A journalist by training, Meline Toumani shocked friends and family by moving to Turkey and embarking on a journey to understand a people and a country she'd been taught were the enemy. The result is "There Was and There Was Not," part political history, part deeply personal memoir.
Antibiotic-resistant “superbugs” are now rampant in the U.S., causing 23,000 deaths a year. Overprescription of antibiotics is one of the main culprits, yet American doctors continue to prescribe the drugs at one of the highest rates in the world. Adding to the issue is the widespread use of antibiotics for livestock. We find out about new programs, including an initiative launched by the Centers for Disease Control and Prevention, to track and curb antibiotic use.
- Cara Larson Biddle Pediatrician, Center for Community Pediatric Health, Children’s National Medical Center
- Keeve Nachman Director, Food Production and Public Health Program, Johns Hopkins Center for a Livable Future
- Arjun Srinivasan Associate Director for Healthcare Associated Infection Prevention Programs, Division of Healthcare Quality Promotion, Centers for Disease Control
MR. KOJO NNAMDIFrom WAMU 88.5 at American University in Washington, welcome to "The Kojo Nnamdi Show," connecting your neighborhood with the world. Antibiotic resistant superbugs are now rampant in the US, causing something on the order of 23,000 deaths a year. Over prescription of antibiotics is seen as the biggest reason these infections have developed. And while it's something doctors and most patients are aware of, the problem has been hard to get under control, in part because we don't collect enough detailed information about when and why antibiotics are prescribed.
MR. KOJO NNAMDIAdding to the issue is the widespread use of antibiotics in livestock. Joining us to talk about this is Dr. Cara Larson Biddle. She's a Pediatrician in the Department of Community Pediatric Health in the Children's National Health System. Cara Larson Biddle, thank you for joining us.
DR. CARA LARSON BIDDLEGlad to be here.
NNAMDIAlso joining us in studio is Dr. Keeve Nachman. He is the Director of the Food Production and Public Health Program with Johns Hopkins Center For A Livable Future. He also teaches in the Department of Environment Health Sciences at the Bloomberg School of Public Health at Johns Hopkins. Keeve Nachman, thank you for joining us.
DR. KEEVE NACHMANThank you for having me.
NNAMDIAnd joining us from studios at the Centers For Disease Control in Atlanta, Georgia is Dr. Arjun Srinivasan. He is Associate Director For Healthcare Associated Infection Prevention Programs in the Division of Healthcare Quality Promotion at the Centers For Disease Control. Arjun Srinivasan, thank you for joining us.
DR. ARJUN SRINIVASANA pleasure to be with you.
NNAMDIArjun, I'll start with you. What kinds of antibiotic resistant infections are we talking about?
SRINIVASANIt really runs the full spectrum from infections that occur in hospitals in very, very sick patients to infections that occur outside of hospitals, that we see in clinics and emergency departments. It's in children, it's in adults, so it really cuts across all sectors of healthcare. It impacts everyone. So we say that antibiotic resistance is one of those issues that does not discriminate. Everyone is at risk for these antibiotic resistant infections. And it's certainly become a serious and growing public health threat that we have to tackle as a society.
NNAMDIWhat's behind the rise in these antibiotic resistant infection?
SRINIVASANIt's certainly multi-factorial. There are a lot of issues at play, but one of the most important is the one that you just identified. It's the overuse and misuse, frankly, of antibiotics in a host of different settings. In livestock as well as in human medicine. In outpatient clinics and in our hospitals.
NNAMDI800-433-8850 is the number to call if you'd like to join the conversations. What concerns do you have about taking antibiotics? Are you concerned about the overuse of antibiotics and the rise in the number of superbugs out there? 800-433-8850. You can send email to firstname.lastname@example.org or you can send us a tweet @kojoshow. Our website is kojoshow.org. You can also ask a question or make a comment there. Cara Larson Biddle, one big issue is that antibiotics are often prescribed for infections that may not be helped by them. Can you explain?
BIDDLEWhen parents bring their kids in, and they're sick, they are looking for something that's gonna make them feel better right away. And so many times, they think that an antibiotic is what's gonna make them better, even if their child has a viral infection that really is not gonna be made better by an antibiotic at all. Doctors may feel some of that pressure to please the parent, or they may not be sure what -- whether the child really has an infection or not that needs an antibiotic.
BIDDLESo, sometimes it's not totally clear.
NNAMDIWell, you know, I'm just thinking that in normal conversations with people who are feeling a little under the weather, you hear them say, I need an antibiotic. And so that's essentially what we call and tell the doctor that we want, is an antibiotic.
NNAMDIWe've all heard, Keeve Nachman, that animals, given antibiotics, are contributing to this issue. What do we know about how antibiotics, given to animals, affect human health?
NACHMANWe're learning more and more all the time, but we don't know as much as we'd like to. We've started to learn, with recent research, that living near a site where animals are produced, or living near a site where animal waste is applied to land as fertilizer, can increase your risk on contracting an antibiotic resistant infection. So, as our opportunities to study the problem continue, we will have more certainty and understanding just how that use impacts peoples' infections.
