OP-ED

The End of Antibiotics. Can We Come Back from the Brink?

Tom Frieden CDCAntibiotic resistance — bacteria outsmarting the drugs designed to kill them — is already here, threatening to return us to the time when simple infections were often fatal. How long before we have no effective antibiotics left?

It’s painfully easy for me to imagine life in a post-antibiotic era. I trained as an internist and infectious disease physician before there was effective treatment for HIV, and I later cared for patients with tuberculosis resistant to virtually all antibiotics.

We improvised, hoped, and, all too often, were only able to help patients die more comfortably.

To quote Dr. Margaret Chan, Director General of the World Health Organization: “A post-antibiotic era means, in effect, an end to modern medicine as we know it.”

We’d have to rethink our approach to many advances in medical treatment such as joint replacements, organ transplants and cancer therapy, as well as improvements in treating chronic diseases such as diabetes, asthma, rheumatoid arthritis and other immunological disorders.

Treatments for these can increase the risk of infections, and we may no longer be able to assume that we will have effective antibiotics for these infections.

Last September, CDC published our first report on the current antibiotic resistance threat to the United States.

The report conservatively estimates that each year, at least 2 million Americans become infected with bacteria resistant to antibiotics, and at least 23,000 die.  Another 14,000 Americans die each year with the complications of C. difficile, a bacterial infection most often made possible by use of antibiotics. WHO has just issued their report  on the global impact of this health threat.

It’s a big problem, and one that’s getting worse. But it’s not too late. We can delay, and even in some cases reverse the spread of antibiotic resistance.


Clinicians, health care facility leaders, public health leaders, agriculture leaders and farmers, policymakers, and patients all have key roles to play.
The FY 2015 President’s Budget requests $30 million for the CDC’s Detect and Protect Against Antibiotic Resistance Initiative (known as the AR Initiative), part of a broader CDC strategy to target investment and achieve measurable results in four core areas:

Detect and track patterns of antibiotic resistance.

A new five-region lab network, if funded, will speed up our ability to detect the most concerning resistance threats. The network would increase susceptibility testing for high priority bacteria and keep pace with rapidly mutating bacteria so labs are ready to respond to new threats as they emerge.

A new public data portal will show national trends as well as variations in rates of antibiotic prescribing and resistance among states and regions. An increase of $15 million in the FY 2015 President’s Budget for CDC’s National Healthcare Safety Network (NHSN) will allow full implementation of electronic tracking data from U.S. hospitals on antibiotic use and resistant bacteria.  (I’ll talk more about this in a future post.)

Respond to outbreaks involving antibiotic-resistant bacteria.

Enhanced information from hospitals and the new lab network will help detect outbreaks that might previously have gone unnoticed.  We’ll be able to better track the movement and evolution of bacteria, helping local and state responders better prepare for and stop outbreaks of antibiotic-resistant bacteria.

Prevent infections, prevent resistant bacteria from spreading, and improve antibiotic prescribing.

We’re establishing AR Prevention Collaboratives, groups of health care facilities around the country working together to implement best practices for inpatient antibiotic prescribing and preventing infections. Hospitals, long-term acute care hospitals, and nursing homes can all work together to protect patients from drug-resistant infections as patients move between medical facilities in a community.

They’ll scale up or extend the reach of interventions proven to reduce or stop antibiotic-resistant threats, improving antibiotic prescribing and stewardship programs and ultimately reduce antibiotic resistance.

Discover new antibiotics and new diagnostic tests for resistant bacteria.

Because antibiotic resistance occurs as part of the natural evolutionary process of bacteria, it can be slowed but not completely stopped. New antibiotics and therapies will always be needed to keep up with resistant bacteria, as will new tests to track the development of resistance.

To support these efforts, CDC will create a Resistance Bacteria Bank that will make drug-resistant samples available to diagnostic manufacturers, pharmaceutical companies, and biotech firms to develop new diagnostic tests and evaluate new antibiotic agents and therapies.

