ANTIBIOTICS - BLESSING OR SCURGE? LUDICROUS OVERUSE

It never ceases to amaze me how a lot of doctors dish out antibiotics as if they were sweeties. This week I saw a young 4 year old boy who had taken 18 courses of antibiotics in his short lifetime. The mother was pulling her hair out as her son was developing ear infections and sore throats with high fever every 5-6 weeks, and she now knew that if she took the child back to the pediatrician he would be given even more antibiotics.

There are many more young children in the same boat, as well as adults who get dosed with antibiotics for a common cold, "just in case they were to develop a sore throat." Ludicrous overuse of antibiotics not only has caused many old diseases to reappear, but very possibly they are responsible for the emergence of new diseases too.

Now, more than 60 years after the discovery of penicillin, we find ourselves back to the future. Throughout the medical press you will find the concept of the "emergence" of new strains of superbugs. But emergence is really regression, a frustrating return to the standard which prevailed universally in the previous century (JAMA, 1996; 75(3): 243-6).

In theory antibiotics are a good thing - and in life-threatening situations they still are. When all goes well an antibiotic quells an infection by attacking and destroying the organism's protective cell wall; by blocking its production of essential proteins; by interfering with chemical messages essential for reproduction; or by some other equally effective method or combination of methods. But through a number of factors, largely involving misuse and overuse of antibiotics, some "bugs" have developed defence mechanisms to repel these attacks. They undergo genetic mutations which allow them to produce stronger cell walls, for example, or to change chemical messages.

RESISTANT ORGANISMS Penicillin was already being associated with resistant organisms when it was introduced in the 1930s. Today, 25 per cent of patients are suffering from a drug-resistant strain of pneumonococcus. This figure shoots up to 40 per cent among white children under six (N Eng J Med, August 24, 1995). This alarming rise came to light when researchers at the Centers for Disease Control and Prevention in Atlanta examined 431 patients (adults and children). They found that 25 per cent were penicillin resistant (7 per cent were highly resistant); 26 per cent were resistant to trimethoprim/sulphamethoxazole (Septrin); 15 per cent were resistant to erythromycin; 9 per cent to cefotaxime and 25 per cent to multiple drugs. In the UK, the frequency of penicillin-resistant pneumonococci doubled between 1990 and 1995; the microbe's resistance to erythromycin trebled in that same time (BMJ, 1996; 312: 1454-6). This is a picture which is repeated throughout the world.

MRSA -THE SUPER-BUG In 1992 in the United States some 23 million people underwent surgery, and nearly every one of them received prophylactic antibiotics. Up to 920,000 of them developed post-surgical bacterial infections, the majority of which were due to staphylococcus, in particular methicillin-resistant staphylococcus aureus or MRSA (N Eng J Med, 1992; 326: 337-9). MRSA was first reported in 1961 just after methicillin was introduced (BMJ, 1993; 307: 104954). Despite evidence, a curious mixture of complacency and arrogance allowed us to continue widespread use for another 30 years. That same year 15 per cent of all staph strains in the US and nearly 40 per cent of those strains isolated from patients in American hospitals were MRSA (Infect Control & Hospital Epidemiol, 1992; 13: 582-6). Significant problems were occurring elsewhere.

In New York a tuberculosis strain resistant to seven different types of antibiotic was discovered (J Clin Microbiol, 1994; 32: 1542-6). In England one man had an escherichia coli strain resistant to 20 different antibiotics (Lancet, 1993; 342:177). In one extreme case in Australia a staph virus contracted by one patient was immune to 31 different types of antibiotics (J Med Microbiol, 1990; 35: 72-9). By 1993 it was thought that nearly every common pathogenic bacterial species had developed some degree of clinically significant drug resistance. And over two dozen of these emergent strains could outwit most commonly available antibiotic treatment (Science, 1066-7). Super-resistant bugs are no respecters of class. You are just as likely to get a case of Salmonella from a Caesar salad in a high class restaurant as you are from a hot food cart in an underdeveloped country. Since 1993 salmonella has been an essentially untreatable disease - there is now nothing which will relieve the three or four days of agony it brings (J Infect Dis, 1993; 168: 1304-7). Resistant bacteria are not checked by national or natural barriers, and it's likely that greater mobility is contributing as much to the spread of resistant microbes as are crowded, unhygenic hospital clinics and wards (JAMA, 1990; 263: 2569-70).

