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Antibiotic Resistance II

Today's Wall Street Journal has a nice short piece juxtaposing the reaction to swine flu and to antibiotic resistance. It begins as follows:

In March of this year an epidemic of H1N1 influenza virus, otherwise known as swine flu, began in Mexico. It spread to the United States within weeks and has since affected over 100 countries. Between the start of the outbreak and the end of July, a total of 1,154 people worldwide had died of the virus, about one-third of them in the U.S.

The World Health Organization and other public-health agencies have responded to the epidemic with appropriate urgency. International organizations have disseminated information and guidelines and coordinated with public authorities across the globe to ensure an effective response. The pharmaceutical industry is developing antiviral agents and vaccines and producing them on a mass scale.

The U.S. also has responded rapidly and forcefully. Just two weeks after the report of the first case on American soil, President Barack Obama asked Congress to allocate $1.5 billion to fight the virus.

Compare this response to the scant media and political attention that have been given to several silent but no less deadly outbreaks of disease in recent years caused by antibiotic-resistant bacteria. Most such outbreaks are treated as the poor stepsisters of pandemic influenza, even while they have killed far more people than swine flu over the same period.

Per my previous post, I've got a new article on the problem of antimicrobial resistance, which is currently out at the law reviews. One of them rejected it in 5 hours, which is a new record for me. My coauthor and I are debating whether this is an example of market efficiency, rational ignorance, or satisficing.

The previous post was headed "Only Two Things Scare Me." Most commentators got the reference to Austin Powers, but several inquired what the other thing was. I will reveal that after the article is accepted.

Related Posts (on one page):

  1. Antibiotic Resistance II
  2. Only Two Things Scare Me:
Houston Lawyer:
Swine Flu is a typical case of government over-reaction. From every report I've seen, it is less virulent than most forms of the flu. I guess it could be good practice though for a situation where an actual pandemic breaks out. Nothing like a dry run to show what doesn't work.
8.12.2009 11:40am
Raționalitate (www):
I think you're missing the fact that swine flu actually WAS a result of antibiotic resistance gone amok. And in fact, there is a perfectly libertarian solution to the problem: stop subsidizing factory farms by subsidizing commodity crops! Research has already been done that links farm subsidies to increases in factory farming above the free-market equilibrium, and many have already pointed out that swine flu was the result of highly antibiotic-resistant strains escaping the confines of the factory farm. No farm subsidies, no swine flu.
8.12.2009 11:59am
GM Roper (www):
Flu is a VIRUS, MRSA is caused by a bacteria gaining resistance to anti-biotics. Different issues
8.12.2009 12:21pm
Curt Fischer:
Rationalite: Antibiotics are effective against bacteria; swine flu is caused by a virus. In light of that it is difficult to understand why you think there is a link between antibiotics use in farming and swine flu.
8.12.2009 12:23pm
Michael Masinter (mail):

I think you're missing the fact that swine flu actually WAS a result of antibiotic resistance gone amok.



Swine flu is a viral disease; all viral diseases are inherently antibiotic resistant since antibiotics target bacteria, not viruses. There are a handful of antiviral drugs, but none of them are, to my knowledge, in use in factory farms.

Factory farms may or may not have contributed to the spread of MRSA (a bacterial disease) from a hospital acquired disease to a community acquired disease, but it is unquestionably true that MRSA is now a community based pathogen. From a recent article published by Dr. Kent Sepkowitz in the New England Journal of Medicine, commenting on community acquired MRSA:


It's everywhere; it's deadly; it has changed the day-to-day management of skin infections and pneumonia in clinics, emergency rooms and intensive care units. It's a true public health disaster. It's just a different disaster from the one we were exercised about.


abstract
8.12.2009 12:31pm
JDS:
Raționalitate is right that antibiotic use in animal husbandry is a principal creator of resistant bacteria strains. You mention this in your article - "Work with Department of Agriculture to reduce use of antibiotics in food
production" - but why not stump for a complete ban?

It's not clear to me that there is any other role for government intervention... How can government stop patients from abandoning prescribed courses of antibiotics as soon as they feel better? Should physicians fill out more paperwork to justify use of second- and third-line drugs? Should doctors hold off on presumptive treatments - even when evidence-based, and instead risk patients' lives by waiting for culture results which are unreliable anyway?
8.12.2009 12:37pm
subpatre (mail):
Well of course they rejected it.
"...market efficiency, rational ignorance, or satisficing"
It's marketing.