Exciting new molecular diagnostics may be able to determine if patients have an infection, and whether it is resistant, within hours instead of days, allowing treatment to be tailored to the patient’s particular infection.

With $30 million annual funding over the next five years, CDC’s AR Initiative could cut the deadliest resistant organism, CRE, in half, and also cut healthcare-associated C. difficile in half, saving at least 20,000 lives, preventing 150,000 hospitalizations, and cutting more than $2 billion in health care costs.

Other projected outcomes include a 30 percent reduction in healthcare-associated multidrug-resistant Pseudomonas; a 30 percent reduction in invasive MRSA; and a 25 percent reduction in MDR Salmonella infections.

Urgent action is needed now by everyone who manufactures, prescribes, or uses antibiotics. Drug development for new antibiotics and antifungals is necessary but not sufficient to deal with our antibiotic resistance threats.

Doctors and health care systems need to improve prescribing practices.  And patients need to recognize that there are both risks and benefits to antibiotics – more medicine isn’t best, the right medicine at the right time is best.

Consider this a down payment for our country to start tackling our biggest drug-resistant threats.  The actual funding needed to effectively address all of our drug-resistant threats will likely be many times this amount.

But with this type of significant public health investment, we can open a new chapter in the fight against resistance.

Tom Frieden, MD, MPH (@DrFriedenCDC) is Director of the Centers for Disease Control and Prevention.

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38 replies »

  1. Resistance to antibiotics has always been a worrying issue for years. The race to find new alternatives is a bit complex to handle as long as prescribing habits don’t change for good… and we all know this is probably the weakest link.

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  4. We know about C-Diff but only because a family friend who’s a nurse told us about it. No doctor or nurse that was treating either of us talked to us about it. It seems that educating people about C-Diff during antibiotic treatment would be a given.

  5. As a patient, discuss with your prescriber the role antibiotics might play in treating your current illness. Encourage your family and friends to use antibiotics wisely and to remember simple and effective germ-fighting steps such as hand washing.

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  8. Tom Frieden: So by all accounts, an ENT prescribing post-surgical Levaquin PLUS methylprednisolones TWICE, during the post-surgical period, would be deviating from “standard of care, initiating tendinopathies”

    Would this have set up an on-going Staph Aureus, Moraxella Catarrhalis and Klebsiella Oxytoca Pneumonia situation into 2014 and beyond, in an immune-compromised patient (Lyme, Babesia and b. Burgdoferi and hypogammaglobulinemia)

  9. It is important to note that the data on prophylactic antibiotics given to reduce the risk of surgical site infections demonstrates that the most important time to give the antibiotics is prior to the incision. There is not evidence that continuing prophylactic antibiotics beyond the surgery provides any additional benefit. Hence, the recommendations that prophylactic antibiotics be stopped within 24 hours after the procedure.

    As you point out, it is important to ensure that prophylactic antibiotics are giving only before procedures where they are recommended. More data on the use of antibiotics for preventing infections after surgery would certainly help identify the most effective strategies in various patient populations.

  10. SCIP and the Joint Commission now mandate stopping prophylactic antibiotics for surgery after 24 hours. Doesn’t this practice risk INCREASING the number of resistant organisms that survive? After all, we always tell patients to finish their full dose of oral antibiotics for that reason–because of the risk that the less resistant ones will be the only ones killed off, leaving the resistant organisms to thrive.

    Would it make more sense to REDUCE the amount of prophylactic antibiotics that are given for clean cases not involving implants? And investigate the wisdom of continuing prophylactic antibiotics LONGER than 24 hours for clean cases with implants or clean-contaminated cases such as bowel resection, especially in patients who are diabetic or have other risk factors for infection?