MRSA AND VANCOMYCIN Today only one antibiotic, vancomycin, is thought to be effective against most MRSA. But even this drug is becoming increasingly ineffective, especially against the enterococci bacterium (JAMA, 1993; 270: 1796; Lancet, 1996; 347: 252). It has also been shown that transfer resistance (one organism passing its resistance on to another) can occur between enterococci and the staph virus (FEMS Microbial Health, 1992; 93: 195-8; Antimicrobial Agents and Chemotherapy, 1989; 33: 1015), and it is now believed that within a few years both staph and strep viruses will have acquired widespread vancomycin resistance. This process is thought to be helped along by the practice of giving poultry and livestock antibiotics in their feed. New antibiotics are costly and time consuming to produce - there have been no new antibiotics for more than a decade. It is unlikely that newer, stronger drugs such as Upjohn's proposed oxazolidinone or the proposed new class of peptide antibiotics (Lancet, 1997; 349: 418-22) are the final answer to this dilemma.

In addition to creating more resistant bugs, antibiotics have also been implicated in a rising number of unrelated diseases and disease-like states. The most well known of these is fatigue, mild to moderate gastrointestinal upsets, candida overgrowth (which can lead to other problems) and antibiotic allergy. However these are just the tip of the iceberg.

ANTIBIOTIC SIDE-EFFECTS Antibiotic use has been associated with severe skin rashes (Contact Derm, 1996; 35: 116-7), seizures (Lancet, 1991; 338: 259), psychosis (Am J Med, 1991; 90: 5289) facial paralysis (BMJ, 1994; 309: 1411); metabolic abnormalities mimicking Bartter's syndrome (Cancer, 1984; 54: 808-10; Am J Kidney Dis, 1986; 7: 245-9) and other renal abnormalities (Lancet, 1995; 345: 732-3; Nephrol Dialysis Transplant, 1994; 9(Suppl 4): 130-4; Am Fam Phys, 1996; 53(1): 227-32); severe diarrhea and pseudomembranous colitis (Gut, 1987; 28: 1467-73; J Infect Dis, 1985; 151: 476-81; Clin Ther, 1991; 13: 270-80; BMJ, 1985; 290: 1112). Only recently MRSA has been found in the stools of those with post-antibiotic entercolitis (Lancet, 1993; 342: 804).

ANTIBIOTICS AND OTHER DISEASES Antibiotics have been implicated in unrelated diseases and disease-life states. Australian doctors report that flucloxacillin, a semi-synthetic penicillin, can cause cholestatic jaundice (Med J Aust, 1989;151: 701-5), though it is thought that its relation to the drug may largely go unrecognized because of a delayed onset (Lancet, 1992; 339: 679). Older patients and those receiving flucloxacillin for more than two weeks are most at risk (BMJ, 1993; 306: 233-5). These are not new findings. Liver damage associated with this antibiotic was first noticed in the Netherlands and reported in 1982 (Neth ] Med,1982; 25:47-8) and has been reported again and again (Drug Safety, 1996: 15(1): 79-85). Newer combination antibiotics such as Septrin, a combination of trimethoprim and sulphamethoxazole, sometimes known as co-trimoxazole, have been linked with disfiguring skin rashes and blisters (Ind J Derm, 1982; 48:207-8; Br J Dermatol, 1987; 116: 241-2; Dermatol, 1986; 172: 230-1), and a host of HIV like symptoms including anemia, loss of appetite, nausea, vomiting, numbness, convulsions, chills, fever, swollen glands and ulcers in the mouth, eyes and urethra. Its use has also been associated with adverse effects on kidney function in renal transplant patients (Lancet, 1984; i: 394-5).

