Arsenal of Antibiotics Failing as Resistant Bacteria Develop : Medicine: ‘Close calls’ getting closer as deadly strains invade and esoteric drugs lose potency. People are dying and more will die.
The woman’s prognosis was grim. She had undergone extensive surgery for blocked arteries and had developed an inexorable infection in a blood vessel deep in her abdomen.
Not a single antibiotic in the nation’s arsenal, not even the big gun, vancomycin, could destroy the bacteria ravaging her.
So Dr. Jim Rahal went to the Food and Drug Administration with a plea: He needed the agency’s permission to try an antibiotic that had never been used or even tested in the United States. The FDA consented and doctors gave the middle-aged women pristinamycin, a French drug.
She survived. But her story is really only a subplot of a much larger and frightening tale: the beginning of the end of the antibiotic miracle.
“This is just the harbinger of things to come,” said Rahal, head of the infectious disease center at the New York Hospital Medical Center of Queens. “There’s not a plague upon us as yet. But it’s an example of what’s likely to happen.”
“We’ve had other close calls,” he said, “and they are getting closer and closer.”
Since 1942, when the government dispatched a relatively new drug called penicillin to save the burn victims of a nightclub fire in Boston, the world largely has been safe from killer bacteria.
Penicillin and other antibiotics, natural substances found in mold and in soil, saved millions of lives. Bacteria that invaded the body through nasty cuts and infected the blood no longer killed. Pneumonia and tuberculosis, almost certain killers, were vanquished.
In 1979, Surgeon General William Stewart declared that it was time to “close the books on infectious diseases” and concentrate on killers such as cancer.
But in the last decade, a broad resistance to antibiotics has begun to emerge. And because bacteria can transfer genes among themselves, experts only expect the resistance to grow.
The potential nightmare is an Andromeda strain, a super-microbe immune to all antibiotics that could wreak havoc.
Enter the post-antibiotic era, when people could die of infections that once were treatable.
“It’s a major crisis because people are dying, and people are going to die in the future,” said Dr. Stuart B. Levy of Tufts University and the author of “The Antibiotic Paradox: How Miracle Drugs Are Destroying the Miracle.”
“People say, ‘Oh, it’s a rare event.’ But now we know that the rare event is happening again and again.”
Making matters worse, no new antibiotics are expected on the market by the end of the century. The pharmaceutical industry listened to Stewart and turned its attention to more profitable drugs.
But not all the blame for the growing resistance can be ascribed to the drug companies. Indiscriminate use of antibiotics also is to blame, and the main culprit is the average person with sniffles.
Many people, at the slightest sign of a cold, demand the drugs--never mind that colds are caused by viruses and antibiotics are useless.
“Patients come in and just demand antibiotics and say, ‘If I don’t get them, I’ll just go elsewhere.’ And there will be a doctor who will prescribe it,” Levy said.
“Once they have antibiotics in their hands, they act like they’re aspirin. This is 50% of the misuse that is leading to resistance.”
Resistance occurs when bacteria survive the onslaught of an antibiotic. Doctors say this happens largely when patients do not follow their prescriptions.
A common scenario: A doctor prescribes an antibiotic, to be taken three times a day for 10 days. The dosage is meant to destroy the bacteria entirely. But the patient takes the drug haphazardly, feels better and doesn’t finish the prescription, and then saves the drug and takes it later or gives it to a family member who doesn’t feel well.
Chances are the bacteria causing the infection have been knocked down, but not out. Those that survive will be resistant, and the patient could pass on the bacteria to others.
Although experts insist that people must begin using antibiotics more judiciously, there is no consensus on what that means. Levy goes so far as to question the common use of tetracycline by teen-agers trying to save their skin from acne.
In his book, he tells the story of a young woman who threw a fit when a doctor refused to give her the antibiotic for a minor case of acne. The doctor insisted she could control the blemishes with the proper diet and skin care. The woman resorted to yelling. He didn’t give in, but many doctors do for fear of losing patients.
Chris Foreman, a senior fellow at the Brookings Institution in Washington, is writing a book that looks at this and other emerging medical issues.
