ON Thursday, Dr. David Patrick, director of the School of Population and Public Health at UBC, had a cold.
He was working from home.
"I'm practising what I preach," he said over the phone. What he preaches is a cautious approach to the use of antibiotics, plenty of hand washing and good respiratory hygiene - which includes staying home when you're sick.
As the medical epidemiology lead on antimicrobial resistance at the B.C. Centre for Disease Control, he's been involved with the seven-year-old community education program "Do Bugs Need Drugs?" The campaign was created to address the problem of antibiotic resistance; one that, if not addressed, could become the next global crisis, according to the World Health Organization.
During last year's World Health Day, WHO directorgeneral Dr. Margaret Chan said the world is on the brink of losing antimicrobial cures in the face of drug-resistant pathogens.
"In the absence of urgent corrective and protective actions, the world is heading towards a post-antibiotic era, in which many common infections will no longer have a cure and, once again, kill unabated."
If that happens, we will have only ourselves to blame.
. . .
It was thanks to his slightly sloppy approach to lab work that Scottish researcher Alexander Fleming discovered the bacteriakilling properties of penicillin in 1928. According to a 1999 Time magazine article naming him one of the 100 Most Important People of the 20th century, he'd returned to his lab after a holiday to find an old culture of Staphylococcus bacteria had been contaminated by mould, and that colonies of bacteria adjacent to the bloom were being dissolved. After growing the mould in a pure culture he discovered it produced a substance that killed a number of bacteria. Though he initially called it "mould juice" he went on to name that substance penicillin.
"It was a discovery that would change the course of history," stated the Time article. "When it was finally recognized for what it was, the most efficacious life-saving drug in the world, penicillin would alter forever the treatment of bacterial infections. By the middle of the century, Fleming's discovery had spawned a huge pharmaceutical industry, churning out synthetic penicillins that would conquer some of mankind's most ancient scourges, including syphilis, gangrene and tuberculosis."
In typically human fashion though, we went overboard. If a small amount of medicine was a good thing, it seemed taking antibiotics for every sniffle and cough must be even better. Even farmers began using antibiotics for their livestock.
In his 1945 Nobel Prize lecture, Fleming himself warned of the danger of bacteria becoming resistant to the cure. "It is not difficult to make microbes resistant to penicillin in the laboratory by exposing them to concentrations not sufficient to kill them, and the same thing has occasionally happened in the body."
Natural selection comes into play. The bacteria able to survive the onslaught of the antibiotic - whether because of their own inherent capability to resist or because they have acquired resistance from other bacteria - are the microbes that will reproduce. And their progeny will inherit that same resistance.
The more we use antimicrobials, the more resistant bacteria become to them.
"It is a problem," said Patrick. "The trick is to make people better without the wasteful use of antibiotics."
The B.C. Centre for Disease Control has been tracking the use of antibiotics through PharmaNet, the province-wide network that links all B.C. pharmacies to a central set of data systems. Every prescription dispensed in B.C. is entered into the system. The most recent program evaluation report found "the overall consumption of antibacterials for systemic use has declined since 2005, with a particularly notable drop between 2008 and 2009."
"We're winning some and we're losing some," explained Patrick. "Where we're winning - doctors are prescribing fewer antibiotics."
That's a good thing. The centre states "With the exception of pneumonia, most respiratory tract infections resolve on their own, without antibiotics. Infections that are due to viruses include colds, influenza (the "flu"), croup, laryngitis, bronchitis, bronchiolitis, most sore throats as well as some ear and sinus infections. Viruses do not need antibiotics. Although ear and sinus infections are often bacterial in etiology, they are almost always preceded by viral infections and usually resolve without antibiotics. The Canadian Pediatric Society recommends watchful waiting as the preferred treatment for ear infections in children over the age of six months to see if the infection will go away on its own."
Reducing the volume of antibiotics prescribed by B.C. doctors seems as simple as suggesting new guidelines, but it's not. Antibiotics remain the key to treating many infectious diseases and writing a prescription is an efficient and effective way to deliver health care.
"The average family doctor has a very busy office, if you have someone begging for antibiotics, it might not seem like a big deal. It's just one patient. The problem comes down the road, for that patient or for someone else."
Patrick compared it to The Tragedy of the Commons, ecologist Garrett Hardin's 1968 metaphor about herders sharing a common parcel of land, on which they are each entitled to let their cows graze. In Hardin's example, it is in each herder's interest to let all of their cows graze on the land, even if it suffers as a result of overgrazing. The herder receives all of the benefits from an additional cow, while the damage to the common is shared by the entire group. If all herders make this individually rational economic decision, the common will be depleted or even destroyed, to the detriment of all.
