By Louis Jamart
Louis is a Human Scientist, part of the Pills and Policies team, and keen rower.
Two pills. Four times a day. Ten days straight.
Imagine the pain caused by changes in air pressure as a plane takes-off or lands. Or the same suffering caused by your first experience scuba-diving when you forget to blow into your blocked nose to relieve the pressure from your ears as you descend. Imagine that pain. Now imagine it persisting for 24 hours non-stop for over a week. On Monday two weeks ago I was diagnosed with Streptococcal Pharyngitis, or, to put it more bluntly as my friends prefer: “a simple case of bacterial tonsillitis” – a few days of Penicillin V and it’s solved! Right?
As I took my 8 pills per day, over the course of the week my symptoms only worsened. In my hopeless attempt to self-diagnose and convince myself I was not “dying”, I dared to take the risk of venturing online. To my surprise, I discovered case after case on internet chat groups of individuals complaining of the same inefficacity of the penicillin antibiotic – the global text-book medicine prescribed for tonsillitis. I decided to look into penicillin to understand the effect of the drug on my body, and to my horror, found myself confronted with a terrible truth.
Antibiotic resistance is one of the largest problems we, as a human race, are faced with within the coming half-century yet nobody is talking about it! Bacteria are not limited by borders like humans, and routine operations today could become deadly within the next twenty years. So how does bacterial resistance work? What effect does the overuse of antibiotics have? What is the future looking like for antibiotics today? Could my tonsillitis have actually killed me? Intrigued? Read-on.
HOW BACTERIAL RESISTANCE WORKS
The concept behind how bacterial resistance works is fairly simple. Consider humans and bacteria for a second. As humans, we are made up of eukaryotic cells which in the case of our cells on our sex chromosomes divide through the process of meiosis. This enables the random distribution of half our genetic information which we obtain from our mothers, and the other half from our fathers. Such a process leaves a lot of room for mutations and adaptations to occur. On the other hand, bacteria consist of prokaryotic cells. Unlike humans, bacteria reproduce asexually through binary fission, which means that each offspring becomes an exact clone of its parent. Hence, in such situations mutations that lead to bacterial resistance can spread throughout a population in several ways and at a rapid pace: either through vertical transmission or through horizontal transmission.
In the case of vertical transmission, a single bacterial cell may undergo a mutation at any point which happens to make it resistant to a strain of antibiotics. When this cell then self-replicates to produce offspring, its clones consequently contain the exact same mutation which makes them too resistant. Here is where things become interesting: whilst this strain of antibiotic resistant bacteria is replicating at a rapid rate, the strains of non-mutated bacteria are being killed off by the antibiotic through Darwin’s well-known process of natural selection. By the end of this process, only the mutated and resistant bacteria are left alive, and will continue to reproduce, thus creating new strains of antibiotic resistant bacteria. Because of the speed at which bacteria replicate as they do not require other individuals, this process can occur extremely fast with bacterial resistant individuals multiplying exponentially.
But what makes bacterial replication so dangerous in the case of antibiotics is their ability to transmit genetic information horizontally. This can occur through three main mechanisms, namely transformation, transduction or conjugation. In transformation bacterial cells uptake genetic material from their external environments. In transduction, genetic material in transferred between bacterium through viral vectors. Finally, conjugation corresponds to transmission of genetic material between bacterial cells through cell-to-cell contact. What is most interesting however is not how this transfer of genetic resistance to antibiotics occurs, but that it can occur both between individuals of the same species of bacterium and between individuals of different species. This means that a single mutation that entails a resistance to a certain antibiotic can be transmitted between different strains of bacteria with various degrees of effects on human health at an exponential rate – and there is little we can do to stop it once this process has been set off! What may start off as a harmless bacterium developing antibiotic resistance can become very dangerous in no time at all!
THE OVERUSE OF ANTIBIOTICS AND THE EFFECT
But who is to blame for the increase in antibiotic resistance? Where the biggest problem rests, is that each time any one of us falls ill and takes antibiotics, we are increasing the chances of bacteria building up resistance. In simpler terms, the primary actors responsible for the risk of antibiotic resistance is each and every one of us. We’ve set a time bomb and we’re just waiting for it to explode. Increased pressure by patients on doctors to prescribe antibiotics, along with a misperception that antibiotics can treat any illness, means that we are unnecessarily increasing the risk of antibiotics developing resistance every day.
Such an issue is easily fixed though through several steps. Firstly, antibiotics must not be prescribed for viral illnesses. Unlike bacteria, viruses are not living organisms, and taking antibiotics to attempt to heal viral infections merely exposes other bacteria present in our body to the antibiotics and increases the likelihood that they will build a resistance to them. Common viral illnesses include chicken pox, bird flu, and the common cold – so if ever you’re infected by any of these, hold tight, dose up on pain killers, because no quantity of antibiotics will help make you any better! If anything, they’ll upset the pro-biotics in your stomach and make your symptoms worst! Secondly, it is essential that if prescribed a dose of antibiotics, we complete the full dose prescribed. Doing otherwise leaves the resistant bacteria who survived the first half of the dose to reproduce, increasing their frequency in their population and significantly increasing the risk of horizontal or vertical transmission of resistance.