    It seems to me that this “quality measure”, like so many others, is too general and at the same time too rigid. So many problems such as postop wound infections don’t seem to be getting any better. More of “The Dark Side of Quality”–the flaws in the quality quest. See http://wp.me/p2bC3h-g7

  11. Dear Dr. “Victory Medical Strategist”
    My previous comment was referring to a global problem that affects all countries regardless of economic or social situation and, in particular, the intensive care units. Since I graduated in medicine I’ve been watching and trying to follow all CDC recommendations related to hospital infection control. Actually the whole world knows the CDC is a global authority on health and its actions goes well beyond American borders. It is true that the reality of the underprivileged countries does not always allow that optimal measures are adopted in full. However, when we talk about hospital infection, we are referring to organisms that are on this planet for billions of years before our arrival, and possibly will remain here after our departure or extinction. So, I believe that we should approach the subject in a scientific manner and also philosophically, questioning even our limit when facing the terminal phase of human life.
    I wonder if in a future not so distant, we may have to deliver the latest technology and medical knowledge to critically ill patients where they are, rather than gather them into a single unit where the transmission of resistant germs would be more likely, even if we adopt all necessary precautions.
    Regarding your “rambomycin” it will always be very welcome and should, like all other antibiotics, be used wisely.
    In your last paragraph you wrote:
    “Do we dare allow our last-ditch antibiotics to be exported to places where we risk that they will be beaten by the germs due to inadequate infection-control procedures?”
    This thought bothered me a lot, especially being in the 21st century. This kind of questioning, about denying access to scientific progress that can save human lives, besides being impractical, would be unethical and contrary to the UNESCO Universal Declaration on Bioethics and Human Rights.
    http://unesdoc.unesco.org/images/0014/001461/146180e.pdf

  12. Dr. De Lorenzi,

    My sense is that you have identified the true problem: outbreaks of antibiotic-resistant bacteria are not being tracked back to ambulatory pediatric health clinics that overprescribe antibiotics for colds and ear infections. They are coming out of ICUs like the ones for which you do infection control in Rio de Janeiro. In one or more of the URLs I supply above Dr. Paul Ewald describes the reasons.

    The CDC is a jewel in the crown of American Medicine. When an outbreak of antibiotic-resistant bacteria hit a Florida long-term acute-care hospital, the CDC rushed to the rescue:

    http://www.cdc.gov/hai/state-based/pdfs/HAIpreventionStories_FL_CRE.pdf

    “Florida Stops Outbreak of Carbapenem-Resistant Enterobacteriaceae”

    Note the similarity between the measures employed and those Israel used in similar facilities in the same situation:

    http://www.michigan.gov/documents/mdch/Israeli_Experience_with_CRE_-_Marchaim_403295_7.pdf

    “CRE Epidemiology-Global & Israeli Perspectives–Assaf Harofeh Medical Center Infection Control and Prevention Unit”

    Interesting (to me anyway), there was no discussion of antibiotic prescribing practices in the Israeli paper, and in the CDC’s fact sheet on the Florida CRE emergency they said:

    “What We Learned

    • Spread of CRE can be reduced through tracking CRE and targeting prevention practices to patients who are colonized or infected with CRE.

    • Critical strategies to stop CRE spread include: quickly detecting patients with CRE, separating patients with and without CRE and dedicating nursing staff and equipment to each group. Facilities must ensure constant adherence to isolation and hand hygiene practices to protect patients and save lives.

    • Reducing CRE within and across healthcare facilities will require a regional public health approach.”

    Now, we Medical Victory Strategists are always for the development of decisive new weapons. In the battle against mankind’s oldest and most-remorseless enemies, the only thing better than a new antibiotic that is to staphylococcus aureus what the atom bomb was to enemy cities, is a new antibiotic that is more like a hydrogen bomb (with the precision of our latest-generation guided missiles, of course). For saving individual patients who have already developed sepsis, “Rambomycin” (to invent a name) will be essential, and all measures to speed its development should be taken.

    But by the time doctors fall back to using Rambomycin, some patient is going to be really, really sick. So your point about rethinking the very *existence* of facilities that answer to the description Dr. Ewald gives of breeding grounds for MDR bacteria is well-taken. CDC’s actions in the Florida crisis were designed to take a facility that was such a breeding/transmission ground and make it into one that was not. The Israelis went farther and looked at their larger system of rotating very sick people from long-term care facilities to long-term intensive medicine facilities and back.

