The bright side of antibiotic resistance

My parent’s generation grew up in fear of a nuclear apocalypse: the cold war was raging, team USA and team USSR were competing in a frightening arms race, and people were building bomb shelters in preparation for a nuclear end to the world. That’s like so 1950’s though; what’s hot now is the environmental apocalypse. We all know about rising water levels, and some doomsayers are even warning that enough methane is about to be released from the icecaps to cause the greatest mass extinction since the dinosaurs.

Me? I’m not too concerned about either of these scenarios, but it’s not because I’m much of an optimist. It’s because I’m convinced that bugs will kill most of us before we kill ourselves.

In 1928, Alexander Fleming discovered penicillin, and it was being mass produced by World War II. This means it has effectively been around for at least 70 years, and it still works against a broad range of bacteria. Superb; 70 years is a hefty amount of time–enough for billions of doses to have been administered–and we’re still going strong.

But bacteria don’t care. They’re (still) here, they’re (always) evolving, get used to it.

I say that because I don’t believe we’re going to be able to keep discovering new classes of antibiotics ad infinitum–although I certainly hope I’m wrong. But if I’m not, it means that we’re only ever going to have so many treatment options, and that the bugs are eventually going to become resistant to all of them (although probably not in our lifetime).

What then? And what do we do until then? Let’s start with the first one, since post-apocalyptic scenarios are always fun:

Medicine will certainly have to change. Hospitals will become very, very dangerous places (much more than they already are!)… There’s going to be much stronger and urgent pressure to reduce hospital stays and readmissions to the absolute minimum, and most patient care will have to be shifted to community and home settings…. Health systems will have to go through major structural transformations to improve prevention…. GP’s, primary-care specialists, and allied healthcare professionals will become much more important and esteemed members of the healthcare professions…. The notion that individual health is highly interdependent will become a part of popular culture.

Funny–apart from the first part about hospitals becoming (more) dangerous, none of these sound all that terrible. In fact, they’re all changes I would very much like to see in my lifetime, bacterial apocalypse or not. It sounds like we would save a lot of lives, avoid a lot of suffering, and spend a lot less money doing it. It certainly makes me wonder why we aren’t doing a lot of those post-apocalyptic things now (i.e. way before the apocalypse.)

We should probably also be trying harder to prevent resistance, even if it does happen to be true that it’s battle we will eventually lose. For example, we should make a bigger effort to identify “germ sheds” and bacterial “breeding grounds,” and we should be making an even bigger effort to eliminate them. (One would think that the imperative to eliminate them is an obvious corollary of the imperative to identify them, but we’ve known for a long time that overcrowded prisons are a major source of super-bugs, and yet we still seem quite pleased to have overcrowded prisons proliferating… I guess corollaries just aren’t very popular nowadays.)

However, the idea that we will not be able to keep our drugs effective forever suggests that there are certain things we should not be doing in the name of “stewardship.” For example, we should not withhold antibiotics from patients for whom they are currently a life-saving or suffering-ending option simply because doing so might save/help other patients tomorrow. (Again, to me this seems like a line out of “Deep Thoughts by Captain Obvious,” but millions are currently dying from lack of access to antibiotics that are still effective for their conditions, and I suspect that “stewardship” could become a way of justifying that.)

To summarize: Antibiotic resistance is a scary thing. Last summer I would probably have lost a loved one due to a ruptured appendix (i.e. due to a failure of early detection, which is part of primary care). Peritonitis is a serious condition even now, but it would most likely have been fatal if the bugs that hit her had been resistant to the antibiotics we have available. I don’t like antibiotic resistance one bit.

But at least it serves to remind us that there are better approaches to healthcare that could be realized within our lifetime, and at least it does not give us any reason to deny each other proper care and consideration if we happen to get sick today.

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