Although antibiotics have been used for over 50 years, we are now just beginning to understand the impact of their use. Since everyone is affected by antibiotics, it is important that we all understand them.
In the 1800s, the average life expectancy in the United States was only about 40 years. The most dangerous times were the first year of life and the elderly years. Infants often succumbed to infections such as pneumonia and septicemia (“blood poisoning”) in their first few months, due to an immature immune system. The elderly often died of these infections because of an aging immune system. Soldiers wounded in battle were also vulnerable. When these bacteria caused wound infections, they were often fatal. Because of the fear of infections spreading into the blood, injured limbs were amputated. The most common fatal infections were caused by bacteria, now known as Streptococcus Pneumonia, Beta Hemolytic Strep Group A, and Staphylococcus.
In the 1890s, science advanced when Louis Pasteur revealed the concept that microbes in dirt cause infections. Cholera and typhoid fever and typhus epidemics, which often killed millions, were contained by the institution of sanitation practices at around the turn of the century. The introduction of flush toilets, sewers, and waste-processing systems and clean drinking water greatly improved the health of the community so that by the early 1900s the life expectancy had increased to 55 years.
Despite the progress that was made, people often died of infections. It was found that Staphylococcus caused skin and bone and joint infections, Streptococcus Pneumonia (also called “Pneumococcus”) caused severe pneumonia, ear infections, mastoiditis and meningitis, and Beta Strep caused throat infections which could be followed by Rheumatic Fever. H. Influenza was responsible for 90% of childhood meningitis. Unfortunately, there was no treatment for these diseases.
In the early 20th century, a scientist named Fleming noted that a specific mold was killing bacteria in his Petri dishes. When this observation was investigated, he isolated the responsible component and discovered Penicillin. By the 1940’s it was mass-produced, and it saved many soldiers’ lives during World War II. By the 1950s, an oral form was developed, and the drug was prescribed by doctors to millions of patients.
It appeared that medical science would soon gain control of all bacterial infections, as modifications of the penicillin molecule were developed to treat a wider and wider spectrum of bacteria. Erythromycin, tetracycline, and cephalosporins, new and different types of antibiotics, were invented. The fatality rate for pneumonia and other infections decreased, and life expectancy increased to 65 years.
Antibiotics are effective only in bacterial illnesses. They do not have any benefit in illnesses caused by viruses, such as colds, influenza, and intestinal viruses. Despite this fact, for over forty years, antibiotics were prescribed freely by many primary care physicians to everyone who was ill with fever, often even to people with viral illnesses.
During this time, everyone was blissfully unaware that the bacteria were growing stronger and more resistant to control. Each time infection was treated, a few germs escaped because they had a mechanism to counter the effect of the drug. With all of the susceptible germs killed off, there was room for these hearty survivors to grow and multiply.
No one was particularly worried since new antibiotics were constantly being developed to control the newer and stronger germs. In the setting of hospitals, the bacteria that survived exposure to the most advanced intravenous antibiotics became true superbugs.
In the 1990s, a very resistant strain of Pneumococcus appeared in South America, which quickly spread to the United States. For the first time, the medical community stopped and took notice. This dangerous, untreatable, germ was spreading in the healthy community. We trembled in fear of returning to the helplessness of the 1930s.
Looking back at the previous four decades, it became evident that our philosophy of treatment had caused a serious miscalculation. The problem was created by the treatment of common childhood infection, Otitis Media, or infection of the middle ear. Although this infection rarely caused serious complications, it was treated routinely with antibiotics. When a pediatrician saw an infected ear, the standard of practice was to prescribe an antibiotic to control the infection. The treatment hastened the resolution of the infection and averted rare but serious complications, such as mastoiditis and meningitis.
There are three major organisms that cause most ear infections; H Flu, M. catarrhalis, and Pneumococcus. In the 1980’s one germ, H Flu became resistant to ampicillin, so new anti-resistance antibiotics had to be prescribed. M. catarrhalis, which started as a benign throat germ, became a pathogen that started causing ear infections and also developed resistance. Pneumococcus, a particularly dangerous organism, was ignored since it had remained susceptible to Penicillin throughout the 1980s. It became the routine practice to prescribe the more powerful antibiotics for all ear infections. As the years passed, the escalating war against resistant ear infections caused millions of doses of broad-spectrum antibiotics to be used by pediatricians everywhere.
These antibiotics are so powerful and broad in their spectrum that they routinely eradicate many of the germs that normally inhabit the healthy throat and the healthy digestive system, known as “normal flora.” As these benign, protective organisms are cleared out, yeast has more room to grow, and diarrhea often develops from the lack of helpful bacteria in the gut. More importantly, newer germs, which have developed means of protecting themselves from the strongest antibiotics, take up residence. Even healthy people become colonized with these resistant germs. The germs live quietly in a healthy person until some weakening of the immune system allows them to invade. When this happens, treatment becomes very difficult.
As a result of the growing threat of resistant Pneumococcus, a call went out to the pediatricians in 2003 to reconsider the use of antibiotics in ear infections. Studies had shown that 80% of children over one year of age would be able to fight off their ear infections in a few days without the use of antibiotics. Doctors were urged to give pain control simply, and if the child improves, just observe. If a day or two goes by, and there is no improvement, antibiotics should be prescribed. The recommended treatment should be with very high doses of older antibiotics. This seems to be the best way of eradicating an infection completely, without leaving over any resistant organisms and without killing the “normal flora.”
There is one exception - the child with a recurrent ear infection who has been treated recently with antibiotics should not be merely observed. These rebound infections tend to be more difficult to overcome naturally.
To help overcome the threat of resistant Pneumococcus, a new childhood vaccine was released, Prevnar, that induces immunity to the seven most resistant strains of Pneumococcus.
There are still many bacterial infections which must always be treated to avert disastrous complications. Throat infections caused by Group A Beta Hemolytic Strep still require treatment to avoid the complications of Rheumatic fever. Bacterial pneumonia, kidney infections, cellulitis, bone and joint infections, meningitis, and other life-threatening infections must be treated with appropriate antibiotics.
Fortunately, the result of the change in prescribing habits for ear infections has been very encouraging. Millions of antibiotic doses were avoided in the last year. There is some evidence that fewer new resistant strains of bacteria appeared in the United States in the last year.
We, as physicians, have been taught a real lesson. As intelligent as we think we are, the lowly bacteria has outsmarted us continuously since we began this war. This experience is very humbling to all of us. We now know that even doing what seems correct can cause enormous harm.
With G-d’s kindness and many recent advances in medical care, the average life expectancy in 2004 has increased to 75 years.
We know that we, as physicians are only the messengers of G-d who send healing to our patients through us. We must never assume that we know the mysteries of nature. Only the Creator has real knowledge. He sometimes allows us to glimpse a tiny bit of it.
Experience has taught us to be rational and respectful when we attempt to make use of this wonderful, life-preserving gift.
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