    As for vaccines, absolutely. In:

    http://www.pbs.org/wgbh/evolution/library/01/6/text_pop/l_016_06.html

    Dr. Ewald discusses the development and use of vaccines not just to protect us humans, but to “domesticate” our microbial enemies.

    Another issue we will have with “Rambomycin” is whether we let it be used in health care facilities that don’t follow Dr. Freiden’s guidelines. Of special concern are those outside the United States, to which CDC’s writ does not reach. Consider this article from little more than a year ago:

    http://blogs.wsj.com/indiarealtime/2013/04/23/india-has-lost-superbug-war/

    “India ‘Has Lost’ Superbug War”

    Do we dare allow our “last-ditch” antibiotics to be exported to places where we risk that they will be beaten by the germs due to inadequate infection-control procedures?

  13. I don’t think most people realize how urgent it is to get all of this under control. My husband and I had heard the term MRSA. But like most people it was something that was out there but we didn’t give it much thought. I became sick in April 2013 and ended up in the hospital for months, several weeks of that in a coma. I had somehow gotten MRSA in my lungs. I had no outwardly cuts or sores, nothing to indicate something like that was wrong, but I had gone to an ER for a migraine three days before. My family was told I likely would not make it but I did and I left the hospital as a double amputee. I know that sounds terrible but knowing all the things that could have happened I feel very lucky! About two months after coming home my husband got MRSA in his arm; he did have a very tiny scratch where the MRSA occurred. He was treated successfully but he has gotten it again in the exact same place, this time there was no outward wound of any kind. He just finished the antibiotics but that’s two huge rounds of antibiotic treatment for him in less than six months. When he got MRSA the first time, they insisted on treating me as well. They explained it as “just in case”. Knowing what I know now I would not take the antibiotics but we were still in shock at that point and so terrified of what we felt like we couldn’t get away from.

    Patients need to be educated so they know when to say no to antibiotics. They also need to know that they must complete the treatment if they start it and not just until they feel better. The general public needs education in the proper use of antibiotics.

    We know about C-Diff but only because a family friend who’s a nurse told us about it. No doctor or nurse that was treating either of us talked to us about it. It seems that educating people about C-Diff during antibiotic treatment would be a given.

    We live in Arkansas in a small resort town, tourism is the main industry. The doctors here told us that at least 1/3 of the people in our town would test positive for MRSA and that we can get it going to Walmart or Kroger but that we couldn’t give it to each other. It’s all very confusing.

    I’m glad to see the government getting involved. I hope that the medical community and the public can be educated and that the answers can be found. What can I do to help?

  14. Dear Dr. Frieden , congratulations on your initiative, always acting in the fight against antimicrobial resistance. However, I am working in infection control in Rio de Janeiro for over 15 years. These measures suggested by the CDC, while very effective when put into practice, do not seem to be sufficient in our reality. I believe that the issue should be discussed with the entire society, even to try to define the extent to which we must fight desperately for maintaining a life that often has come to its natural end. The intensive care units remain overcrowded with chronic patients with multiple invasive devices and exposed to several episodes of infections by resistant germs.
    I think it will be needed more radical attitudes, such as rethinking the architecture of intensive care units or even the very existence of these units. We may have to deal with critical patients in public wards, taking to them the necessary equipment and specialized health professionals. ICUs as they are now are true incubators of resistance. Moreover we should consider developing vaccines against bacteria, because, to my knowledge, very little has been invested in this particular activity.
    Thank you very much for the opportunity.
    Best regards ,
    Andre De Lorenzi

  15. As always, an interesting conversation.

    Thank you for your comments on new drug development and antibiotic use in agriculture. Bacteria learn in a very short time how to outsmart antibiotics, and new drugs are years away. Making new antibiotics is both expensive and difficult. However, even when new drugs arrive, their effectiveness will quickly disappear if the prescribing and use doesn’t improve. We need to be doing a better job of improving appropriate use of antibiotics in all sectors – humans and animals.