After hyping a pandemic of avian flu for the last 10 years, the numbers of avian to human infections steadily decreased. Foiled by this foul conspiracy of microbes, pork-swilling, attention-hogging bureaucrats (www.pandemicflu.gov) turned to the lowly swine in their next attempt to stampede the public. As this 'epidemic' flops into the mud, expect to be buffaloed into a flock of other animal-name flus. There is a lot of money and power in disease mongering.

Every year, flu normally kills 20,000 to 80,000 Americans. Most of those who die have weak immune systems, are elderly, or are already in bad health. Flu normally causes a smaller number —but sometimes twice as many— of the fatalities from car crashes. For reference, think of how many people you know that died in auto wrecks.


IMO your paper's weakness is a lack of concrete numbers for the scientific minded. There's no quantification of doctors overprescribing, no analysis of agricultural antibiotic use (if just to blow off the idiotic 'Rationalitate' arguments), or statistical judgment on increased infection due to increased exposure. I'm not convinced we know there is a drug use problem —and if so— where it is. Worse is whether any regulatory regime can make the slightest difference.

More to the point about the article's acceptance, is making it relevant to today's scary-sounding threats. Your intro and abstract doesn't "grab" the way that it could. If the problem is a problem, that should jump out at the reader. If it's a bigger problem than the $1.5 billion emergency funding for pork-flu, then you paper needs to be clear it's a bigger threat to health. There's nothing wrong with highlighting goverment's disregard for real public health.
8.12.2009 1:07pm
Michael Masinter (mail):
I have no love for factory farms, but no evidence links them to antibiotic resistant TB, and we're reasonably certain that MRSA and its nasty cousin, VRSA, evolved in hospitals. We should not be surprised by antibiotic resistant bacteria; we should expect them. Again, quoting Sepkowitz from his New England Journal of Medicine article:


We should marvel at the raw, restless power of microbes. They have the numbers — trillions and quadrillions and more that replicate wildly, inaccurately and disinterestedly. Nothing microbes do, whether under the duress imposed by antimicrobials or from some less evident pressure, should surprise us. It's their world; we only live in it.
8.12.2009 1:18pm
luagha:
If we were really concerned about swine flu, we would have used the military to close the border with Mexico when the CDC and WHO warning level was at 5, instead of now when it's at 6.

But politics beats health every time.
8.12.2009 1:19pm
DennisN (mail):
subpatre :

Worse is whether any regulatory regime can make the slightest difference


... particularly when antibiotic use is completely unregulated in much of the world. Countries where prescriptions are needed to purchase drugs are in the minority.

US regulation would amount to putting your finger in a dike that only runs halfway across the low ground.
8.12.2009 2:08pm
Mike& (mail):
I trained jiu jitsu and mixed martial arts. I've had a couple of staph infections. I haven't trained in several months due to concern over MRSA.

I've made the point, several times, that doctors are afraid of giving patients pain medication due to regulatory issues. Yet doctors will give out a Z-Pak for the flu.

How many more people are killed each year from antibiotic overuse verses pain medication overuse?

No one ever found my argument persuasive. No one understands what MRSA is - or seems interested in learning.

Good luck.
8.12.2009 2:17pm
einhverfr (mail) (www):
HoustonLawyer:

Swine Flu is a typical case of government over-reaction. From every report I've seen, it is less virulent than most forms of the flu. I guess it could be good practice though for a situation where an actual pandemic breaks out. Nothing like a dry run to show what doesn't work.


Well... Many of us were worried at first due to initial data regarding death demographics. These initial figures were genuinely worrysome and as such I followed the story until more data was available which suggested it was just an artifact of the sample.

After that point, I concluded that the rest was follow-through on what was a legitimate mobilization due to the initial concerns even if those concerns later proved to be unfounded.

The problem was that the initial reports suggested a similarity in death statistics to the 1918 flu pandemic. It turned out the sample was skewed but in that case, better safe than sorry.
8.12.2009 2:39pm
einhverfr (mail) (www):
Mike:

I've made the point, several times, that doctors are afraid of giving patients pain medication due to regulatory issues. Yet doctors will give out a Z-Pak for the flu.


