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Well informed skeptic
on 7 July 2016
So we're all agreed - it's shocking and frightening. The world is about to end. We're all going to die at the hands of a superbug. 200,000 years of Homo sapiens wiped out because of 60 years of antibiotic overuse, and a sluggish pharmaceutical industry that won't do the decent thing and invent a load more drugs for pennies.
Except, as a doctor with a fascination in microbiology, I don't buy it.
The only frightening thing here is how credulous everyone is here, including almost every reviewer. The author may be a dame, a professor, may have published a thousand papers and be at the top of her profession - she's certainly very good at getting noticed - but she does NOT have a crystal ball. There is a difference between an educated short term prediction about the future, and then there is wild extrapolation of the most tenuous evidence, and this is definitely the latter. In general in science, the more conviction an author shows that they are right, the more you should question their assumptions.
The basic error made by all these Cassandras is to forget that most of us live long, healthy lives without the need for antibiotics most of the time. They do know this, because they spend the other half of their time telling us all not to go to the doctor and telling off well-meaning GPs, frightened for their licenses, for prescribing antibiotics in good faith when they believe a chest infection (for instance) to be bacterial in nature and not viral.
Staphylococci, Streptococci and E. coli are all around us - and on us, and in us. They were here first and we evolved in their presence. One might even say we live by their permission! When you cut yourself, millions of bacteria flock to the wound. And yet 9 times out of 10, no infection. Your immune system deals with it. Commensal (friendly) bacteria also help. The not-so-friendly bacteria don't even "want' to kill you - they just want to replicate. In fact many diseases get less virulent the longer they are around. It is in the invading organism's interest for you to survive, or even not notice. Look at bed bugs!
Sometimes, a Strep A gets into the cut. This is life threatening. Penicillin + your immune system is effective in the majority of cases. If not, it's almost never the penicillin's fault - it will be late diagnosis, inadequate care, immune compromise or just a really nasty virulent bug.
Some bacteria are multi-resistant, sure. They get in my way as a doctor, sure. But we did not invent them. Most antibiotics are based on naturally occurring compounds. Penicillin from Penicillium fungus, etc. Again, bacteria have had aeons to develop resistance to these things, and so, unsurprisingly, antibiotic resistance is found in nature. (Not that much though, because in nature species do not tend to throw industrial quantities of the stuff at each other, with the exception of the occasional poison dart frog, or whatever. But I digress)
What is interesting is that so many bacteria remain sensitive to the drugs. Why? Because outside hospital, or the antibiotic-soaked patient, it simply is not important to that strain / species to be resistant. This is why MRSA (a resistant Staphylococcus) is pretty uncommon in the community. In hospital, it is commoner because we need to use flucloxacillin quite a lot to treat Staph infections. As evolutionary theory predicts, this selects for and encourages the resistant MRSA strain. As long as people don't stay too long (and we wash our hands and beds and curtains) they don't generally get MRSA. In England the NHS has had great success in reducing MRSA simply by screening for it and isolating it when found - NOT by inventing a better antibiotic (although luckily, a few exist that work for MRSA). But also, most Staphs are going to remain sensitive to flucloxacillin simply because they never encounter it, so there is no need for them to become resistant. It is not as if most of us are on antibiotics most of the time.
Some farm animals are on antibiotics most of the time, and that is where the Cassandras are right to warn us - this will create universally resistant strains in our food which is a terrible idea. This, not GP prescribing, should be the real target if we want to reduce resistance.
Finally, to tackle one of the commonly advanced theories head on - the idea that you will not be able to have your appendix out safely in 20 years. This is bunkum because, when I was a house doctor only 15 years ago, I remember some surgeons still did not use any antibiotics at all for appendicectomy, or for abscesses, or other "surgical" infections. It did not matter whether the bowel bacteria were sensitive to antibiotics, or not, because you weren't getting any! The vast majority of patients recovered uneventfully. A few caught infections (from themselves) and required antibiotics and/or further surgery to drain an abscess. Antibiotics do reduce, but not eliminate, that number, if used universally, so we do that now. If all bacteria became resistant - which I do not accept they will, see above - but if they did, only that small percentage of appendix patients would suffer. Going by current experience, even with resistant strains we will usually find one or two drugs that will work. This current, small problem may get worse, but on a population-wide basis, I predict it will remain small.
Unlike the author, my views are moderate, and cautious. I may be a little wrong, or very wrong. I do agree that we need to think about antibiotic resistance and that it may be on the increase in some quarters, though on the decline in others. We need to monitor it, use drugs rationally, and continue to improve infection control in and out of hospitals. Multi resistant TB from Russia for instance, brought about by shoddy disease management, is a threat to world health - but a relatively small threat. Most people survived TB before we had any antibiotics, and most still do, until they become malnourished or immunocompromised. Yes, it would be good to invent a new antibiotic or two in the next decade. But I simply refuse to indulge in the scale of hysteria that is being encouraged here. AIDS, BSE, SARS, Swine flu, Ebola, all produce terrible effects on small portions of the population and all should be fought, but each time we are told a quarter of us are going to be wiped out, lots of sage professors get articles published and get promoted, lots of newspapers are sold, and yet each time the predictions are wildly over-estimated. This book will join the long list of forgotten inaccurate disaster predictions. Mark my words in 2040.