Sir Alexander Fleming might be one of the reasons you’re alive today. In 1928, the Scottish scientist noticed that an overgrowth of mold inside a petri dish was harming neighboring bacteria. Fleming isolated the specific mold, Penicillium notatum, and named his antibiotic discovery penicillin.
Penicillin made it into human drug trials by 1940 and earned Fleming a Nobel Prize in 1945. While his medical breakthrough would go on to save countless lives from deadly and advancing bacterial infections, Fleming readily acknowledged the need to limit its use. He even issued a stern warning to anyone who saw penicillin as a cure-all: “The thoughtless person playing with penicillin treatment is morally responsible for the death of the man who succumbs to infection with the penicillin-resistant organism.”
Decades later, Fleming’s warning has taken on a chilling relevance. Each year, according to the Centers for Disease Control and Prevention, 2 million people develop bacterial infections that are resistant to penicillin and other antibiotics. Of those people, 23,000 die from their infections or resulting complications. The reason why is exactly as Fleming explained it: We’ve been using antibiotics too often, in dosages too large or potent, even when they’re not necessary.
The result is an increasingly stubborn wave of illnesses and bacterial strains, including gonorrhea, pneumonia, blood infections and foodborne germs (E. coli), that no longer respond to conventional treatment with antibiotic drugs in the bactericidal penicillin and cephalosporin families. These illnesses aren’t rare either: According to the CDC, 30 percent of the bacteria that can cause pneumonia are potentially antibiotic-resistant.
“We’re now seeing essentially ‘superbugs’ that are pretty much resistant to most every drug we have,” said Dr. Cindy Liu, chief medical officer of the George Washington University’s Antibiotic Resistance Action Center. “There’s been a huge rise in the number and types of antibiotic-resistant infections in the U.S. and abroad.”
Worldwide consumption of antibiotics soared 39 percent between 2000 and 2015. Some of this uptick can be explained by the increased availability of antibiotics in developing nations, but overuse everywhere is a major culprit too. Antibiotics are handed out more liberally when patients go to urgent-care facilities or emergency rooms instead of seeing their primary care physicians. Just 7 percent of primary care visits yield prescriptions for antibiotics, according to a 2018 CDC analysis, compared to 39 percent of those at urgent care. Of those prescriptions, 45 percent were found to be unnecessary.
“Patients will come into an emergency room expecting a prescription,” Liu says, “and the easiest way to manage that is to give it to them.”
How overuse breeds resistance
When our bodies are continually exposed to antibiotics, bacteria have more opportunities to mount an effective defense against the medication — a “know thine enemy” adaptation that bacteria use in order to thrive.
Say you develop a sore throat. You go to the doctor, say “ah” and kvetch about the pain. Your doctor promptly prescribes an antibiotic, without waiting to see if a swab sample comes back positive for bacteria — even though sore throats are more likely to be caused by viruses, which antibiotics can’t treat.
Worse, your doctor might prescribe a broad-spectrum antibiotic, which kills a wide variety of bacteria beyond those responsible for any single infection. As you follow this unneeded course of treatment for seven to 10 days, the bacteria in your system learn to tolerate the medication, finding ways to neutralize it or to create a barrier in the bacterial wall. The next time you actually need antibiotics for a bacterial infection, you’re up against a strengthened enemy. Bacteria can also develop immunity to multiple antibiotics, sending doctors on a chase for an effective solution as the infection spreads.
While overprescribing plays a large and undeniable role in antibiotic resistance, doctors say they don’t deserve all the blame. “The human body is a very complicated system,” says Dr. Audrey Schuetz, associate professor of laboratory medicine and pathology and co-director of bacteriology at the Mayo Clinic in Rochester, Minnesota. “Patient disease symptoms can be nonspecific, and it can sometimes be difficult for doctors to know whether a disease is due to bacteria or not. Doctors may not know because of limitations in diagnostic tests currently available, or the patient may have several issues going on at once, which confuses the picture.”
In those situations, antibiotics become a “see what sticks” solution — something to take just in case it ends up working. Multiply this scenario by the millions and it gets easier to understand how diseases evolve to fend off drugs that once knocked them out.