NNAMDIArjun, the antibiotic resistant infections that you are looking at are those spread in hospitals. What are treatment options when someone acquires an antibiotic resistant infection?
SRINIVASANWell, that's one of the frightening things about this problem, and one of the reasons why urgent action, really, is needed. We really are running out of treatment options. And in some instances, we're totally out of treatment options. There are patients in hospitals, in this country today, who have infections, bacterial infections, that one, two, even three years ago, we could have treated fairly readily with antibiotics, that now we have absolutely no antibiotics left to treat. So, there's no question that we have reached the situation where we are out of antibiotics completely, in some instances.
SRINIVASANAnd really, really limited in the antibiotics that we have available to us in many others.
NNAMDIBut this is a problem, not just in the US, but worldwide. Europe does seem to have been focused on addressing it for a while. Can you talk about that, Arjun?
SRINIVASANAbsolutely. This is a worldwide problem, as you're pointing out. There is no country, that I'm aware of, at least, that is completely spared this problem of antibiotic resistance. And, for a long time, Europe has really, I think, led the world in its dedication and focus on tracking these types of antibiotic resistant infections, both in hospitals and outside of hospitals. And also tracking how antibiotics are used, both again, inside their hospitals and out of their hospitals.
SRINIVASANTracking not just how much antibiotics are being used, but also how well they're being used. And I think we have a lot to learn from what they've done to track and monitor the use of antibiotics and antibiotic resistant infections. And I think those are lessons that we've taken to heart and we are doing a lot here at CDC that is...
NNAMDITell us a little bit about what you are doing.
SRINIVASANYeah. Absolutely. So, a lot of the things that we're -- one of the big things that we're doing is working on improving how we track antibiotic use, especially in hospitals, which is an area where we, historically, really have been somewhat blind, really have very little information on how antibiotics are used in hospitals. And so, a couple of years ago, at CDC, we launched a monitoring system called the antibiotic use option of the National Healthcare Safety Network. It's a web based network that's available to all hospitals in America.
SRINIVASANAnd, in fact, all hospitals in America are enrolled in this network and reporting different types of information to CDC. And that network, now, has the ability to track antibiotic use. And so we're encouraging hospitals to gather that information and submit it to CDC. It can be done electronically. And what this does, this antibiotic use option, is it allows facilities to track their own antibiotic use, so they can see how they're doing over time. And it also allows us at CDC to track antibiotic use from all of these hospitals throughout the country, and get a better sense of what's being used, where it's being used, and how well it's being -- how much is being used.
SRINIVASANAnd hopefully, someday, we'll be also be able to assess how well it's being used.
NNAMDIIn case you're just joining us, that's Dr. Arjun Srinivasan. He is Associate Director for Healthcare Associated Infection Prevention Programs in the Division of Healthcare Quality Promotion at the Centers For Disease Control. He joins us from studios at the CDC. In our Washington studio is Dr. Keeve Nachman, Director of the Food Production and Public Health Program with Johns Hopkins Center For a Livable Future. And he also teaches in the Department of Environmental Health Sciences at the Bloomberg School of Public Health at Johns Hopkins.
NNAMDIAlso in studio with us, Dr. Cara Larson Biddle. She's a Pediatrician in the Department of Community Pediatric Health in the Children's National Health System. You can call us at 800-433-8850. What concerns do you have about taking antibiotics? I'll go to Tenzer in Bethesda, Maryland. Tenzer, you're on the air. Go ahead, please.
TENZERYes. Hi. Thank you so much for allowing me to join the conversation, Kojo. I'm a big fan of yours, by the way.
TENZERAnd this discussion that you're having is very interesting to me, because it did outline what I have experienced in my life. I'm originally from Turkish descent. You know, I lived in Turkey, studied in Switzerland for a very long time. My father is a brain surgeon. And so, when I was getting sick when I was in Turkey and/or in Switzerland, and when I was seeking medical attention, going to the doctor for a flu or a cold, their approach to me was always to verify how bad it was, how bad the sickness was, whether it needed an antibiotic treatment.
TENZERAnd if they decided that it didn't, they would give me, you know, some remedy such as some tea, or different type of (unintelligible) remedies. You know, not antibiotics, and exactly because of the point that antibiotics would create -- would adjust my immune system to get immune to antibiotics, and when I really needed antibiotics, that it wouldn't work. And so, that was my comment, but then my follow up question to that is, when I came to the United States, all I saw is doctors prescribing me antibiotics because I was cold and the practice was, oh, okay, you have a cold?
TENZERGet antibiotics. And I had to tell my doctor that that was, you know, I had to question my doctor to say, why are you prescribing me antibiotics with just a cold? Is the infection really that bad that it requires antibiotic treatment? And they would have to start -- look at me to say, well, you know, that's what we do. So the question that I have is why do doctors -- why are doctors as experienced, or why aren't they brought -- why isn't the attention brought to the doctors to say, you know, change the way in which you look at your patients.
NNAMDII'll put that question to Cara Larson Biddle. How are doctors trained when it comes to prescribing antibiotics in the US?
