The Nuance

The Risks of Antibiotic Overuse

‘Taking Antibiotics Is a Gamble Every Single Time You Do It’

The first piece I ever wrote for Medium was titled “8 New Diseases That Are Coming to Wipe Us Out.” I interviewed epidemiologists and other knowledgeable people to find out what sorts of novel illnesses are most likely to emerge in the coming years.

Among the plagues and pestilences they told me about, several experts mentioned the risk of a new and deadly virus. The fallout from such a virus, they warned, would likely be worsened by online conspiracy theories and crumbling trust in governments, traditional media, and other institutions.

Referring to recent outbreaks of yellow fever and Ebola in West Africa, the leader of one non-profit group told me, “We’ve already seen conspiracies that scientists created an outbreak, or that it wasn’t real, or there were rumors about side effects of the vaccines that weren’t true.” She and I were speaking in 2018.

Four years and 15 million deaths later, it’s clear that foresight and forewarnings of catastrophe are not enough to motivate the responsible parties to action. As has been documented elsewhere, including in this excellent Atlantic piece, just about every major public health agency and threat-assessment group in the world had raised alarms about our collective unpreparedness for a viral epidemic, but their warnings were ignored. One of the enduring lessons of this pandemic will be that if there is no short-term political or financial profit in something, that something doesn’t get done.

Today, the threat posed by antibiotic resistance — the “future disease” that topped my list in 2018 — could dwarf the pandemic. It’s also not a theoretical concern; antibiotic-resistant bacteria are here now, and they already kill tens of thousands of Americans every year. Once again, we seem unwilling to do what must be done to prevent a foreseeable catastrophe.

“By 2050, the rough estimate is that 10 million people will die each year of resistant bacteria,” says Gautam Dantas, PhD, a professor of pathology and immunology at the Washington University School of Medicine in St. Louis. “That could make it the number one killer in the world — greater than cancer.”

Infectious bacteria cause all sorts of illnesses — from food poisoning to tuberculosis. Antibiotics are a group of antimicrobial drugs that either kill or stop the spread of these harmful bacteria.

While we depend on these drugs for lifesaving medical purposes, the more we use them, the more the bacteria they target are likely to develop successful defenses. This is known as resistance. Dantas says the development of resistance is unavoidable; it’s part of the natural evolutionary dance between living microorganisms. But it’s speeded up by the unnecessary use of antibiotics and other antimicrobials.

A lot of our current use is unnecessary. According to recent figures from the Centers for Disease Control and Prevention, up to 50% of the antibiotics prescribed in outpatient settings — doctor’s offices, walk-in clinics, etc. — is inappropriate, meaning the antibiotic given is too powerful or it’s unlikely to do a person any good.

‘As far as imminent threats to human health go, I would put antibiotic resistance second only to global warming.’

Dantas says this sort of inappropriate use happens in part because a lot of doctors assume that these drugs have no downsides. “They think if there’s even a tiny chance the drugs may work, they are worth prescribing because there’s no harm done if they don’t work,” he says.

Meanwhile, because it isn’t lucrative, private sector interest in discovering or developing new antibiotics is scant. Some governments and non-profit groups are trying to subsidize programs to identify novel antibiotics or treatments for resistant bacteria. But at the moment, we’re rocketing toward a future where more and more pathogenic bacteria are resistant to our medicines, and yet we’re not doing half as much as we could to fill these shortfalls. An increasingly possible scenario, one expert told me, is that we end up back in a world where children die of scraped knees or women die of urinary tract infections.

“As far as imminent threats to human health go, I would put antibiotic resistance second only to global warming,” says Lance Price, PhD, a professor of environmental and occupational health at George Washington University and president of GW’s Antibiotic Resistance Action Center.

Resistance is only one of the problems posed by unnecessary antibiotic use. Even when these drugs are warranted, such as in cases of an illness-causing bacterial infection, Dantas says that taking them may still be risky.

For a first-of-its-kind study published last month in the journal Cell Reports, he and his colleagues found that antibiotics can cause lasting disruptions to the guts of healthy people.

‘Just say, doc, can you please explain to me what you think is going on here and what infection are you trying to treat?’

The gut microbiome is a community of trillions of microorganisms that play a starring role in digestion, immune functioning, and many other vital health processes. Antibiotics can kill bacteria indiscriminately, and so they often take out good gut microbes along with the bad. “As soon as you give an antibiotic, diversity dives and abundance crashes,” Dantas says.

Drops in microbiome diversity and abundance are associated with all manner of GI dysfunction, including inflammatory bowel disease. Historical data show that IBD is far more common now than it once was, and doctors who study the condition say the overuse of antibiotics may partly explains its rise.

Dantas’s study found that, in most cases, the microbiomes of healthy people tend to gradually bounce back following these post-antibiotic depletions. But sometimes they don’t.

Six months after their antibiotic course, three of the 20 people in his study still showed signs of major gut imbalances. “They appeared to move much closer to the dysbiotic microbiomes we observed in people in the ICU,” Dantas says. “This suggests that even if you’re healthy, taking antibiotics is a gamble every single time you do it.”

There are a handful of ways we could all reduce the risks posed by antibiotic overuse.

First of all, if you’re prescribed an antibiotic, Dantas says it’s worthwhile to ask one or two polite questions of your healthcare provider. “Just say, doc, can you please explain to me what you think is going on here and what infection are you trying to treat?” he advises.

A lot of antibiotics are given because doctors think their patients want them, he says. By asking questions or showing a disinclination to take an antibiotic, you may find that you have other options. Especially if you’re prescribed an antibiotic at an urgent-care clinic and your provider has not taken any swabs or run tests to confirm that you have a bacterial infection, it may be worth getting a second opinion before bombing your gut with a powerful antimicrobial drug.

At a broader level, fighting back against antibiotic resistance is going to require policy action, and also changes in how we shop and eat.

Antibiotics are often administered to livestock in order to keep them alive in brutally unhealthy conditions. Just as antibiotic overuse in people drives up resistance, so does overuse in animals. A landmark program in Denmark’s pig and pork industry found that severely restricting the use of these drugs can lead to a measurable drop in resistant-bacteria infections in nearby human populations.

“Buying power is really important,” GW’s Price told me. He recommends buying meat labeled “raised without antibiotics” and asking for these products from restaurants and food suppliers. (Already, growing demand from consumers has led some fast-food giants to make changes in the meat they buy, and this has a huge impact, Price says.)

He also urges us all to pressure our elected officials and federal authorities to better regulate antibiotic use and to fund programs that will lead to the development of new antibiotics. “This is something worth fighting for,” he adds. “We have a responsibility.”

The world has no shortage of problems. Prioritizing isn’t easy. But as with climate change, we know enough about antibiotic resistance to recognize the urgency of our situation. Whether we’ll prevent this preventable disaster remains to be seen.