughtered, shipped, and sold in supermarkets to oblivious consumers. A recent study by the FDA reported that "20 percent of supermarket samples of ground beef, pork, chicken, and turkey were contaminated with Salmonella. Even more worrisome, 84 percent of the Salmonella were resistant to at least one antibiotic and half were resistant to at least three antibiotics" (Barlam 4). The increased prevalence of antibiotic resistant Salmonella should serve to augment the vigilance of consumers when it comes to cooking and preparing meat products because "We have to worry that it would be harder to treat food poisoning because the Salmonella is antibiotic-resistant" (Barlam 4).
Consumers are often negligent in their insatiable demand for and misuse of antibiotics. Patients often times make asinine mistakes including instances where the antibiotics are not taken as prescribed. "Patients will often stop taking the prescription when they start to feel better," comments a pharmacist at the UMC "thus, they [the antibiotics] may not kill all the infecting organisms, thereby leaving the most resistant ones behind to continue to grow" (interview 3-28-02). Other frequent mistakes made by consumers are the demanding of antibiotics for viruses such as colds, coughs, and the flu (antibiotics are not meant for viral infections), saving antibiotics for later use, and by not washing their hands
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(Callahan 5). This consumer recklessness enhances the problem of drug-resistant microbes. By increasing the microbes’ exposure to antimicrobials, the consumer is unknowingly creating resistant microbes by encouraging the processes of mutation and horizontal gene transfer to take effect (these survival measures help bacteria become resistant).
Another factor that contributes to the rise of resistant infections is the over-prescribing of antibiotics by physicians. Often times, the physician will succumb to a patient’s demands for antibiotics even when the medication is not designed for the patient’s particular infection. Stuart Levy, founder of a worldwide coalition called the Alliance for the Prudent Use of Antibiotics, recently gave a seminar where "more than 80 percent of the physicians present admitted to having written antibiotic prescriptions on demand against their better judgement" (Levy 7). Researchers at the CDC have come up with similarly disturbing statistics concerning superfluous prescriptions in which it is estimated that some "50 million of the 150 million outpatient prescriptions for antibiotics every year are unneeded" (Levy 7).
Antibiotic resistance is a dilemma that warrants the public’s attention. As long as pathogenic bacteria continue to exist, so will their natural tendency to find ways to evade antibiotics. Treatment of people with resistant infections in the U.S. is estimated to exceed $30 billion (Radetsky 2). Despite vigorous treatment, hundreds of thousands of people die each year as a result of antibiotic-resistant infections. Because we live in a developed area where access to healthcare is first-rate, the over-prescription of antibiotics to meet patients' demands and the overuse of antimicrobials in food production are more prevalent than in most other areas. It is vital to increase the general awareness about when and under what circumstances antibiotics are appropriate for use. Farmers, consumers, and physicians all hold a joint responsibility for the increased resistance in contemporary America, and it is imperative that they change their ways in the future.

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