BIDDLESo, the general philosophy is that you want to use antibiotics only when necessary, so it's interesting to me that the experience that the caller has had here with the US healthcare system. Certainly, viral infections are not gonna respond to antibiotics, and it would not be appropriate to prescribe an antibiotic if -- for someone who just has a cold. We always are thinking about, what's gonna be the benefit to the patient? Do we think they have an infection that needs to be treated by an antibiotic? And what are the risks to the patient of prescribing this antibiotics?
BIDDLEAre there side effects we're concerned about? Allergic reactions? And thinking about what's gonna be in the best interest of the patient. There also are specific guidelines for different types of infections. An example would be strep throat. Many patients come see the doctor with a sore throat, and they're certainly looking for an antibiotic, but we really should be testing to make sure that that sore throat is caused by a strep infection and not caused by a virus before we would prescribe antibiotics.
NNAMDIArjun, before joining the CDC, you were at Johns Hopkins where you founded a program to manage antibiotics. Clearly, even before the CDC program, hospitals recognized this problem. What are they doing to address it?
SRINIVASANHospitals are, I think, taking a variety of actions. We know that some hospitals in this country have the types of programs that you're referring to, like the one that I started when I was at Johns Hopkins, and that continues to this day. They're called Antibiotic Stewardship Programs now. And as their name implies, their job is to steward the use of, the good use, of antibiotics in hospitals. But it's something that we need to see more hospitals do. These types of antibiotic stewardship programs are not ubiquitous in hospitals.
SRINIVASANAnd, we really do think that they need to be present everywhere. There's good data showing that these types of programs can have significant benefits.
NNAMDIYeah, I was about to ask when they are in place, what are the results?
SRINIVASANThe results are dramatic. They improve antibiotic use. They've been shown to improve treatment rates, to reduce treatment failure rates. They can reduce adverse events related to antibiotics, like patients who get a deadly type of diarrhea called clostridium difficile, which is a very serious side effect from antibiotics. And these stewardship programs can reduce that. They can reduce other side effects from these drugs. And they've been shown to even reduce antibiotic resistance in hospitals. So they're very, very effective.
SRINIVASANProviders tend to like the input that they get from these programs. And they've been shown to save money. So we really think that this is a win for everyone, for providers, for patients and for society. And so we're really urging and pushing hospitals to start these types of programs. We know that they can be started in hospitals of all sizes. There are very large hospitals, like Johns Hopkins, that has a program. And there are very, very small hospitals that have effective antibiotic stewardship programs. We just need all hospitals to take this action.
NNAMDIWe're going to take a short break. When we come back, more about antibiotics given to animals and their effect on humans. But you can still call us, 800-433-8850. Do you buy organic foods in part because of concerns about antibiotics given to animals? 800-433-8850, or you can shoot us a Tweet @kojoshow, email to email@example.com. I'm Kojo Nnamdi.
NNAMDIWelcome back to our conversation on antibiotics. We're talking with Dr. Cara Larson Biddle. She's a pediatrician in the Department of Community Pediatric Health in the Children's National Health System. Dr. Arjun Srinivasan is associate director for Healthcare Associated Infection Prevention Programs in the Division of Healthcare Quality Promotion at the Centers for Disease Control. And Dr. Keeve Nachman is the director of the Food Production and Public Health Program with Johns Hopkins Center for a Livable Future. He also teaches in the Department of Environmental Health Sciences at the Bloomberg School of Public Health at Johns Hopkins.
NNAMDIKeeve Nachman, I'd like to get back to antibiotics in our food system, mainly those given to animals we eat. Many people assume that if they take certain steps, if they handle meat properly or buy only organic meat they don't have to worry about antibiotics in animals. What do you say?
NACHMANI think safe handling of meat is never a bad idea. I think it certainly decreases the probability that you'll actually become infected with bacteria that are resistant to bugs or bacteria that aren't resistant to bugs. And I think there is a concern though, even with organic meats, the research has actually shown that there are comparable rates for many food borne bacteria of the presence of those bacteria on meats. And there are a lot of theories as to why that may be.
NACHMANThere are a lot of steps along the way from the production of the animal to purchasing the meats in stores that create opportunities for cross contamination of those meats with bacteria. And in many cases organic meats are actually produced by some of the same producers as conventional meats and processed in the same facilities. They may have a separation temporally speaking of processing of the conventional meats that were raised with antibiotics versus the organic meats which were raised without. And those common processing locations can actually create that cross contamination risk.
NACHMANI think one thing that a lot of people sort of don't understand is the idea of if I'm a vegetarian, I'm not at risk of coming into contact with antibiotic-resistant bacteria.
NNAMDIYep, a lot of vegetarians don't eat meat because they have those concerns.
NNAMDIBut there's a reason they too should be concerned?
NACHMANAbsolutely. What I think a lot of people don't realize is that produce farms are typically fertilized with waste from animal production sites. And that waste could come from a conventional animal production site where antibiotics are routinely used. And what happens is that bacteria that are present in the gut of the animals can end up in the animal waste, which is then used as fertilizer and can contaminate those crops. So unfortunately being a vegetarian isn't enough. Safe produce handling is paramount in limiting your exposure to those resistant pathogens.