  16. Thank you for your comment, Catherine.

    CDC does not encourage the restriction of antibiotics. It’s important that patients receive the correct antibiotic and the right dose at the appropriate time for the best duration. Each one of us can help limit antibiotic resistance by changing the way we use antibiotics.

    As a patient, discuss with your prescriber the role antibiotics might play in treating your current illness. Encourage your family and friends to use antibiotics wisely and to remember simple and effective germ-fighting steps such as hand washing.

  17. Daniel – We appreciate ABIM Foundation’s and Consumer Reports’ partnership with CDC to improve appropriate use of a variety of medical procedures and medical products, including antibiotics.

    We agree everyone has a role to play in improving antibiotic use and prescribing. CDC is working diligently to help ensure prescribers, patients and others understand the whole picture – these are miracle drugs that must be used correctly.

    Thank you for your efforts to spread these important messages.

  18. Thank you for your comment – I recall your notes on my last blog.

    A recent CDC report shows that health care facilities can have a direct and almost immediate positive impact by implementing a seven-step antibiotic stewardship program. Improving prescribing practices in hospitals help ensure patients receive the correct antibiotic and the right dose at the appropriate time for the best duration.

    Research shows these programs can improve patient outcomes, reduce overall antimicrobial resistance within the facility and save health care facilities money. To learn more, see CDC’s March Vital Signs on antibiotic prescribing in hospitals: http://www.cdc.gov/vitalsigns/antibiotic-prescribing-practices/

  19. Antibiotic resistant bacteria are indeed as terrifying as Dr. Freiden describes. In addition to his suggestions, I would favor policy changes that incentivize the development of new drugs to combat these super bugs. The Orphan Drug Act was instrumental in getting pharmaceutical and biologic companies to invest in targeted cures for rare diseases. A similar act (including things like patent extensions and FDA drug approval fast-tracking) for anti-microbial products/medicines could be very helpful and don’t cost tax payers anything.

  20. So not a single bullet point on stopping factory farms from dumping tonnage of antibiotics into animals for the sole purpose of growth and profit? This could be undone overnight. Why hasn’t the CDC done this already? This is not about “sick” animals. This is about routine antibiotic use to combat squalid conditions, and fattening animals.
    Would the CDC like to address the NIH funding or drug company dereliction in this matter? We have about 30 medicines so that someone doesn’t have to go pee-pee too much, but no new antibiotics?
    Would the CDC like to address formulary restrictions which force physicians to prescribe the same antibiotic over and over again, encouraging resistance?
    I won’t hold my breath for CDC action. Physicians are an easy target and don’t give near enough campaign money to be considered. So of course, it’s our fault again. Much easier for the CDC to protect their corporate owners and their associated markets for short term profit objectives.
    I wash my hands to protect patients. I also wash my hands because medicine is a filthy business.

  21. I agree with Peter1.
    Here is a link you may find instructive:

    http://www.smithsonianmag.com/science-nature/microbes-the-trillions-of-creatures-governing-your-health-37413457/?all

    This blog’s spam filter often catches comments with more than one hot link, so I will leave only that one, but do a few searches for “fecal transplant” and “microbiome” and see what comes up. Believe it or not I just saw a link to a site for DIY fecal transplant instructions!

    Two personal anecdotes…

    => A few years ago I took my wife and children along for a company trip to Acapulco. A dentist who knew we were going wrote a prescription for enough erythromysin for everybody, with instructions for eveybody to take one in the morning daily, beginning the day before we left. This, he said, would protect us against “Montezuma’s revenge” (diarrhea) that American tourists to Mexico often get. He was correct…but I learned the hard way. I took my pills faithfully but we were in a world-class hotel, never left the property and the food looked great to me. Since I was a cafeteria manager who knew everything about food [irony alert] I decided to skip the last two pills. All went well and we had a great time, but the first day back as I was putting my key into the door returning to work I messed up my pants bad enough to go home to change — and get the two pills I had neglected to take!

