
Antibiotic resistance: The grim prospect - known
http://www.economist.com/news/briefing/21699115-evolution-pathogens-making-many-medical-problems-worse-time-take-drug-resistance
======
uptown
Medical professions risk losing a patient or being sued if hey misdiagnose a
condition, so the understandable reaction is to throw antibiotics at the
problem rather than waiting for test results to come-back to determine whether
a specific course of care is appropriate.

The good news is that some test times are decreasing dramatically ... from
days to minutes in many cases:

[http://nanologix.com/test_results.html](http://nanologix.com/test_results.html)

    
    
      * tuberculosis from 21+ days to 1.5 hours.
    
      * e.coli from 18 - 24 hours to 30 minutes
    
      * salmonella from 24 hours to 30 minutes
    
      * group b streptococcus from 48 - 72 hours to under an hour
    

My hope is that faster results leads to fewer unnecessary prescriptions being
administered, and better overall care for the patients.

~~~
atmosx
> Medical professions risk losing a patient or being sued if hey misdiagnose a
> condition, so the understandable reaction is to throw antibiotics at the
> problem rather than waiting for test results to come-back to determine
> whether a specific course of care is appropriate.

As a pharmacist, my experience says otherwise. I think the following are the
main reasons for bacterial resistance:

a) Patient doesn't respect doctor's/pharmacist's guidelines. He feels _much
better_ after day 3, so he stops his class X ATB in day 4 instead of day 7. If
bacteria survives, might very well be class X ATB-resistant.

b) Patient has a relative who when _was feeling sick_ took ATB XYZ and got
better. The main reason for this is poverty: A visit to the doctor might cost
25-120 EUR.

c) Hospitals. MRSA became "MR" in hospitals, where bacteria conjugation takes
place.

That said, at some in point, we should expect bacterial organisms to evolve
some kind of resistance. That's how evolution works.

~~~
iLoch
Regarding (a) - do you know that I've never been told _why_ I need to finish
my antibiotics? For some reason (arrogance?) doctors don't _explain_ their
reasoning in many cases (I live in Canada FWIW.)

If I was told "hey, you need to finish your antibiotics or you'll risk
becoming immune to them, potentially putting yourself or your family,
colleagues, or friends at risk" I don't think even the dumbest person would
ignore that warning. Then they could even explain WHY that is, if the patient
was curious.

Instead, here in Canada, you say you're sick, the doctor will likely
immediately perscribe antibiotics, then shuffle you out the door in less than
5 minutes.

~~~
loopbit
Not only in Canada, it's like that in every country I've seen a doctor.

As for the 'why'... You'd be surprised on how difficult is to get an answer
like that from any doctor. My suspicion[0] is that they simply don't know
anymore: It's something they learnt in college, but after a few years of
dealing with symptoms and prescribing treatments, they forget about the why.

Don't get me wrong, I kind of understand it. On one hand I've found that most
people don't care about the 'what's or 'why's of medicine. They go to the
doctor and either take the treatment they prescribe or not. I think the people
that want to know the 'why' are a minority and doctor's time is valuable, so
they end up processing people as fast as they can.

On the other, medicine is a vast field and they need to keep up to date with
the latest developments, so I can see how they can start to forget seemingly
superfluous pieces of information when faced with all the new info they have
to absorb.

[0] From personal observation, so I can (I hope) to be mistaken.

~~~
chimeracoder
> My suspicion [from personal observation] is that they simply don't know
> anymore: It's something they learnt in college, but after a few years of
> dealing with symptoms and prescribing treatments, they forget about the why.

If your doctor actually doesn't know why it's necessary to take the full
course of antibiotics (antibiotic resistance), please get a new doctor.
Seriously. (And report the old one, since he/she should not be practicing).

Of course, if the problem is simply that you can't get a layperson-
intelligible answer from them, or get enough time with them for them to
explain it to you, or if they're willing to explain it to you, but only if you
ask... that's another story, and much more commonplace.

The sad truth is, even for the most compassionate, attentive, dedicated doctor
- the one who would always go the extra mile to provide you with the best care
imaginable - over the years, it's become increasingly difficult (read: next-
to-impossible) to dedicate that extra time to the patient unless they really
press for it. Insurance reimbursements have been cut to the point where the
only way most physicians can stay afloat is to make their practice a volume
game[0]. As the patient, you're not actually the paying customer (the insurer
is), and the insurer doesn't care if the doctor takes an extra five minutes to
talk about bacterial resistance and evolution. They'll reimburse him/her the
same amount either way[1].