NNAMDIYou say the greatest concern is for people near farms or where animals are transported. Maryland is a particular concern because of the number of chickens raised there?
NACHMANRight. We raise about 300 million broiler chickens or meat chickens in Maryland each year. And there have been a number of studies that have shown that some vectors that you might not normally think about are capable of transmitting resistant bacteria. A couple of studies published by colleagues of mine looked at flies that originate from animal feeding operations and can be caught in residential locations near those animal feeding operations, can carry resistant bacteria. And also, like you mentioned, animal transport trucks have been shown to be sources of antibiotic-resistant bacteria.
NACHMANSo there are lots of ways these bacteria find their way off of farms and into communities. And those communities surrounding operations are most exposed compared to any part of society.
NNAMDIBefore I get back to the phones, Arjun Srinivasan, is the CDC also looking at where infections come from, including the spread from animals?
SRINIVASANWe certainly are.
NNAMDIOh, okay. Then on to the telephones now. We'll start with Kathy in Gambrills, Md. Kathy, you're on the air. Go ahead, please.
KATHYThank you, Kojo. My concern is the -- of course the profligate prescription of antibiotics that has been in our, you know, country for decades now. Very briefly, I was on a long term tetracycline regimen for rosacea sometime between 10 and 20 years ago. My common sense dictated to me eventually that it was not a good idea to be on an indefinite regimen of antibiotic every single day. So I did eventually take myself off it. I have since done a lot of research, particularly Dr. Natasha Campbell McBride's research. Anyway, demonstrating the very deep gut trauma that results from long term exposure to antibiotics, namely being on an antibiotic regimen for a long time.
KATHYI have since become very, very cautious with the use of antibiotics. I will literally only take them if I'm on my deathbed. The reason being, I have -- I am now in the process of giving my immune system a chance to recover from all the damage that was done by killing off the good flora along with the bad when I had the rosacea. So I am, as I said, highly, highly skeptical of continuing to rely upon antibiotics in our culture. We need a thorough re-education of our culture in terms of strengthening the immune system as the best prevention against super bugs. So that's my statement.
NNAMDIOkay. Thank you very much for your call. I'd like to hear both from you, Cara Larson Biddle and from you Arjun Srinivasan about that.
BIDDLEWell, I think the caller brings up a really interesting point about side effects of antibiotics because we've know for a long time that there are lots of short term side effects of antibiotics, like diarrhea and rashes and allergic reactions. But we're really just starting to understand what some of the long term effects of antibiotics can be, including the effect on the gut and whether that has long term effects on other types of chronic health issues like asthma and obesity and eczema. That's definitely an area that we'll be looking at over the next decade.
SRINIVASANYeah, absolutely. And I think this is something that we really are only beginning to fully appreciate, which is the impact that taking antibiotics has on the healthy bacteria in your gut. And I think this is a side effect that we tend not to think about very much. And most people don't consider that to be a relevant side effect when they think about asking their doctors for an antibiotic. But I think there's a growing body of literature and a large and growing body of work that suggests that the damage that's done to the bacteria in your gut may ultimately be one of the most serious side effects of these types of antibiotics. And certainly one in a very long list of reasons by you don't want to take an antibiotic unless you really need an antibiotic.
NNAMDIThank you very much for your call. Keeve, we've just heard about what hospitals, doctors and federal entities like the CDC are doing to try to address over prescribing of antibiotics for people. When it comes to antibiotics in animal feed, what are the FDA rules that now guide how and when antibiotics are used?
NACHMANThe FDA's most recent action on antibiotic use in animal agriculture has been to ask the pharmaceutical industry voluntarily to eliminate drug approvals for production uses. And what that means is that the FDA no longer endorses the use of antibiotics for use in promoting growth, making animals grow faster or making animals grow with a reduced reliance on feed. There have been some problems with the way the FDA has decided to approach this. Not only are the guidelines voluntary, but when you look closely between the lines at the finer details of what they're requesting, there's concern that the action will really only result in a relabeling or renaming of the drug use. And that the actual nature of the drug use will not change.
NACHMANWhat continues to be endorsed is the use of antibiotics for something called disease prevention, which on the face of it sounds reasonable. Who doesn't want to prevent disease? But in practice the dose ranges, the durations of use for disease prevention look a lot like growth promotion. So we are concerned that these voluntary guidelines will implore the pharmaceutical manufacturers to just change the labels in a way that won't actually change use.
NNAMDIWhich is why one of the biggest issues, it's my understanding, that you focus on is transparency. Can you talk about that and why you feel it's so important?
NACHMANWell, there's so little transparency in drug use in the animal agricultural industry. The only data we have regarding antibiotic use are sales data from the drug manufacturers. We do not have any data on usage within the industry. The FDA does not collect it. They don't ask the producers to save it for them. And that's a real problem. If we are to conduct studies that can help us better understand how these uses may contribute to human illness, we need to know something about the way the drugs are used.