An infection doesn’t need to be serious at first to become potentially life-threatening later on. One common infection that’s vulnerable to antibiotic resistance is a urinary tract infection. “There are 10 million cases a year, most caused by E. coli,” Liu says. “If you can’t treat it with an antibiotic, it can travel from the bladder to the kidney and then the blood.” Increasingly, Liu says, UTIs aren’t responding to first-line drugs that worked well for years.
The evolution of fortified, antibiotic-resistant infections also stems from agricultural practices. Food suppliers pump poultry, cows and other animals full of antibiotics to ward off illness, inadvertently making bacteria tougher. Food-borne germs, from contact with animals and raw meat, is the source of about one in five resistant infections, according to the CDC. The government is taking measures to curb misuse of antibiotics on farms, but as the New York Times reported, experts say these policies are weakened by loopholes. In 2017, for instance, The FDA banned the use of antibiotics for the purpose of fattening up animals. But ranchers and farmers can still administer the drugs to prevent disease, a reason they can cite even if animals don’t show symptoms of illness.
The patient’s role
Across the board, it’s getting harder to kill previously treatable bugs. While this sounds like a job for medicine and food safety regulators, Liu says patients can do their part too. Among the steps you can take:
Don’t push for antibiotics. If your doctor says you don’t need them or that it’s better to wait out an infection for a few days, listen to the expert and stick to over-the-counter remedies.
Don’t treat yourself. Some people use leftover antibiotics to self-treat new illnesses, reasoning that if they have similar enough symptoms, they can use the same drugs. Without confirming an infection is bacterial, you risk filling your body with antibiotics for no reason. If it is bacterial, only a medical professional can determine the proper type, dosage and course of drug treatment. It’s best to use as narrow a spectrum of antibiotics as possible, to avoid targeting other bacteria in the body. Antibiotics do also carry some health risks beyond potential resistance and ineffectiveness, such as diarrhea.
Protect yourself against unnecessary antibiotics. If you’re healthy, the simple act of washing your hands can help ward off bacterial infections. If you’re hospitalized, you might benefit from a stewardship program that works with physicians to make sure antibiotics are warranted and then monitors their use for effectiveness. (Several institutions, including the Mayo Clinic, will be participating in an Antibiotic Awareness Week from Nov. 12 to 18.)
No matter what state of health you’re in, seeking out food suppliers that minimize antibiotic use communicates public concern over the drugs entering the food supply. But watch out for misleading food labels. “Antibiotic-free” is an empty term, as explained in this New Food Economy story. Meat labeled “certified organic” is the only type legally guaranteed not to come from animals treated with antibiotics.
What happens if antibiotics don’t work?
If you develop an infection that doesn’t respond to conventional treatment with antibiotics, physicians can try a number of other therapies. They might lengthen the course of treatment or combine different antibiotics. In the case of wounds or chronic skin infections, they might tackle the problem with topical antibiotics that only get absorbed into your system in very small amounts. They might even steer clear of antibiotics altogether. In women, for example, the diuretic drug spironolactone has shown promise fighting acne, an issue often treated with prolonged use of antibiotics.
In the future, we may not have to rely solely on antibiotics to treat bacterial infections. Some researchers are looking into plant-based compounds with naturally occurring antibacterial properties. Probiotics, for example, may be able to help us stave off infections before they start. And both peptides (tiny proteins produced by plants, animals and fungi) and phages (viruses that attack singular strains of bacteria) are demonstrating bacteria-killing properties in clinical studies.
“There are newer antibiotics on the market which have activity against multidrug-resistant bacteria,” Schuetz says. “Some antibiotics are in development, and some are currently available. However, there is a concerning trend right now towards fewer antibiotics being developed to fight these superbugs.”
Still, “more drugs” isn’t the ultimate answer. Even with research efforts underway, it will be a long time before new antibiotics or alternatives can defeat infectious diseases. More antibiotics also mean more bacteria learning to survive our drugs. In addition to hoping for a better mousetrap, we need to use the traps we already have more carefully.
The best thing the general public can do, Liu says, is stop thinking of antibiotics like a consequence-free fix. “It’s not a benign drug,” she says. “Just don’t take it unless you need it.”