    => I was an Army medic in Korea in 1965 and we were warned not to eat any food off base. I had many Korean friends and paid no attention, and learned to enjoy everything, especially the Chinese food which (very popular) as well as kimchi and Korean cuisine, which most GIs made fun of. One of our doctors was from Columbia, South America, and when I asked him about the food he said no problem. “If you get sick, we can give you a shot and it will go away. When you get ready to go home, you can get a shot before you leave and you won’t take anything back with you.” I furnished the lab tech with a stool sample and he reported two or three kinds of intestinal parasites, and was particularly excited to find “clonorchis sinensis in the trophozoite‎ stage” which he had only seen pictures of before. I had no idea what that meant until later or I would have been alarmed, but sometimes ignorance in your twenties is your friend.

  22. “They are invaluable in those WHO NEED THEM!”

    Key words Catherine along with “immunocompromised”. Your sister-in-law had a lot of issues going on – I don’t. I wonder if the C-Diff came from anti-biotics?

    Good gut bacteria gets destroyed every time people take anti-biotics and your gut is about 50% of your immune system.

  23. My sister-in-law (post second open heart surgery , post TAVR pig valve, post pacemaker insertion and post bouts of hospital induced C-Dff and MRSA under her belt and a post all of this, “pyogenic cyst” which came through the sinus floor into her upper right gum, can CERTAINLY attest to the NEED for pre-biotics. They are invaluable in those WHO NEED THEM!

    Oral sugeons counseled heart surgeon who would NOT operate on her heart UNLESS she removed about 7 teeth pre-TAVR AND took pre-biotics and for a year she was being told her gum issues were “bone tragments trying to make it through toughened oral tissue on her upper ridge” Until I stepped in and asked to take a look-see, thenI took a picture and we can tell you, it was an extremely painful, fluid filled sac the size of a small plum!

    I wonder what pathology made of the fluid? was it C-Diff/MRSA or combo or anything else? Not sure yet, deaing with my own issues at this time. Will find out.

    SO i do NOT feel they are handed out like candy, if a doctor feels it warrants prescribing, ESPECIALLY in the immunocompromised, I would take them without hesitation; that is exceptions of FLUOROQUINOLONES, which are nasty end of line antibiotics, not for common sinus (staph/kelbsiella oxytoca infections!)

  24. Thanks for this. I’m of the opinion that there is no shortage of evidence but there is a vast shortage of interest in meeting the challenges. I’m a throwback to the era of Rachel Carson, Ralph Nader and Jessica Mitford but those and other early warning voices triggered as much opposition as positive results. It comes down to a conflict between beliefs versus facts — and beliefs always trump facts, often with dismal results.

    Polarization has become so extreme that record weather extremes have no effect on the closed minds of climate-change deniers. Political extremism approaches the level of McCarthyism. Opposition grows to the Common Core, public education and vaccinations. For-profit healthcare providers troll for business, carefully sifting prospective customers through a means test, selecting the deepest pockets for the most luxurious regimens, which naturally include showers of soothing alternatives ranging from unproven to clearly ineffective.

    Thanks again and keep up the good fight. Meantime, I’m settling in to my role as a complaining old curmudgeon.

  25. My recent hip replacement has hit me smack in the face with the anti-biotic dilemma. There is not much science and no blind study, yet every time I even drive by a dentist’s office they want me to pre-med with anti-biotic. I’ve read as many studies as there seems to be where the incidence is minute in what seem to be mostly immune compromised patients. The ADA last recommended none were needed unless for infections, but now they again recommend every time the gums are “manipulated” or pierced.

    What bothers me is everyone is treated the same and fear is the driving force for most patients and fear of lawyers for dentists. The developer of the device (British) in my hip does not recommend anti-biotic after 2 years of post op, except for oral infection. My surgeon takes the same opinion. Yet here in the U.S. pre-med is handed out like candy.