NACHMANWhat we do know about the way the drugs are used is that they're often used in the absence of any clinically-diagnosed disease. And what that means is healthy animals are receiving a good fraction of the antibiotics that are sold for use in the country each year. And just to give you a statistic, the little bit of data we have, the annual sales reporting from drug manufacturers tells us that 80 percent of the antibiotics sold for use in the U.S. go to food animals. And the majority of that volume of drugs is administered to animals through feed or water, which are not very good ways to deliver drugs. So certainly there is a rampant misuse within the industry.
NNAMDIOn now to Rosemary in Baltimore, Md. Rosemary, you're on the air. Go ahead, please.
ROSEMARYHi there. I feel like I will be preaching to the choir. I have been in medical equipment sales for over 15 years and my product has always been the same. I have a sensitivity identification system which gives rapid results and cut the resulting time to the physicians by 24 hours. And sometimes I feel in the hospital the physicians are only as good as the information they receive about the, you know, infecting organisms. And about half the hospitals in my area, Maryland and D.C., are still on a system where they would give the results to the physicians, IDs and sensitivities, you know, an older system.
ROSEMARYOurs is a little newer and can cut the turnaround time for results by 24 hours. And that's what I try to sell. And I've been trying to go to the CFOs, the CEOs, the antibiotic stewardship committees in these hospitals to say, listen we need to stop and we need to get the patient on the right drug earlier and maybe get them out of the hospital, maybe on oral drugs. Get your (unintelligible) patients out of the hospital. Save the patient's health, their money. And the bottom line is the hospital money because that's kind of where it's going.
ROSEMARYSo I'm very frustrated and I didn't know if anybody had any advice as to the right people to direct my talk to when I go to the hospitals.
NNAMDII'm not exactly sure I understand but I'm pretty sure that my guests do. So I'll start with you, Cara.
BIDDLESo unfortunately I'm not quite sure who to direct you to in terms of your business. But the caller is really talking about something that is a challenge for physicians. And that is that when patients have an infection, we have a general idea of what types of bacteria can typically cause that infection and what types of antibiotics are likely to be helpful.
BIDDLEWhen patients are really sick though, I as a physician need to make a decision. Am I going to start with an antibiotic that usually works but might not work if it's an unusual bacteria causing that infection, or am I going to start with an antibiotic that's really broad and covers lots of different types of bacteria and then adjust once I know for sure what type of bacteria is causing the infection.
BIDDLESo an example would be a urinary tract infection. I can check a sample of the patient's urine, and typically in two days I'll know what bacteria it is and what antibiotics are going to treat that bacteria effectively. But I need to do something for the patient in the meantime so I'm going to use my best judgment to treat the patient until I know for sure what type of bacteria it is.
NNAMDISo the faster you can know for sure the better.
NNAMDIArjun, you have said that for a long time we have thought of antibiotics as essentially harmless. But that thinking is changing. Can you talk about that?
SRINIVASANAbsolutely. We've touched on it a little bit before but I think, you know, when we used to think about antibiotics we would say, well, you know, there's so much potential benefit and really no harm. So the scales should always tip on the side of giving an antibiotic rather than not giving one. And I think what we're finding out and what we're learning now is that that's really not the case.
SRINIVASANThere are a lot of harms that we can do when we give antibiotics. And it's not just harms to society in the form of antibiotic resistance, although that is of course very important. But the harms are much more important for the individual patients. Adverse drug reactions, we know that among patients who come to emergency departments with an allergic reaction to a drug, antibiotics are one of the most common causes of those emergency department visits. More than 100,000 people per year end up in emergency departments for drug reactions to antibiotics.
SRINIVASANThe problems of clostridium difficile diarrhea, which we know kills more than 14,000 people in this country every year, antibiotics are the number one risk factor for that. And as we talked a little bit about earlier, the damage to the healthy bacteria in the gut has both short term and long term side effects that are serious. And so I think it calls upon all of us again to not say -- we're not saying don't use antibiotics. Clearly when antibiotics are needed, they need to be given and given quickly. But what it does call on us is to weigh that decision carefully to think carefully about the downside of antibiotics each time we're confronted with a decision of whether or not we have a patient who needs antibiotics.
NNAMDICara, you would agree with that also with the pretty serious side effects that Arjun was talking about and the newer concern. Researchers are beginning to understand more about how so-called good bacteria affect our systems. Can you talk about that?
BIDDLEWe all have bacteria that live throughout our body. They live on our skin, they live in our intestinal tract and in our nasal passages and everywhere. And those good bacteria are really responsible for keeping our body in balance and making sure that the types of bacteria that live and grow thee not only don't make us sick but really, we're learning more and more, keep us healthy. When we take antibiotics, those antibiotics kill the bacteria we're trying to kill but they also kill our good bacteria, and that all of our systems can get out of whack and let other bacteria grow that shouldn't be there and flourish.
NNAMDIBack to the telephones now. Here is Sonya in Manassas, Va. Sonya, thank you for waiting. You're now on the air. Go ahead, please.