There has been a suggested link between antibiotic use, particularly the penicillins, and the development of diabetes (Lisa Landymore-Lim, Poisonous Prescriptions, 1992, PODD), epileptic seizures (J Neurosurg,1993; 78(6): 938-43) and Crohri s disease (HepatoGasteroenterol, 1994; 41(6): 549-51). Antibiotic eyedrops have been shown to cause aplastic anemia (Drug Safety, 1996; 14(5): 273-6; Br J Opthamol, 1996; 80(2): 182-4).

ANTIBIOTIC USE AND BRAIN DAMAGE IN CHILDREN Children are on the receiving end of so many antibiotics these days. One of the most disturbing links are those between antibiotic use and possible brain damage. Recently a survey of youngsters between the age of 1 and 12 years by the Developmental Delay Registry has found that those who had taken more than 20 cycles of antibiotics in their lifetime were 50 per cent more likely to suffer developmental delays. Children who have had three rounds or fewer were half as likely to become developmentally delayed (Townsend Letter for Doctors, October 1995).

In the same vein, an American doctor has discovered a link between high functioning autism and at least three doses of broad spectrum antibiotics such as Augmentin and Ceclor. Normal development can be arrested overnight at between 18 to 30 months (Townsend Letter for Doctors, January 1995). While the medical profession may remain sceptical about such a link, the experience of parents says otherwise. Sally Smith wrote to WDDTY to say that her son Luke fell ill with a respiratory infection when he was 17 months old and was prescribed amoxycillin. After taking the drug he "lost his vocabulary. In fact he did not speak again for almost eight years." She now runs the Tomatis listening therapy centre specifically for children with developmental delays or similar problems and says in the last three years she has encountered at least 200 other children who have been similarly affected.

Another reader wrote that when her 4-year-old daughter was given antibiotics as a precaution, "Her fat metabolism went haywire. Her heart was affected. After six months she was skin and bones, and I feared the worse. Later her adult teeth were affected, as was her liver. I could go on at length." In one study from Iceland among children aged 7, researchers found a close link between the level of antibiotic prescribing and antibiotic-resistant pneumonococci. Of 919 children recruited for the study, nearly 50 were carrying either penicillin-resistant or multi-resistant pneumonococci (BMJ,1996; 313: 89791). Pneumonococcus is the bug responsible for pneumonia, meningitis, sinusitis and otis media (middle ear infection).

ANTIBIOTICS AND HEARING LOSS Doctors first made the connection between antibiotic use and hearing loss in children in the 1980s. By 1990 about a third of all ear infections in young American children were due to pneumonococcus, and nearly half those cases involved strains which were resistant to penicillins (Morbidity and Mortality Weekly Report, 1994; 43: 216-23). Today it is thought that up to two-thirds of all cases are caused by the overuse of antibiotics such as streptomycin and gentamicin (BMJ, 1996; 313: 648). There has also been a marked increase in the incidence of hearing loss among children in the developing world, and it is thought that up to two-thirds of cases are caused by the indiscriminate use of antibiotics (BMJ, 1996; 313:648).

WHAT DO WE DO ABOUT ANTIBIOTIC OVER-USE? Unfortunately stopping the use of antibiotics is not necessarily the answer. Although it is commonly assumed that once "antibiotic pressure" is taken away, most organisms will lose their resistance, a research team from Emory University has shown otherwise. They tested this hypothesis on a strain of streptomycin-resistant E coli. After 135 generations the researchers found that offspring still had a high degree of streptomycin resistance (Nature, 1996; 381: 120-1).

As a cause of death, infectious diseases are still outranked by heart disease and cancer, but the numbers are rising (JAMA, 1996; 275(3): 243-6). The big questions are no longer those pondered in movies such as Outbreak. It's not Ebola, Machupo or Lassa which are likely to do us in. The bugs which will be our downfall are more likely to be less glamorous: pneumonococcus, tuberculosis, streptococcus and staphylococcus, escherichia coli, salmonella - all bugs which, 20 years ago, our microbiologists were confidently predicting would be eradicated by the end of the century. Medical literature about antibiotics is infused with the language of war. We "fight", "combat", "vanquish" and "annihilate". We are involved in a "chemical arms race". We require "more effective strategies" and draw "battle lines" (and, almost inevitably, we "lose").

