Germs, Chapter 1

Germs! Viruses, bacteria, fungi. Never mind the parasites. Bacteria are very much in the news lately. The headlines scream: "Flesh eating, superbugs, resistant to all antibiotic". The problem is real and getting worse all the time. As the great philosopher Walt Kelly (writer of the comic strip Pogo) phrased it, "we have met the enemy and he is us".

Bacteria live in us and on us. The human gastrointestinal tract harbors up to a trillion bacteria. A newborn ingests bacteria along with mother's milk. The bacteria in our gut are beneficial. They help us digest and absorb nutrients. They even produce nutrients that we need to survive. They deter the growth of pathogenic bugs. Our skin, including the the sweat and oil glands and hair follicles, swarm with bacteria. the respiratory system including the nostrils, sinuses, air ways and lungs are also home to innumerable bacteria.

Companies that sell cleaning products have made us all germophobes. Hand soap, shower products, kitchen and bathroom cleaners and now even clothing contain antibacterial chemicals. Yes, you can buy socks that have silver impregnated fibers to kill the bacteria that make your feet stink. Children's toys are touted to have antibacterial compounds in the plastic. My kitchen cleaner will kill 99.9% of germs. The problem is that 0.1%.

Bacteria reproduce rapidly, if conditions are right. The bugs not killed by the cleaner are resistant to the antibacterial chemical. Random mutations or environmentally induced mutations will allow a few bacteria to survive. The offspring of these resilient bugs are all resistant.

Antibiotics have saved millions of lives. Before penicillin and sulfa, any wound often led to a lethal infection. Today few bacteria are susceptible to these antibiotics. At first the answer was to increase the dose of the antibiotic. Higher doses of penicillin could overcome early resistance in strep and staph bacteria. Bacteria evolved. A mutation led to the bacteria producing an enzyme that deactivated the penicillin molecule.

Humans are also resilient. Chemical manipulation of the penicillin molecule by adding a B-lactam ring produced methcillin. Mankind gave the bugs a new challenge. B-lactamase was the bugs response. MRSA is methcillin resistant Staphylococcus Aureus. One of the superbugs is now resistant to the antibiotics that was designed to kill this menace. A recent patient in the ER was noted on his nursing home records to have MRSA and VRE (vancomycin resistant enterococcus). The nurses gowned up and followed the infectious disease recommendation to try and minimize the chances of this bug spreading to our other patients.

In this war between bacteria and humans, the bugs are winning. NDM-1 (New Delhi metallo-beta-lactamase-1) is the latest and greatest superbug. Be afraid, be very afraid. The bacteria are developing resistance faster than the drug companies can modify old antibiotics or formulate new drugs.

Tuberculosis is as old as mankind. Human remains from our earliest ancestors show evidence of Tb infections. Public health initiatives in the late 19th and early 20th centuries along with effective antibiotics and forced quarantine, made Tb rare in the USA. Laws still exist that allow the confinement of Tb patients, if necessary, to force completion of their treatment.

Enter MRDTb and XDRTb. Multi-drug resistant and extreme-drug resistant Tb have become a scourge in many countries. Tb was once curable with one or two antibiotics. As resistance developed, additions drugs were added to the treatment regimen. MDR and XDR have rendered standard treatment ineffective.

Resistance develops as the few survivors of our antibiotic bombardments reproduce new generations of resistant bugs. Resistance based on a enzyme defense may be encoded on a plasmid. This piece of genetic material can be swapped between bacteria of different species. The bugs can pass on their defenses leading to superbugs. Bacteria also like to hang together. In our bodies pathogenic bacteria produce biofilms. This material screens the bugs from the physician's assault weapons. The antibiotics can't even get at the bugs.

What went wrong? Physicians and patients are to blame. Doctors prescribe antibiotics for conditions that are caused by viruses, or that will resolve without antibiotics. 80% of ear infections resolve without antibiotics. When I try and explain this to the mother of a 2 year crying because of his or her booboo ear, I am met with hostility. The mother insists that she must be given a prescription for amoxicillin or azithromycin. Her child's pediatrician always gives her a script.

Sinusitis, ear infections, colds influenza and gastroenteritis are all treated with often unnecessary antibiotics. Patients given prescriptions for antibiotics, whether needed or not, rarely take the medication as prescribed. If the patient feels better in a few days, he or she will stop taking the antibiotic despite the doctor's admonition to finish the entire treatment course. The unused pills are kept in the medicine cabinet, only to be taken later when the next cold hits.

Physicians must take the lead in preventing the development and spread of antibiotic resistant bacteria. Educate your patients. Patients must become informed consumers. Read about antibiotic resistance. Don't demand antibiotics unless the healthcare provider says that they are truly necessary. If you are prescribed antibiotics, take them on time and until you complete the treatment.

In many countries, antibiotics may be purchased without a prescription either legally or on the black market. I treated a young Cambodian woman in the ER for weakness. Her blood tests revealed aplastic anemia. Her bone marrow had stopped producing red and white blood cells and platelets. She had treated a cold with an antibiotic she purchased in her local ethnic market. Chloramphenicol is an antibiotic that may cause aplastic anemia. This past week, a patient from Brazil was taking tetracycline bought at the local bodega.

Are we doomed? Have the bacteria won? New antibiotics will be created. Better infectious disease protocols will be formulated and applied. The ultimate weapon may be bacteriophages (bacteria eaters). These are viruses that kill bacteria. A patient with a life-threatening bacterial infection may be inoculated with a bacteriophage instead of being given an antibiotic. This treatment is being used in Russia and may be coming to your local hospital.