It would be absurd to believe that any individual misuses antibiotics and risks returning to the age of substantial deaths by infection consciously. Whenever I have, in the past, finished a dose of antibiotics early I certainly was not thinking of any of these effects! The fact that we do misuse suggests a more prominent problem in social knowledge of the issue that can be easily fixed! But the plot thickens…
ANTIBIOTIC DISCOVERY VOID
The scariest thing I discovered however, as I sat in bed ill researching why my tonsillitis had yet to disappear eight days into my treatment, is that for many antibiotics it is already too late. Penicillin has been around since 1928 for example. That means that in 2015 I was being prescribed a drug against tonsillitis which had been prescribed against the same microbes over the last 87 years – No wonder many strains of antibiotics have already developed resistance to it!
An interesting anecdote to reinforce my point is the use of penicillin on injured soldiers in North Africa during World War Two. Story goes, that a deficiency in penicillin at the time pushed doctors to retrieve the drug from the soldier’s urine in order to be able to reuse it. If this were the case, then it would imply that the drug that was being prescribed to me in 2015 had been exposed to wide ranges of bacteria in different individuals’ bodies, increasing exponentially the possibility of any bacterial resistance developing.
Worst however, is the knowledge that the last class of antibiotics invented dates back to Lipopeptides released to the general public in 1987. Bacteria have today been exposed to our newest antibiotic for over twenty-five years, meaning that it is highly likely that certain strains have already developed resistance which they can transmit horizontally! Once again, surprisingly the problems seems to rest in social issues interacting with the medical domain. When an antibiotic is created, because of its uttermost importance to health the recipe must be made public. This implies that pharmaceutical companies who may spend millions in developing the antibiotic gain very little back in return for their effort, clearly taking away all incentives to spend time, money and effort on the research into new anti-bacterial medications. The antibiotic “void”, as it has become to be known as, is consequently the result of laws laid down by society.
HOW THE FUTURE LOOKS
How honest is too honest?
It’s the first question I always ask myself as a Human Scientist when people ask me what the future ahead looks like. Perhaps the easiest way to look at the question is to allow you to answer the question for yourself: The current human population size is of 7 billion people – seven times higher than the ideal predicted “carrying capacity” for the human race. Of these 7 billion people, those most affected by disease are those living in the most densely populated regions – this is where most antibiotics are used, but not every individual in these regions has enough economic power to ensure the completion of antibiotic doses. Furthermore, it is in these regions that most deadly bacteria exist, increasing the risk of horizontal transmission to dangerous strains of bacteria of antibiotic resistance. On top of this, in countries with higher levels on the Human Development Index, such as England, roughly one in four prescriptions of antibiotics are needless. That is to say, in England each year roughly ten million prescriptions are useless and merely increase the risk of the development and transmission of bacterial resistance – and no new antibiotics have been released in over twenty five years! Looking at the image from this perspective, it is hard not to be pessimistic about the future of curing infections, with many banal infections today such as those caused by open wounds predicted to become dangerous once more within the next thirty years.
When faced with pessimism in everyday life though it is easy to just give up and give in. Where hopes remains is in the social roots of the issues discussed: the lack of public knowledge of the effects of antibiotics misuse and the social policies in place that remove the incentives for research into new antibiotics. Each individual is necessary to reinforce social laws, so any individual action could potentially help improve the situation. In other terms, next time you’re ill and are prescribed a dose of antibiotics – think not what society can do for you, but rather what you can do for society, and finish your prescribed dose! You’ll thank me in thirty years’ time!
As for the question of whether lack of antibiotics could lead to deaths caused by simple cases of tonsillitis: Well, the answer remains yes, just as tonsillitis could lead to death today. Untreated, or ineffective treatment of cases of tonsillitis can cause sepsis – the presence of bacteria in the bloodstream – which could become extremely dangerous and lead to death in the lack of serious medical intervention. What would change from today is not whether tonsillitis can cause death as such, but rather how likely it is to cause death. If antibiotic resistance continues to spread, then cases of ineffective treatment will rise, and what today appears a banal infection could quickly become a worrying epidemic. This is not to say that we should all start panicking – the end of humanity will not be caused by the build-up of antibiotic resistance. In fact, until the 20th century antibiotics were considered medicines of the future. However increased antibiotic resistance could lead to increased death rates and decreased life expectancies.
The take home message – act now, by spreading the word before it is too late… And most importantly, use antibiotics wisely.
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