SONYAGreat. Thank you, Kojo. I just want to say thank you to everybody -- the panel for being here today. Thank you for accepting my call. I just had a question. I have a lot of friends and relatives within the Latin American immigrant community here in the city and was just sort of curious because there seems to be kind of a black market for this tetracycline. A lot of friends of mine and family members when afflicted with anything sort of self diagnose and get this tetracycline and take it for whatever's ailing them.
SONYAAnd I haven't done the research personally so I was just curious, as long as we're on the topic, what types of adverse effects would this be having? Obviously drug resistance and, you know, sort of self diagnosis I'm well aware are problematic. But just curious as to sort of the specifics and if you have any information on that it would be helpful. Thank you.
SRINIVASANI'm not exactly sure but I think the question is about the side effects of tetracycline. They're similar to the side effects from many other types of antibiotics, clostridium difficile and other types of diarrhea that can occur, skin reactions. All sorts of adverse drug events can occur. And certainly obviously we would want to discourage anyone from engaging in that type of self diagnosis and trying to obtain antibiotics without a prescription. Because that obviously can lead to a lot of potential problems.
NNAMDIDo some people in this area tend to see it as a cure all, as our caller seemed to be saying?
BIDDLEAbsolutely. And it's understandable. Like you said, Kojo, when you're sick you want to feel better. When you're a parent and you have a sick child, you want your child to feel better and you want to be able to get back to work as soon as you can. So I absolutely understand the drive on everybody's behalf to be looking for something that's going to make them feel better. But unfortunately, as we know, that's just not the case.
NNAMDIGoing to have to take another short break. When we come back, more on this conversation on antibiotics in humans and in animals and your calls at 800-433-8850. Has your child been prescribed antibiotics for ear infections or other illnesses? Do you know if you have taken antibiotics for an illness that may have been viral and not bacterial, 800-433-8850? Or you can send us email to firstname.lastname@example.org. I'm Kojo Nnamdi.
NNAMDIWelcome back. We're discussing antibiotics with Dr. Arjun Srinivasan, associate director for Healthcare Associated Infection Prevention Programs in the Division of Healthcare Quality Promotion at the Centers for Disease Control. Dr. Keeve Nachman is the director of the Food Production and Public Health Program at Johns Hopkins Center for a Livable Future. He teaches in the Department of Environmental Health Sciences at the Bloomberg School of Public Health at Johns Hopkins. And Dr. Cara Larson Biddle is a pediatrician in the Department of Community Pediatric Health in the Children's National Health System.
NNAMDIKeeve Nachman, we got a Tweet from Dee who says, "Please define safe handling of meat. Is water enough or should we use a soap?"
NACHMANThat's a great question. I wouldn't recommend washing meat. I think that has been a recent recommendation from the USDA. Washing meat creates opportunities to spread bacteria further. I think wash your hands with soap and water after handling meat. Don't use the same preparation surfaces for raw meats and other foots that you plan to eat without cooking. And clean those cooking surfaces with soap and water after you're done using them. But certainly don't wash the meat.
NNAMDIWhen it comes to antibiotics for animals, the issues are slightly different than in humans. You would make a distinction between drugs given to treat an illness versus those given for disease prevention. But that's not always clear in the regulatory world, is it?
NACHMANNo. The FDA gives four different classifications for drug use in food animal production. The first is growth promotion or production purposes, which they've recently said they're no longer willing to accept. But then there are the three other classifications treatment which is something that I think most people agree is an acceptable use where you've identified an animal with an infection and you treat that infected animal.
NACHMANThere's also disease control where you have a flock of animals and a disease has been identified within the flock. And the entire flock is treated to prevent spread of that bacterium through the flock. That's generally regarded as acceptable as well, but then there's disease prevention, which is where the biggest battle is being fought. And the concern there is that disease prevention, as defined by the FDA, is the use of drugs in a situation where no animals has been diagnosed as having an infection but where an infection may occur.
NACHMANAnd so really there's concern within the public health community that FDA continues to allow drugs to be used under the disease prevention guise. And that is certainly problematic from a public health perspective.
NNAMDICara Larson Biddle, kids are prescribed antibiotics more than any other group and young children tend to get the most antibiotics. What are the most common uses that result in prescribing antibiotics for kids?
BIDDLEThe number one reason is ear infections, which we've already talked about a little bit. Strep throat, skin infections like boils and abscesses, urinary tract infections. But by far the number one is ear infections.
NNAMDIOkay. Back to the telephones now. We go on to Debra in Rockville, Md. Debra, your turn.
DEBRAI had a question about Lyme disease and whether antibiotics might in the future be less effective against that with resistance.
NNAMDIWell, hold on a second because I think we have another caller who'd like to address that issue. So I'll go to Dave in Annapolis, Md. Dave, you're on the air. Go ahead, please.
DAVEThanks, Kojo, for taking my call. So I live in an area quite wooded. The last two years I've taken antibiotics at least twice, if not three times for tick bites that looked susceptible to Lyme disease, you know, the red target, a round target. And my question is, is there any alternatives to that because that seems to be the prophylactic way of dealing with this.