  26. As part of the Choosing Wisely campaign, six different specialty societies have recommended against the use of antibiotics for conditions ranging from sinusitis (American Academy of Family Physicians) to conjunctivitis (American Academy of Ophthalmology) to otitis (American Academy of Otolaryngology – Head and Neck Surgery Foundation). These recommendations are designed to fuel conversations between physicians and patients about the appropriateness of antibiotics. We believe that there is a significant demand-driven element to the overuse of antibiotics, with patients often requesting care that they do not need and that will not help them get better. To address this, patients need to hear from credible sources like the CDC, medical specialty societies and Consumer Reports about the limitations of antibiotics, and the dangers of antibiotic resistance. As part of Choosing Wisely, Consumer Reports has produced patient-friendly handouts describing when antibiotics are, and are not, appropriate for a variety of common illnesses affecting children and adults. This sort of consumer education should make it easier for physicians to decline to prescribe antibiotics, as their patients gain a stronger understanding of the fact that taking antibiotics for the wrong purposes can reduce the effectiveness of antibiotics when they are needed.
    Daniel Wolfson @wolfsond
    ABIM Foundation

  27. I find it alarming that this article and the others like it on The Health Care Blog neglect an important *category* of responses to the evolution of antibiotic resistance: human-guided evolution of the same pathogens away from virulence.

    Dr. Paul Ewald wrote at some length about this in his book PLAGUE TIME:

    http://www.amazon.com/Plague-Time-Germ-Theory-Disease/dp/0385721846/ref=sr_1_1?ie=UTF8&qid=1399397341&sr=8-1&keywords=plague+time+ewald

    He also mentions it in papers such as:

    http://www.pophealth.wisc.edu/PopHealth/files/file/Weekly%20Update/WU%20-%2003_03_10/Ewald-03_18_10.pdf

    and also in his PBS interview:

    http://www.pbs.org/wgbh/evolution/library/01/6/text_pop/l_016_06.html

  28. I have heard that the amount of antibiotics used in livestock – which are truly given willy nilly since the animals are generally not even thought to be infected – is a much greater the amount uses in humans.

    Any further information about this?

    If so, shouldn’t we be trying to change agricultural use?

  29. John: have a look-see here, to how mcuh we have POISONED our own environment, this is just GADOLINIUM form MRI’s but antibiotics are also playing a part in our demise, whether your doctor prescribes them OR NOT! I personally know cases wehre a patient NEVER had an MRI yet have HIGH amounts of GADOLINIUM in them! thee are but 2 of my links I have over 20!
    Monitoring of iodine- and gadolinium-containing contrast media in drinking water treatment plants.
    http://www.metrohm.co.uk/contentimages/Product2Images/tp-ic_contrast_media.pdf

    U.S. – Anthropogenic gadolinium as a micropollutant in river waters in Pennsylvania & in Lake Erie, northeastern United States
    This is only the abstract of the 2006 study.
    http://www.sciencedirect.com/science/article/pii/S0009281906000031

    Increasing levels of rare earth Gadolinium found in Berlin’s Drinking Water
    This is a short 2013 update on a 2009 study. Interestingly, it says that the presence of Gadolinium in the water does not pose a health risk/
    https://www.jacobs-university.de/2013/05/increasing-levels-rare-earth-gadolinium-found-berlins-drinking-water

    U.S. – Toxicity of Gadolinium to Some Aquatic Microbes
    http://sti.srs.gov/fulltext/ms2000638/ms2000638.html

    Occurrence of anthropogenic gadolinium in water intended for human consumption. (France)
    You might have to scroll down the page a bit to find the link to the article on the right-hand side of the page.
    http://www.ansespro.fr/euroreference/numero5/index.htm

  30. In the name of progress we have poisoned the world’s fresh water, trashed the oceans, spewed poisons into the air, destroyed rain forests, and are now slaughtering microbiomes with antibiotics. I want to make positive suggestions how to ameliorate these problems but nothing promising comes to mind. I think it has to do with patents, corporate “personhood” and market economics (also termed cost/benefit analysis).

  31. The only way this is going to happen is if we come up with new guidelines that seriously restrict inappropriate use. Asking providers to do the dirty work for us is not going to work, the psychology of overprescribing is by now well known. Let’s make cerrtain categories of antibiotics partially-controlled or create a new control class and legally prohibit use except under certain circumstances.That may involve letting people stay sick when they could get better. A form of rationing, yes – but one that is necessary.

