We live in an age of scientific enlightenment. Science, through technology, has made remarkable advances in the 20th and early 21st centuries.
Health advances over the same time include sanitation and hygiene with cleaner water and food, advanced imaging technologies using ionizing radiation and nuclear magnetic resonance, minimally invasive surgical techniques, organ transplantation, the discovery of DNA and sequencing of the human genome, the relationship of the genome to heritability and disease with great promise for future health, the discovery and mass production of antibiotics and widespread vaccination. Because of these and other health innovations, the average U.S. life expectancy increased from 47 years to 77 years in the 20th century.
Most bacteria are still susceptible to at least one or a few antibiotics, but we are getting uncomfortably close to the abyss.
In spite of these advancements, there is a skepticism of science in general and of medicine in particular. Skepticism can complicate daily medical management. Let’s look at an example:
Antibiotic Abuse
There, I’ve said it – abuse. Not overuse, but abuse. Antibiotics, one of the most important discoveries in the history of medicine are abused and, as a result, are losing their life-saving power.
Antibiotics are substances produced by microorganisms, including molds, that inhibit or kill competing microbes. Alexander Fleming accidentally discovered penicillin, the first antibiotic, in 1928. Fleming saw that staph bacteria growing in a petri dish were inhibited by a green mold (Penicillium notatum) contaminant. Through further testing, he found that “juice” produced by this mold inhibited or killed any number of pathogenic bacteria. Penicillium “mold juice” ultimately became the first antibiotic, penicillin. During World War II the U.S. War Production Board recognized the strategic value of penicillin and made its production a priority under the direction of Albert Elder, known as the “Penicillin Czar.” I mention Elder for this quote:
You are urged to impress upon every worker in your plant that penicillin produced today will be saving the life of someone in a few days or curing the disease of someone now incapacitated.[1]
While true then, we have squandered the value of penicillin and many more antibiotics today. How do bacteria become resistant to antibiotics? It’s all about selection pressure. The CDC explains it well:
Every time a person takes antibiotics, sensitive bacteria (bacteria that antibiotics can still attack) are killed, but resistant bacteria are left to grow and multiply. This is how repeated use of antibiotics can increase the number of drug-resistant bacteria.[2]
This is true whether the person given antibiotics has a bacterial or viral infection. The overuse of antibiotics promotes resistant bacteria, even if the infection is not bacterial. The “bathing” of our population in unnecessary antibiotics for medical illnesses that are not or only rarely bacterial – colds, bronchitis, sinusitis, etc. – has led to resistance and a tragic loss of antibiotic effectiveness. You have undoubtedly heard about “MRSA” – Methicillin Resistant Staph Aureus. You are just as likely to have not heard about VASA, VRE and the hundreds of other highly resistant bacteria for which there are few antibiotic choices. In just the past year, resistance was reported to the last remaining antibiotic, colistin, to which no resistance had previously been described. Fortunately, most bacteria are still susceptible to at least one or a few antibiotics, but we are getting uncomfortably close to the abyss.
There is a delicate balance between clinical need and preventing resistance. To prevent resistance, antibiotic use must be thoughtful and frugal. The world is lacking that balance.
There are three culprits:
- agricultural use of antibiotics in livestock feed
- overuse of antibiotics through free access in much of the world
- over-prescription of antibiotics by medical providers.
Our focus at Medcor has been on appropriate antibiotic prescribing practices or “Antibiotic Stewardship.” Our perennial campaign is comprised of patient education materials, including handouts and posters, specific provider support through education, monitoring of prescription practices, and feedback.
A world with effective antibiotics sounds like a place we’d all like, but there are considerable obstacles to antibiotic stewardship, not the least of which is skepticism. When it comes to antibiotics, physicians and other medical providers seem to have little credibility with patients. Providers seem unable to convince patients that not every infection can be successfully treated with antibiotics and further that indiscriminate antibiotic use is unnecessary and unwise. In a study published in the British Journal of General Practice, antibiotic prescribing volume was a strong predictor of “doctor satisfaction” and “practice satisfaction.” In this study, 55% of physicians reported pressure to prescribe antibiotics, 45% had prescribed antibiotics for a viral Infection knowing that they would be ineffective, and 44% admitted that they had prescribed antibiotics in order to get a patient to leave. The authors calculated that a 25% reduction in antibiotic prescription would result in a 3-6 percentile decrease in national satisfaction ranking.[3]
There is a clash between what is right for patients and what is desired by patients. It is borne of the skepticism surrounding what is right.
The Point
So, what’s the point of this exercise? It’s to give you a better idea of the surprising pressures, born of skepticism, under which healthcare providers operate today and the complex realities of medical practice. Who would predict that dedication to evidence-based care would meet with patient resistance and poor impressions of provider performance? Overcoming skepticism is not easy, nor does the pressure relent. Toward the goal of better health for all, it is up to all involved in healthcare to show grit – passion plus perseverance wielding science as a weapon.
[1] Quoted In John Parascandola. “The Introduction of Antibiotics into Therapeutics in Sickness and Health in America: Readings in the History of Medicine and Public Health Third Edition Revised, ed. Judith Walzer Leavitt and Ronald L. Numbers (Madison University of Wisconsin Press 1997), 106
[2] Centers for Disease Control and Prevention, “Antibiotic Resistance Questions and Answers” last modified May 29, 2018. https://www.cdc.gov/antibiotic-use/community/about/antibiotic-resistance-faqs.html
[3] Mark Ashworth et al., “Antibiotic prescribing and patient satisfaction in primary care in England: Cross-sectional analysis of national patient survey data and prescribing data” The British Journal of General Practice: The Journal of the Royal College of General Practitioners 66, no 642 (2016 ): e40-e46. doi: 10.3399/bjgp15X688105.
Author Thomas Glimp, MD, Chief Medical Officer, Medcor. Dr. Glimp, MD joined Medcor in 1994. Tom is board certified in internal medicine and in emergency medicine. Dr. Glimp’s clinical affairs team provides standards, scope, guidelines and protocols, quality assurance, and other support for Medcor’s clinical services and staff. Medcor helps employers reduce the costs of workers’ compensation and general health care by providing injury triage services and operating worksite health and wellness clinics. Medcor’s services are available 24/7 nationwide for worksites of any size in any industry.