The exception to this is high-end, self-paying practices (think 'concierge
medicine'). Unsurprisingly, those tend to have the best service (of course,
you pay heavily for this).

[0] Or to go bankrupt, and sell to a hospital/practice group. Which is subject
to the same pressure to generate volume, except the hospital cares a _lot_
less about you, the patient, on an emotional level than a private practitioner
does.

[1] In fact, in the _worst_ case, the provider is getting reimbursed exactly
$0 for providing you this care, because you're on a capitated plan. Under
captitation, the provider (usually a hospital) gets a fixed, annual amount per
patient that they are responsible for, and that's all the payment they ever
get. The idea there is that it discourages unnecessary care - which is true,
but it also disincentivizes _necessary_ care as well. And spending an extra 5
minutes to educate the patient in a way that _may_ have an impact on broader
public health, but is unlikely to affect their own actual care in any
measurable way? They don't have time for that, and they're certainly not
getting paid for it.

~~~
loopbit
As I said in other comment, the antibiotics one is a very simple case, but
I've had plenty of other examples.

As to report the doctor... To whom? Do you know how difficult it is to prove
almost any kind of malpractice? I've had a doctor insist that I had a sprained
wrist when it was a broken radius (as another doctor and a simple x-ray
proved). Another said that the cramps I was having were from an unborn brother
(ahem). My wife was told in the hospital that she wasn't having an allergic
reaction to antibiotics because she had had them before (surprise,
antihistamines helped and further tests detected she's allergic to penicilin).

Of course, nothing gets written and doctors are very quick to cover each
other. So how do you report these?

As for the doctors not being able to dedicate extra time to patients, I
totally agree and indeed mention it in my first message.

------
tomkinstinch
Chemical antibiotics are currently the best and most developed tool we have
for bacterial infection, but other options are being explored, including
defensins[1,2,3] (antimicrobial peptides) and—as mentioned in the
article—phage therapy[4,5,6,7] (viruses that infect and replicate within a
bacterium). Like many of our current antibiotics, they have their origins in
nature. As therapeutics, they're far off, and would have to be characterized
and go through the usual clinical trial process to be evaluated for efficacy
and safety. Specificity is an issue for phages, and delivery is a challenges
for both. One novel application is a defensin-based chewing gum being
developed by the US military to combat the bacteria responsible for dental
plaque[8,9].

1\.
[http://www.nature.com/nri/journal/v3/n9/full/nri1180.html](http://www.nature.com/nri/journal/v3/n9/full/nri1180.html)

2\.
[https://en.wikipedia.org/wiki/Defensin](https://en.wikipedia.org/wiki/Defensin)

3\.
[http://onlinelibrary.wiley.com/doi/10.1002/biot.200700148/ab...](http://onlinelibrary.wiley.com/doi/10.1002/biot.200700148/abstract;jsessionid=502B8ABC8A1924B726025B62168619BE.f03t01)

4\. [http://www.nature.com/news/phage-therapy-gets-
revitalized-1....](http://www.nature.com/news/phage-therapy-gets-
revitalized-1.15348)

5\. [https://www.amazon.com/Forgotten-Cure-Future-Phage-
Therapy/d...](https://www.amazon.com/Forgotten-Cure-Future-Phage-
Therapy/dp/1461402506)

7\.
[https://en.wikipedia.org/wiki/Phage_therapy](https://en.wikipedia.org/wiki/Phage_therapy)

8\. [http://www.newyorker.com/tech/elements/zero-dark-
cavity](http://www.newyorker.com/tech/elements/zero-dark-cavity)

9\.
[http://www.usaisr.amedd.army.mil/news/news_stories/2014_FEB/...](http://www.usaisr.amedd.army.mil/news/news_stories/2014_FEB/DTRD_developing_anti_plaque_chewing_gum.html)

~~~
dredmorbius
I just want to say thank you for a hugely informative, referenced, and brief
comment.

You've pointed me at more information on a concept I'm familiar with
(bacteriophages), and taught me two new terms -- defensins and antimicrobial
peptides.

Clipped & saved.