The only case I have seen of this happening was where either:
1) One in a foreign country without prescription requirements
2) There was additional reason to believe there were secondary infection complications
2) There are cases where folks get "preventative prescriptions" and misuse them, for example bringing antibiotics with them for travel to developing countries in order to avoid questions of drug quality in those places.

In short, it does happen, but usually in the US, it only happens where there are substantial other factors. In the rest of the world, though, that is a MAJOR problem.
8.12.2009 3:19pm
subpatre (mail):
Mike&writes:"... doctors will give out a Z-Pak for the flu."

This is a problem if it happens, but I've seen no evidence that it does. The article makes the same evidence-free assumptions; on pg 6 the Misuse section starts "Antibiotic misuse is widespread ..." yet there isn't a footnote (or statistic) to be found. It undermines the whole paper.

Anecdotes are worthless; the problem, if it exists, is an enormous proportion of medical practice routinely follows bad procedures. The only citations alleging "misuse" are from the Infectious Diseases Society and World Health Organization, and neither of them documents bad prescription practices.

It's spooky, there's an entire chain of "we know it's bad" without surety "it" even exists. Frankly, there's not a shred of evidence that lax antibiotic practices are contributing to resistant strains of disease. There may well be evidence, but nobody is forthcoming with it.
8.12.2009 9:11pm
Rich Rostrom (mail):
The difference between MRSA and swine flu is like the difference between a profitable (but stable) company and a start-up with the potential to be another Microsoft or Starbucks.

Which sort of company gets the most attention? Which is more likely to receive investment funds in a very high ratio to current profits? The one which has the potential for orders-of-magnitude larger profits.

Which disease gets the most attention? The one with potential for orders-of-magnitude more deaths. AIDS has received far more funding, in proportion to its death toll, than heart disease. But AIDS is contagious, and heart disease isn't.

MRSA is contagious, but only slightly, whereas flu is highly contagious. Its potential danger is much greater.
8.13.2009 4:39am
Splunge:
The WSJ article is dumb mindless broadside. It reminds me of all those tiresome "If we can send a man to the Moon, why can't we [insert favorite social goal here]?" articles we used to read in the 70s.

The only plausible read is that we have here a case of special pleading by folks in the business who feel (quite naturally) that their own field of research and professional interest ought to receive more public attention and dough. Well might plumbers bemoan the state of our sewers, pilots the state of our air traffic control system, the teachers unions how much dough is spent on public education, yadda yadda. In the real world, we must allocate scarce resources between all such competing cries for attention.

And to do so we need to consider some obvious differences between influenza and MRSA and cousins, viz.:

(1) Influenza is viciously contagious. It can spread like wildfire, and in principle kill 50 to 200 million people in a few months. MRSA can't. It's the difference between terrorists known to have AK-47s and Iran maybe having nukes. Sure, the terrorists are committing steady mayhem, but it tends to pale besides the possibility of the holocaust from nuclear mullahs.

(2) On the other hand, MRSA is readily reduceable by fairly simple measures, like getting everybody in the hospital to actually wash their hands and sterilize their equipment the way they're supposed to. The article itself notes that massive reductions, e.g. 50%, have been achieved by such low-tech measures conscientiously followed. It's only now becoming a firing offense for health-care workers at hospitals to flout hygiene rules.

I suggest the major flaw in your SSRN paper is that you have offered no evidence that any plausible alteration of antibiotic use patterns would change the time-scale of the evolution of drug-resistance.

For example, since the problem of drug resistance has been known for 30 years now, and antibiotics have been more and more carefully used over that time, you ought to be able to point to some measureable (if slight) slowdown in the rate at which drug-resistant bugs are arising. But you don't. I would guess you can't.

So if a modest effort is getting us absolutely nowhere, where will a serious effort get us? Quite possibly nowhere as well. It is plausible that the time scale over which drug resistance develops, once the drugs are in common use, is determined almost entirely by the natural time scales of bacterial evolution and the diffusive velocity of the key genes in the global microbe gene pool, and would vary only trivially with even the most draconian practical regulation of antibiotic use.

In short, you have argued urgently for action guess without any idea of how effective the proposed action would be. Now why am I reminded of Al Gore on Global Warming?
8.13.2009 1:30pm

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