SRINIVASANYou know, I'm not an expert on the treatment and management of Lyme disease. I do know that there are studies indicating that if you live in a Lyme endemic area that the administration of antibiotics, when there is a very high risk, as the caller is describing, has been shown to be quite effective. I'm not aware of other therapies that have been shown to be equally effective.
NNAMDIWhen it comes to children, Arjun, as I was just talking to Cara about, when it comes to children in particular, are antibiotics overprescribed?
SRINIVASANYou know, antibiotics are overprescribed in all groups. So this is not something that's limited to children. In adults when we talk about outpatient settings, issues like bronchitis or the common cold tend to be areas where we see tremendous room for improvement in how antibiotics are given to adults. So this isn't an issue that's limited to children only.
NNAMDICara, it's not all bad news. There has been a downward trend in antibiotics prescribed for children. Is there now more understanding about this issue?
BIDDLEWell, you know, we as a profession in pediatrics look specifically at ear infections. And there were some guidelines published a decade ago and resubmitted about a year ago which really tried to get both pediatricians and then families to think about when do we need to use antibiotics for ear infections? Because the truth is that you don't need an antibiotic for every ear infection. Over half of them will go away on their own. Some of those were viruses all along. Some were bacterial infections that are able to go away on their own without antibiotics.
BIDDLESo we've been looking much more critically at who are the children who really are most likely to benefit from an antibiotic. Who are the children that it's okay to wait a while, wait a day, wait two days before starting antibiotics and observe the child to see if it will go away.
NNAMDIAnd you do find that parents are aware of concerns about overuse of antibiotics today. Can you talk about that?
BIDDLEI think more and more people have been exposed to this idea that particularly antibiotics overuse is causing resistance. MRSA is so widely discussed in the media, in schools, in health care settings that I think just about everybody knows somebody who's had an MRSA infection and has been concerned about that and fearful about this concept of bacteria that will no longer respond to the antibiotics that we have.
NNAMDIBut even though parents are more aware today of the issues around antibiotics, the alternative in many cases is not very satisfying, is it?
BIDDLELike I said earlier, when you're a parent of a sick child who was awake five or six times overnight crying, they have a fever, they're not eating, they're not drinking, it's hard to think globally about the impact on the community and even the impact on your child in terms of side effects because you're focus is on making your child feel better.
NNAMDIOn to Lisa in Leesburg, Va. Lisa, your turn.
LISAOh, hi. Yeah, we had the same problem with ear infections. And we put our boy on kind of a preventative small decongestant every day and kept his ears dry that way and got rid of all ear infections. Never had another one in four-and-a-half years, and never had to be on any kind of antibiotic as a result.
LISABut what I was calling for was that I think with technology and with interactions between what you're already on -- a lot of people are on a lot of medications -- and what you want to get on for whatever your current problem is, we should be walking into a doctor's office or an emergency room or whatever with a cell phone or a device that has everything that you're on, everything you're taking. And you should just be able to hand this to whomever's there and they look at it and they see where the interactions are going to be a problem.
LISAThat's the first thing that doctors ask you, what are you on and what have you changed? What medications have you changed, either dosage or type in the most recent months? And a lot of times they're able to pinpoint what your problem is based on that information. And we should be able to be walking around with this the way you have a Car Fax report when you try to buy a car. I want technology to help us with this rather than -- and just be another thing that we're carrying around that doesn't have the most vital information in it.
NNAMDISounds good to me. Thank you very much for your call. We got an email from Pratt in Silver Spring who says, "Can your guests please comment on how fast some bacteria can become resistant to new antibiotics and how this has affected the development of new antibacterial drugs?" Can you comment on that, Keeve?
NACHMANHow fast, that's a good question. I think it's a very rapid process. Drugs are exposed -- I'm sorry, bacteria are exposed to drugs. And the ones who are capable of surviving in the presence of those drugs are able to live on and reproduce. And what is concerning is that there's research that shows that even very low levels of administration of drugs can cause these genetic mutations in bacteria that allow them to develop resistance to antibiotics. So the more we misuse antibiotics in the wrong context, the greater the risk we have of propagating and creating new resistant bacteria.
NNAMDIOn to Elaine in Chantilly, Va. Elaine, your turn.
ELAINEHi, Kojo. Thank you so much. I love you. You’re the best.
ELAINEI -- sometimes I take my dogs to the vet or I take my kids to the pediatrician and they prescribe antibiotics. And I take the antibiotics but I don't always give it to them. I wait a couple days to see what will happen. And usually whatever was going on clears up. But now I have a cupboard full of antibiotics and I don't know what to do with them. I called a pharmacy and they said, you know, flush them down the toilet, which doesn't seem very smart. So what do I do?
NNAMDIHow should she dispose of her antibiotics, Cara Larson Biddle?
BIDDLEWell, I agree with her that flushing them down the toilet is not a great idea because then they get into the water system. So they need to be ideally disposed of responsibly. It's a good question. The trash is not great either but you can speak with your doctor. It would be best to bring them back to a health care facility.