------
paulgerhardt
See also the May article in Nature in how we can now create endless supplies
of slight variations on antibiotics through semisynthesis to circumvent
resistance:
[http://www.nature.com/nature/journal/v533/n7603/full/nature1...](http://www.nature.com/nature/journal/v533/n7603/full/nature17967.html)

Previous discussion:
[https://news.ycombinator.com/item?id=11740340](https://news.ycombinator.com/item?id=11740340)

------
teh_klev
I think the article above was written off the back of, or at the same time as,
some fairly shoddy reporting about antibiotic resistant strains back around
March to May this year, because who doesn't want to get in on a decent
untreatable rampant killer bug story. It's worthwhile having a read of this:

[http://arstechnica.com/science/2016/05/everybody-be-cool-
a-n...](http://arstechnica.com/science/2016/05/everybody-be-cool-a-nightmare-
superbug-has-not-heralded-the-apocalypse-yet/)

------
reasonattlm
Disaster stories sell papers, but the situation is not a disaster story.
Rather it is the standard plot for development of new things. People see
possible scarcity and react accordingly, far in advance of the non-specialists
of the press figuring it out. The scientific community is and has been
responding well to the threat of running out of antibiotics. In particular,
new advances in mining the bacterial world - a 100-fold enhancement in that
mining - mean that we'll be flooded with many new antibiotic drug candidates
in the years ahead. For example, see:

[https://www.edge.org/response-detail/26701](https://www.edge.org/response-
detail/26701)

[http://www.popsci.com/ichip-new-way-find-antibiotics-and-
oth...](http://www.popsci.com/ichip-new-way-find-antibiotics-and-other-key-
drugs)

Antibiotics Malthusianism has the same problem as all other forms of
Malthusianism, which is that people work to fix the problems they see arising
in the future, and resources are far from static as a result.

~~~
linkregister
Thanks for adding this comment. I do think the facts you presented temper the
"doom and gloom" sentiment of the article, though the new advancement in
bacterial growth has not yet yielded new antibiotic candidates.

------
jkot
> _Hospital hygiene is another focus; there is some evidence that staff are
> more careless about cleanliness than they were in pre-antibiotic days, when
> they saw deaths like Albert Alexander’s on a more regular basis._

~~~
copperx
I spent a month at one of the top US hospitals and I witnessed crazy
unhygienic practices. The most common one is when the nurse assistant puts on
gloves to clean the toilet and other items touched by bodily fluids and then
proceeds to clean the food tray with the same gloves and often even adjust the
IV lines. I got a lot of nurses angry by pointing this out (it must suck to
hear someone else tell you that you're doing your job badly, but still). My
mother caught a C diff infection. After that, I carried a clorhexidine bottle
with me to the hospital and cleaned all surfaces that contacted food with it.

~~~
Smudge
Hospital-acquired infections have become incredibly common. My grandmother
caught a C diff infection after what had already been a very arduous treatment
and recovery, and she received basically no support from the hospital that had
effectively given her the infection.

~~~
Fomite
While she likely got it in the hospital, it should be noted that a fair
portion of the population carried C. difficile in their guts, and could
develop a symptomatic infection purely as the result of a disruption of the
less hardy elements of their gut flora.

------
pklausler
I wonder if there's any correlation between anti-vaxxers and those folks who
insist on getting antibiotics that they don't need.

------
JPKab
At what point do they just move the outdoor water events to the ocean? I
understand it's a hit to national pride to move them, but won't the publicity
be far worse if a bunch of athletes get sick?

~~~
i_live_there
There are lots of other beaches in Rio that could've been chosen to host the
water events.

However, Rio wanted to have some sort of legacy after the olympic games,
something to be proud of after spending so much money while people are
suffering without health and security. So the governors chose Baía de
Guanabara! It's poluted as fuck, but the intent was to cleanse it before the
games and have it as the Olympic legacy.

As always, Brazil screwed it and the bay still is a shit hole. Hell, 2 days
ago they found in the bay the body of a college student that was murdered
nearby.

Source: Live in Brazil. Send help

~~~
brianwawok
Finding a body seems unrelated. Even a clean river can get a body now and
then...

------
dluan
This is such a clickbait title. It's like saying "Dogs that can learn tricks
discovered in NYC".

~~~
sctb
Thanks, we've updated the title to that of the article.

------
ucaetano
Link points to a piece from The Economist, from a month and a half ago, not to
current news. Please change the title.

~~~
known
I'll do. Thank you...

------
chadclan
Can you say clickbait?

We've been on the cusp of an antibiotic resistance epidemic (according to the
media and select physicians) for decades.