There is no easy answer to the problems which antibiotic over-use throw at us. But, for those who wish to maintain the "miracle" for when it's most needed the issue is very simple: the more you use it, the faster you will lose it.

PREVENTION IS BETTER THAN CURE! Prevention is better than cure. The stronger your immune system is, the less likely it is that you will succumb to any kind of bug. Following a good daily programme of a wholefood diet, supplement with VIRAPHEND™, stress reduction through good-quality sleep, will make you less prone to viral illness. Also make sure that "infections" like ear ache are not the result of allergies. If you do get an infection: Consider herbal alternatives. Many botanical preparations have significant antibiotic actions against bacteria, viruses and fungi. These preparations generally enhance our own body's natural defence mechanisms.

For parasites. If you are suffering from the gastrointestinal effects of the cryptosporidium parasite which has made its way into London's water supply it is possible to take a mixture of Artemesin annua (wormwood), clove and black walnut tincture - this is a combination used by Dr. Hulda Clark for eliminating all sorts of parasites from the body. The walnut tincure and wormwood kill the parasites, and the cloves kill the eggs. If it's a virus... antibiotics will be useless.

If you must take antibiotics: Your general level of health will influence how well you respond to both illness and the scattergun mechanism of many broad spectrum antibiotics. So, in addition to the above, consider these points for safer antibiotic use. Make sure you actually have a bacterial infection. It is unlikely that your condition will worsen while you await test results and don't let your doctor pressure you into taking antibiotics which you do not want or may not need.

Ask your doctor to show you the Data Sheet Compendium information on his chosen antibiotic so that you can see for yourself the possible side effects. Steer clear of combination antibiotics which seem to have more side effects. If possible, go for the oldest and most tried and tested variety, which also are less likely to cause mutation in the environment. Take plenty of probiotics. While you are taking antibiotics and for a time afterwards make sure you take high levels of lactobacillus acidophilus and bifidobacteria which will replace friendly bacteria destroyed by the antibiotics.

Finish your prescribed course of antibiotics. If you break off treatment prematurely, you may only have killed off a proportion of those microbes sensitive to your antibiotic. This alters the balance between sensitive and resistant microbes, giving resistant microbes the upper-hand. Eventually these will multiply and dominate the culture in your gut (or wherever). The next time you get ill it will be much harder to treat the infection.

KICKING THE ANTIBIOTIC HABIT At the front line of this battle are GPs. Although most GPs are aware of the wider implications of over-prescribing, it is still very difficult to find ways of helping them break the antibiotic "habit" (GP, February 26, 1993). There is a disturbing trend towards blaming patients for antibiotic overuse. It's the fault of the overanxious mother whose child has an ear infection or the businessman with the common cold who does not wish to take valuable days off work who are pressurizing overworked doctors into doing "something".

There is no doubt that patients can work with doctors in a kind of unholy alliance, but pointing the finger of blame is a little too simplistic and ignores the fact that as much as two thirds of antibiotic prescribing is "entirely irrational" (see Harris Coulter, The Divided Legacy-A History of the Schism in Medical Thought, The Centre for Empirical Medicine, 1995). There is evidence that our doctors (like many of us) are creatures of habit and simply overwhelmed by the sheer number of antibiotics on the market and far too reliant on drug companies for "education" about their efficacy (N Eng J Med 1993; 328: 1047). Clearly, education of doctors and consumers is the best way to break the cycle.

Doctors need to be motivated to keep their knowledge of resistance up to date and, as one journal suggests, improve their communication skills in order to better explain the relatively small gain to be had from antibiotic use. For instance, with a sore throat you have a 90 per cent chance of being symptom-free in seven days whether or not you take antibiotics; with antibiotics you have a 50 per cent chance of being symptom-free on day 3 rather than on day 3 1 / 2. (Med J Aus, 1992;156: 644-9). Patients need to be given reliable information like this and encouraged to trust that they will get better by themselves, albeit a little bit more slowly. Antibiotic drug abuse may be a world-wide problem, but it is still best tackled at the local, individual level.