NNAMDIAnything you'd like to add to that?
NACHMANI agree with what Cara said. I think that makes the most sense.
SRINIVASANI don't know much about the safe disposal of antibiotics. It's an interesting issue and I think the suggestions that have been made are good.
NNAMDIOn therefore to Anthony in Port Tobacco, Md. Anthony, you are on the air. Go ahead, please.
ANTHONYThanks, Kojo. I really enjoy your program. I was just wondering what kinds of efforts are being put in practice to work with the animal industry agriculture so that they can put good antibiotic use into practice. It's not really practical to have a veterinarian look at every sixth sheep or cow in a flock. And that kind of lends itself to corporate farms where they can employ veterinarians that do that. If you're a small farmer you can't really have the vet come out to look at every single cow. Just wondering how that...
NACHMANThat's certainly an important point but there are some farmers that are starting to look at other alternatives for managing bacteria and avoiding infections, like better sanitation of production sites, providing more space for animals, having fewer animals at a given site, better hygienic practices. And those are practices that can decrease the frequency of infections and decrease the need for treatment with antibiotics.
NNAMDIThank you very much for your call. Cara, one of the issues is also how much time we have or don't have to follow up. You mentioned earlier, if a parent comes in with a sick child what are the options?
BIDDLEIn terms of a child with something that we're going to sort of decide?
BIDDLEWell, so a great -- we keep talking about ear infections but it's because it's the perfect example.
NNAMDILet's talk about skin infections.
BIDDLESkin infections. See, in lots of skin infections from MRSA and other types of infections, many of those will also improve on their own with something like a warm compress that's going to help draw the infection out to the surface of the body. The important thing here is that the patient or the parent and the provider are having a conversation so that everybody understands, is this a situation when starting the antibiotic as soon as possible is imperative or is this a situation that there are some other things we can do in the meantime and see if this infection gets better on its own.
BIDDLEBut having that conversation, I think, is really important so that both the parent and the provider are on the same page.
NNAMDIOn now to Will in Greenbelt, Md. Will, you're on the air. Go ahead, please.
WILLHello. I have a slightly different perspective on this as I am kind of in favor of antibiotics. I had a flesh-eating infection. And I spent close to three years in various hospitals and stuff. And I did some back-of-the-envelope calculations and I figured I had 11 gallons of true vancomycin after they -- you know, you add up all the quarts of vancomycin and then divide by -- multiply by .3 percent and blah, blah, blah. And there were two other mycins that I can't -- I won't remember them until I'm off the phone.
WILLBut, you know, if I hadn't been practically embalmed with antibiotics and had lots and lots of surgery, I wouldn't be here. So now because of all the antibiotics, I've got MRSA running through me because, you know, it's not -- but also vancomycin resistant stuff. So I keep a little card in my wallet so if I'm ever picked up off the side of the road, you know, people will know that. But, you know, properly used, I think they're a good thing, although way back when every time we went to the pediatrician, we were guaranteed of getting a tetracycline prescription or whatever...
NNAMDIWell, I think you'll find agreement here that when properly used, and that's what the discussion is all about, how do we as both patients and doctors decide when they are properly used? Of course, doctors ultimately have to make that decision but a patient is a very important part of that equation. Isn't that right, Arjun?
SRINIVASANYeah, absolutely. I think that you don't want to create the perception that anybody on this call is opposed to the use of antibiotics. Antibiotics are life-saving drugs. They, every year in this country, are responsible for saving thousands of lives just in the United States. They , you know, also reduce illness. They get people well quickly. They're miracle drugs. They really are.
SRINIVASANAnd, Kojo, exactly as you have emphasized, the goal is not to prevent people from getting antibiotics when they need them. When people need antibiotics they need to get them and they need to get them quickly. The goal is to preserve these miracle drugs so that they will work one year, five years, ten years from now so that other people who get infections -- serious infections like the caller had have antibiotic options available to them. And we know that if we don't do a better job with using antibiotics, that we won't have them as options for patients in the future.
NNAMDILooking into the future in the next 30 seconds or so that we have, is there research around the next antibiotics? Something powerful that could treat infections that have become resistant to antibiotics, Arjun?
SRINIVASANThere's a lot of research going on but I think there's general agreement that there's nothing that's going to be on the near term that's going to solve all of our problems with antibiotic resistance. So there's work ongoing but I think there's a lot we have to do with improving use. And I also tell people that, you know, if we don't improve the use of antibiotics that means that even when we do get new ones we're going to run out of them too.
NNAMDIDr. Arjun Srinivasan is associate director for Healthcare Associated Infection Programs in the Division of Healthcare Quality Promotion at the Centers for Disease Control. Dr. Keeve Nachman is director of the Food Production and Public Health Program at Johns Hopkins Center for a Livable Future. And Dr. Cara Larson Biddle is a pediatrician in the Department of Community Pediatric Health in the Children's National Health System. Thank you all for joining us and thank you all for listening. I'm Kojo Nnamdi.
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