1979 -
[http://www.ncbi.nlm.nih.gov/pubmed/45521](http://www.ncbi.nlm.nih.gov/pubmed/45521)

1992 -
[http://science.sciencemag.org/content/257/5073/1064](http://science.sciencemag.org/content/257/5073/1064)

But, as @reasonattlm said far more eloquently than I: humans seem need these
stories to provide the motivation to use existing antibiotics less and to get
moving on creating new antibiotics.

~~~
simonh
Sure, but it is a real problem. Many antibiotics that were useful in the past
are much less useful now, and more antibiotics with undesirable side effects
are being used as treatments of last resort. If nothing had been done to
mitigate the issue since 1979 or 1992 we'd be in a pretty dire situation by
now.

~~~
dluan
Not really, new resistant strains and new antibiotics to fight those strains
is a constant inevitable march of evolution, and for the most part, driven by
money from large pharma companies. An equivalent might be murphy's law and
silicon chips.

It's hardly dire, and arguably the disaster headlines of each new MRSA strain
is more damaging to public awareness about how antibiotics actually work.

~~~
photoJ
Not may researchers agree with this view. Note the decrease in discovery of
new antibiotic over time. Cite: [http://smellslikescience.com/a-need-for-new-
antibiotics/](http://smellslikescience.com/a-need-for-new-antibiotics/) Also
if you need more info, more people are estimated to die from AMR then cancer
in 2050. Cite:
[http://www.bbc.com/news/health-30416844](http://www.bbc.com/news/health-30416844)

~~~
dluan
That's given the techniques used so far. See the recent work by the Lewis
group [1] which uses a new method to culture soil bacteria to identify new
antibiotics and opens up an entirely new pipeline. Previously, we've never
been able to keep these strains of bacteria alive, but now we're able to
allowing for sequencing and isolation of tons of new antibiotics. It's
estimated that we'll be using this new technique for a long time.

New antibiotic finds are black swan events, they tend to come from new areas
that unless you specifically are looking there, you're not going to find. It's
like an oil well, and the usage of the the few "last-resort" antibiotics,
which ones get produced and sold, is highly controlled by a handful of pharma
companies so they eke out whatever monetary value is left.

[1]
[http://www.nature.com/nature/journal/v517/n7535/full/nature1...](http://www.nature.com/nature/journal/v517/n7535/full/nature14098.html)
[https://directorsblog.nih.gov/2015/01/13/digging-up-new-
anti...](https://directorsblog.nih.gov/2015/01/13/digging-up-new-antibiotics/)
[http://www.the-
scientist.com/?articles.view/articleNo/41850/...](http://www.the-
scientist.com/?articles.view/articleNo/41850/title/New-Antibiotic-from-Soil-
Bacteria/) [http://www.npr.org/sections/health-
shots/2015/01/07/37561616...](http://www.npr.org/sections/health-
shots/2015/01/07/375616162/compound-from-soil-bacteria-may-help-fight-
dangerous-germs) [http://www.smithsonianmag.com/science-nature/new-
antibiotic-...](http://www.smithsonianmag.com/science-nature/new-antibiotic-
dirt-soil-can-kill-drug-resistant-bacteria-180953828/?no-ist)

~~~
photoJ
"That's given the techniques used so far." By definition, looking at history
does precisely that.

I am familiar with Lewis group and and wish more people were also. Thanks for
the links, as its nice to see the background for those not familiar.
Definitely worth an upvote IMHO.

My concern with this the belief that this is is a steady march where "New
resistant strains and new antibiotics to fight those strains is a constant
inevitable march of evolution" implies there is no need to be concerned. New
technology may save lives, just as unproven carbon neutralizing tech may stop
green house issues, but today, at this moment, there is no proven tech that
obviates this dangers. While, we hope and believe, that new tech will solve
many problem, the widely held scientific view point on AMR is that it is an
unsolved problem that is going to kill a lot of people. Which IMHO is pretty
dire.

~~~
dluan
My point is, the inevitable march is driven by the market pipeline created by
the Glaxosmithkline, Merck, and Amgen's of the world more than anything else.
A good black swan event disrupts this to some extent, but not really. As long
as there is a new MRSA, there is a host of new antibiotics being developed.
This means there is always an arm race that requires lots of investment, but
this pipeline we have set up today is far from optimal. Changing IP rules is a
good place to start.