An obvious answer to the problem could be restricting the use of antibiotics, but that would be difficult, Foreman said, particularly in the case of livestock.
America’s livestock are literally raised on antibiotics which, for reasons scientists do not entirely understand, promote growth--meaning plumper chickens and meatier cows. Microbes that are resistant to at least some antibiotics, including strains of salmonella and E. coli, also are a product of this practice, and the organisms already have been passed on to consumers.
Some congressmen tried in 1976 to raise the issue of antibiotics in animal feed, but the powerful farm lobby stopped any serious discussion.
“You need victims, to be perfectly blunt about it,” Foreman said. “You need people to start dropping. Until then, nothing will change.”
For now, the government and doctors are focusing on tracking resistant bacteria, especially in hospitals, where the microbes pose the deadliest threat. This approach could give them an early warning of things to come.
Some doctors also have talked about limiting the use of the big gun vancomycin, but there are no actual plans for this.
Drug companies are working on 28 new antibiotics, some aimed specifically at resistant bacteria, according to an industry group, the Pharmaceutical Research and Manufacturers of America. But most people agree that it will be at least five to seven years before they could be on the market.
Meanwhile, resistant strains of tuberculosis have killed people.
Many doctors either know of cases or have had cases similar to another of Rahal’s: a man in his 60s who had undergone a kidney transplant and died of a bacterial infection. His body was being attacked by two strains of resistant bacteria that required different antibiotics. But by the time doctors figured out what drug would work, it was too late.
The Centers for Disease Control and Prevention says there were 13,300 cases like this in 1992, the first year the federal agency began tracking the problem.
Pediatricians are seeing pneumococcus, a common cause of upper respiratory and ear infections in children, that is resistant to penicillin. These illnesses commonly are spread in day care centers.
The resistance is spreading to other antibiotics commonly used to treat these ailments, said Dr. Sheldon Kaplan, chief of infectious disease services at Texas Children’s Hospital in Houston.
In some cases, “the only antibiotic really left is vancomycin,” he said. “That’s what’s frightening.”
Vancomycin has been around since the late 1950s, but it wasn’t until the late ‘80s that doctors began to realize it was losing its touch.
The antibiotic now has lost the battle against certain strains of enterococcus, a bacteria that causes many post-surgery infections.
At this point, resistant enterococcus is a problem virtually only in hospitals, making people who are already sick even more vulnerable.
But most experts doubt the problem can be confined to hospitals: Because bacteria can share genes, doctors fear that eventually the resistant gene in enterococcus will be transferred to pneumococcus or staph, bacteria that cause very common infections, in and out of hospitals.
This already has been achieved in an experiment in which resistant enterococcus was mixed with staph on the skin of a mouse.
Now, the question is whether the potentially deadly mingling eventually will occur outside the lab, creating a super-bug that could stalk us all.
“Almost everybody thinks it will happen,” Rahal said. “We just don’t know when.”
And if not in the United States, where?
“What are we going to do if someone reports vancomycin-resistant staph in Spain?” Levy said. “Are we going to limit visits to Spain because it’s a public health issue? We don’t want that organism coming into this country.”
The Congressional Office of Technology and Assessment is studying the antibiotic crisis and will make recommendations to Congress by February.
“The basic issue is that in this country we aren’t doing research on antibiotic resistance,” said Dr. David M. Shlaes of Cleveland Heights, Ohio, a member of a task force studying the issue for the American Society for Microbiology. “The federal agencies responsible for taking care of this are all clearly underfunded.
“We need basic research, we need to get pharmaceuticals back into the game, we need more surveillance to find out how widespread resistance already is.”
For the average person, experts say, general good health and good hygiene--like washing hands and covering the mouth when coughing--all take on new urgency. But even these measures would not stop a killer infection.
“I have a patient in the hospital now,” Shlaes said. “He came in two days ago with chills, fever, muscle aches. He had staph aureus in his blood. Just a normal guy out in the community. Today he’s sitting up in bed talking to me. If he had resistant staph aureus, he’d be dead today.”
