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February 20, 2006

Some Antibiotic Resistance Follow-Up

One thing the Mad Biologist likes to do is pull stuff out of the comments section. In the comments of what I thought was a simple public service announcement about a website dedicated to antibiotic resistance, is this comment.  First, there's the "I hates me my gummint" sentiment:

Being lectured about antibiotic resistance by government employees on a government web site is a little like being lectured by George W. Bush on oil addiction.

And being lectured about world history by public school teachers in publicly constructed buildings is also a little like being lectured by George W. Bush on oil addiction. Do you actually know any government public health workers who deal with antibiotic resistance? I do, and they are very worried about overuse in agriculture and medicine.

I don't know if the author likes public education, but I do. Public education is a good thing. It is good when government employees in a government facility teach people English, history, literature, science, and even algebra. And it is good when the government teaches people about public health. By the way, it's not "millions" spent on educating the public about antibiotic resistance. I would be surprised if government funding of antibiotic awareness programs from all sources totaled over a million dollars per year; most of these programs are 'piggybacked' onto other public health programs–and just how much does a website cost anyway?

Here's another reason why public education campaigns matter: all antibiotic resistance awareness campaigns stress handwashing. This not only cuts down on bacterial infections, but also reduces viral infections that would then mistakenly be treated with antibiotics.

Which brings us to the next chapter in our Profile of Ignorance:

Of course it is worse than useless to take an antibiotic for viral illnesses. But millions spent to educate the public on this is a waste when US agriculture uses almost half of all antibiotics in America for profit, not disease; virtually all antibiotic resistance in America develops in hospital settings; and virtually all antibiotic resistance (like GC to penicillin) begins in less developed parts of the world.

"Of course, it is worse than useless to take an antibiotic for viral illnesses."  Actually, most people don't know that–or more accurately, they don't realize that their illnesses are viral, not bacterial. The last time someone examined this issue in the U.S., 21% of all antibiotic prescriptions written were to treat viral respiratory illnesses. Throw in the constant badgering by parents with kids who have ear infections and that's a lot of misprescribing. Whenever I go to meetings, physicians and nurses always want materials to give to patients about the misuse of antibiotics. Even recently-trained doctors would inappropriately give antibiotics to patients–we're not making much progress.  And patients are often less informed than the doctors.

The next sentence in the comment is confusing; I'll assume that some words were accidentally left out (to claim that educating people about using antibiotics wisely in clinical settings is pointless because of agricultural use, and then to follow this claim with a statement that all resistance begins in hospital settings makes no sense). But let's deal with each of the clauses.

It's correct that half (at least) of all antibiotics used in the U.S. are used in agriculture. That's the only factually corect statement here. Much antibiotic resistance in the U.S. stems from agricultural practices, not clinical use. Ciprofloxacin ("Cipro") resistance in Campylobacter evolved due to exposure on the farm: the farm is a major source Campylobacter infections.  Even Bayer, which wanted to sell enrofloxacin to farmers, didn't try to deny that (note:  resistance to enrofloxacin also confers resistance to ciprofloxacin).  According to the NARMS project data, resistance to older, cheaper antibiotics used on farms is much higher in bacteria isolated from U.S. agricultural settings than in human populations. So agriculture does play a significant role in the U.S. (also see here).

This is not to deny the role of medical use. For example, methicilin resistance in Staphylococcus aureus (MRSA) was first observed in hospitals, and only later spread into the community. The older antibiotics (e.g., tetracycline, sulfa drugs) weren't widely used in agriculture until the late 1960s, much of the increase in resistance is obviously due to medicial use. The farm versus the clinic isn't an either-or situtation: natural selection is natural selection, regardless of where it happens.

Onto the claim about the developing world.  Penicillin resistance did arise in the developing world first if you consider the U.S. in 1948 to be a developing country. The two countries where penicillin resistance was first noticed and became quite prevalent were the U.S. and U.S.-occupied Japan. Vancomycin resistance in Enterococcus is largely found in Europe, not the developing world (this was due to use of a vancomycin analogue in European agriculture). The available surveillance data indicates that in many cases, resistance spread from the developed world to the developing world. However, this depends on the organism and the antibiotic; in other cases, it's headed in the other direction. And sometimes, it evolves independently in different parts of the world. Europe has wide difference in resistance levels: France and Spain have massive problems, while Denmark doesn't (must be the cartoons).

So, agriculture and medicine are both to blame–like most things in biology, there's more than one cause. But we won't be able to stop the problem without public education. That's not waste; that's necessity. If we didn't give Paris Hilton so many tax cuts, we could have both public outreach and increased regulation of antibiotic use (and a national health care system would help greatly too).

(crossposted at Mike the Mad Biologist)

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Comments

(to claim that educating people about using antibiotics wisely in clinical settings is pointless because of agricultural use, and then to follow this claim with a statement that all resistance begins in hospital settings makes no sense)

Though the bit about agriculture doesn't quite fit, the rest of the sentence makes slightly more internal sense if you assume that the commenter is trying to draw a *second* dichotomy, between the patient badgering their GP for antibiotics for a cold, versus sinister medical authority figures forcing antibiotics on immobilized patients in hospitals. Public education would help with the first case but not the second.

My long experience observing paranoids on the Internet has given me considerable paranoid sentence diagramming skills.

How much public education will it take to keep prophylactic use of antibiotics out of overcrowded chicken coops, hog prisons, indoor dairies, etc? SOMEbody has just got to lay down the law to these ninnies! They're screwing future generations (their own, ours) to squeeze a little more money out of their abused livestock.
Who ever told these people that this was a Good Idea?
^..^

Herbert,

Who ever told these people that this was a Good Idea?

Their accountants.

And patients are often less informed than the doctors.

!%$#@$???!?

Should that part be a surpise?

If a doctor (or EMT, or RN, or...) doesn't know this, then we're really fucked.

I come from a family of medical types, of several flavors. I hope we're not weird (I am, I do software, but...) - they know about the overuse of antibiotics . If other HCPs do not... well, the survivalist worldview starts looking a little more appealing.

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