  32. While I recouperate at home after a five day stay for removal of my thyroid (HRAS 61 Cancer) and my left styloid bone, for which I received ONLY post–perative IV Ceftazolin. Point is, I have had five bouts of pneumonia in past (Klebsiella Oxytoca) two sinus/thraot infections last month (Moraxella Catarrhalis & Staph AUreus) and I am immunocompromised beubng told, “”Your NUMBERS aren;t high enough, we only treat when up to 700, you are only at 500!)
    Mind you I had a pre-operative chest xray and had i NOT asked my PCP if he required one and he agreed, I would NOT have known I had PNEUMONIA yet again YET the surgeon insisted it was ok to operate.
    and was about as adamant as anyone I’;d ever seen, in having me to leave the next day as is per the norm, WELL DOc I am NOT normal. THe pneumonia made me develop fever, mucus and not being able to swallow complicating matter, I was FINALLY given a feeding tube on Thursday night, after being only on an IV since entering the hospital on Mon am!
    ALL This because no one wanted to give me LYME antibiotics, (22+ years of Lyme + Babesia + B. Burgdorferi UNNDIAGNOSED!) because chronic Lyme doens’t exist…leading to MRI’s with contrast…leading to Systemic Sclerosis/Bowel Fibrosis…leading to Eagle’s Syndrome (calcified styloid) … LEading to …hell, the list goes on.

    BUT I HAVE NEVER ASKED for antibiotics, willy nilly, I always KNEW I had an infection and MADE the docs perform cutlures to determine WHO THE ENEMY WAS, so we knew if we could fight it.
    now off to bed to travel to two docs tomorrow, to find out if I will EVER get IVIG for my crappy immune system or is that going to be held off until I am on deaths’ door again?! and to determine the need for continued antibiotics becuase all I was given post-op were post-op type Ceftazolin, for 4 days, hardly enough to kill KLEB PNEUMONIA huh? You tell me!?

  33. This is the purpose of having Infection Control Teams in hospitals…to help prevent the emergence of resistant organisms.

  34. I share your concerns.

    Can you comment on what seems to be an increasing number of papers advocating for the treatment of simple appendicitis with antibiotics instead of surgery?

    Instead of one preoperative dose of antibiotics, which may not even be necessary in the laparoscopic appendectomy era, people want to give 7 to 10 days of antibiotics for an initial episode of appendicitis and treat recurrences that same way.

    The morbidity of a laparoscopic appendectomy is very low.

    There are about 250,000 to 300,000 appendectomies for appendicitis done every year in the US and as many as half of those may be for uncomplicated appendicitis.

    It seems to me that to treat so many patients with antibiotics will only exacerbate the problem of resistance.

  35. This is a very frightening prospect, but one that was all too predictable. Setting aside for a moment the use of antibiotics in agriculture, it seems to me that we have dug this hole in two important ways. First, as patients, we are far too nonchalant about our choices, and have come to believe that our choices in antibiotic use (like our unwillingness to exercise and eat well) either don’t matter or really won’t prove that consequential in the end. Second, healthcare providers have been hugely complicit in cultivating this mindset because they just can’t say no.

    A neighbor of mine recently went through a personally stressful period and ended up in urgent care for what turned out to be exhaustion and viral pneumonia…and, of course, she got antibiotics. Why? “Just to be safe…” Who’s fault is that? Seems to me that it two to tango, and this healthy, indeed robust, middle-aged mom, who was much better within a week of onset, should have gotten a much different message than the one she received.

    Maybe it’s time to turn the reimbursement screws: prescriptions for antibiotics must show a diagnosis and ICD code. If its a viral dx, unless the patient is immunocompromised or any a generally accepted risk (the very young or the very old), the antibiotics are not reimbursable. It’s the worst kind of managed care methodology, but it will get people’s attention and it will take this conversation mainstream. This is just another healthcare issue for which we have our heads in the sand.

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