It's the same with drug-resistant pathogens. Remember, it's the bacteria that are resistant, not the individual. Even healthy people who have never taken an antibiotic can become infected with resistant bacteria, like the Staph infections that often make headlines. Methicillin-resistant Staphylococcus aureus, for example, is tough to treat and commonly spreads in hospitals and healthcare settings. If left untreated, MRSA infections may develop into serious, life-threatening complications such as infection of the bloodstream, bones and/or lungs.
"We have to start thinking about it the way we think about global warming," said Patrick. "We tell people to think about their ecological footprint; we've been telling doctors to think about their 'resistance footprint.'"
There are the footprints of other industries to consider as well. In her World Health Day statement, Chan pointed out that in several parts of the world, more than 50 per cent in tonnage of all antimicrobial production is used in agriculture. By feeding animals low doses of antibiotics for disease prevention and weight gain, farmers are also inadvertently creating strains of bacteria that are resistant to common antibiotics. Those pathogens can be transmitted to people.
"We're not trying to blame the agriculture industry," said Patrick. "We own it in terms of human use. But we want to develop an understanding with producers. What might have worked in the '50s and '60s isn't working now."
. . .
Though they've done much to deserve their reputation as wonder drugs, even those antibiotics that are still effective have a dark side.
On an otherwise unremarkable Wednesday last May, I ruptured my Achilles tendon. It wasn't the result of an accident, a fall or a misstep. During a dance-fitness class, as I pushed off from the floor to jump, it simply snapped.
In the long weeks and months that followed my surgery I obsessed over why it had happened. I'm reasonably fit, I work out regularly, I do plenty of yoga; I'd have thought my tendons were limber and loose.
From my own research and from asking my doctor, surgeon and physiotherapist, I learned rupture often happens without reason. It more often occurs in the middle-aged male athlete. In some patients, the tendon has grown weaker over time. In a few others, it's because of the use of fluoroquinolone antibiotics.
In 2008, the U.S. Food and Drug Administration asked that a boxed warning be added to the prescribing information for fluoroquinolones, which include Cipro (ciprofloxacin), Factive (gemifloxacin), Levaquin (levofloxacin), Avelox (moxifloxacin), Noroxin (norfloxacin), Floxin (ofloxacin) and Proquin (ciprofloxacin hydrochloride).
On the information sheet, the warning is set apart from the rest of the possible side effects in an outlined black box. It reads in part: "This medication may rarely cause tendon damage (e.g., tendonitis, tendon rupture) during or after treatment."
I didn't read the prescribing information before taking Cipro for a respiratory infection earlier in the year. Except for the dosage instructions, I rarely ever did. It wouldn't have changed my behaviour anyway. The risk is low, there's no clear timeline for how long the effects might last, and exercise is important to me.
I have no way of knowing whether my use of antibiotics contributed to my injury, but it certainly got me thinking, and reading, about it. My own bad habit of asking for drugs at the first sign of a sinus infection or sore throat has now been firmly set aside.
"It doesn't mean you shouldn't go to the doctor," said Patrick. "If you have a bad cold, cough, flu or bronchitis you should go so they can rule out pneumonia. But you should trust them to make the diagnosis, and trust them if they don't prescribe anything. It's important for the public not to put undue pressure on their doctor to get antibiotics."
It's worth noting the drugs don't discriminate between bacteria that are good for us and bacteria that cause disease. Whenever you take antibiotics, you kill off some of the beneficial bugs, which allows more sinister strains to establish themselves in their place.
If you are prescribed antibiotics be sure to finish the prescription, even if you start to feel better. If you don't, your immune system may not be capable of killing off the stragglers, and any resistant bacteria left unscathed will be able to proliferate.
Don't stockpile leftover antibiotics and try to self-medicate. Your doctor prescribes a drug, dose and length of treatment based on what kind of infection you have. Using an old antibiotic may not work against your infection, but could still work against your immune system.
Of course, the best scenario would have us all staying healthy.
The jury is still out on the use of supplements and probiotics to improve immune function.
"We're only just beginning to understand the complexity of the microbiota in the gut," said Patrick. It's simplistic to think that taking a dose of one strain, such as Lactobacillus, would radically improve immune function.
Patrick recommends a healthy diet, "with a full array of vitamins, including iron and thiamin. Eat lots of vegetables. In this part of the world where we don't get much sunshine in the winter, it's a good idea to take Vitamin D."
Get plenty of sleep. Exercise. And of course, practice good respiratory hygiene: wash your hands. Cough and sneeze into your sleeve, stay home when you're sick.
Because if we can limit our use of antibiotics, we'll be doing the world a favour, said Chan.
"The trends are clear and ominous. No action today means no cure tomorrow. At a time of multiple calamities in the world, we cannot allow the loss of essential medicines - essential cures for many millions of people - to become the next global crisis."
It's in our hands. Now let's go wash them.
