Editorial
Antibiotic Crisis - A Time Bomb?
Belle M Hegde,
MAHE Deemed University, Manipal, India
Nearly seventy years ago, when A l e x a n d e r
Fleming and Professor Florey discovered a moldy
growth on their culture plates to be a powerful
antibiotic, penicillin, a new era began in medicine.
The predictions then were, as usual, that the end of
man’s fight against germs on this planet is drawing
closer. Like all other predictions in linear science,
this one has also been belied. Doctors have been
predicting the unpredictable all these years[1]. That
in itself is not bad! But we are now facing a new
and formidable threat in that many of the germs
that were initially sensitive to antibiotics have now
become resistant and threaten to annihilate man
from this planet. One example would suffice. One
common germ, the stre p t o c o c c u s, was the most
sensitive germ to be killed by penicillin. While 95%
of these germs could be easily killed by penicillin to
begin with, today 95% of the same are resistant to
penicillin.
The history of this universe is very closely
connected to human births and deaths, but illnesses
do change history much more dramatically
compared to the former two. The black death due to
plague in Europe in the sixteenth century and the
white death (so called because it killed most people
with extreme anemia and mostly young
adolescents in particular) of tuberculosis (TB), have
been the greatest tragedies of mankind.
Tu b e rculosis still eludes a cure despite our
euphoria after the advent of antibiotics against the
germ Mycobacterium tuberculosis.
In fact, it has become much more rampant and
dangerous now that AIDS abets and assists the
former to ravage human life. Tu b e rculosis has
assumed a different form these days because of the
changing circumstances[2]. Historical milestones of
tuberculosis include the hunchbacks of Egyptian
mummies, the phthisis (wasting) of the Greeks, and
the English consumption of the lay public. Most
diseases respected wealth and status to a certain
extent, but plague and TB did play truant even with
the rich and the famous from time to time.
Address correspondence to:
Prof. B. M Hegde, Manjunath, Pais Hills, Bijai, Mangalore - 575004, India. Tel: +91 824 221 7575. E-mail:
[email protected]; web:
www.bmhegde.com
The gravity of the situation is such that the
Royal College of Physicians of London organized a
meet to discuss the ‘Clinical Implications of Antimicrobial
Resistance’ on the 28th February 2001. It
has been estimated that around 15,000 people die in
that small country every year from infections
against which no antibiotic is effective. Such of
those germs that are resistant to most antibiotics are
called the ‘super bugs’ and, as of now, we have no
defense against them. One of the biggest hospitals
in that country, Portsmouth Hospitals NHS Trust
was forced to shut down most of its operating
theatres last summer because of the super bugs. At
the Queen Alexandra Hospital, the orthopedic
surgeons could not perform any operation around
that time. Another leading authority in the field,
P rofessor Hugh Pennington of A b e rd e e n
University, feels that the next big problem would be
that of drug resistant tuberculosis. They had an
outbreak of TB in Scotland recently, traced to a
traveling family. He also feels that the Russian
prisons have many inmates who have dru g
resistant TB without proper treatment. Since TB
does not respect geographic borders this time bomb
might explode anytime anywhere!
The usual thinking in the West was that this
kind of uncontrolled infectious disease scenario
could exist only in the poor countries like India and
sub-Saharan Africa. They are now in for a great
shock. In a well researched book, ‘Betrayal of Trust:
The Collapse of Global Public Health’[3], Laurie
Garrett, from the USA, shows how the threat is not
confined to the poor countries but, is greater in the
West, basically because doctors there over-prescribe
antibiotics so that bacterial infections are becoming
i n c reasingly resistant to the most widely used
antibiotics. She writes that “doctors who overp
rescribe antibiotics undermine the health care
system by encouraging germs to become resistant.”
She is dead right there.
The blame must also come on the consumers,
the patients, as many of the latter, who think that
they are well informed, demand antibiotics for the
Kuwait Medical Journal 2005, 37 (2): 79-81
80 Antibiotic Crisis - ATime Bomb? June 2005
common trivial infections, most of which are viral
to begin with. This adds to the problem. Doctors
who follow ethics and refuse to give antibiotics are
not usually popular. The fear of losing the patients
makes many doctors to oblige patients with overprescribing.
Educating the public about the serious
dangers of taking antibiotics for minor infections
against medical advice should go a long way in
reducing this menace.
Studies in the US have shown that it is the rich
kids that suffer more from ear infections and other
common childhood infections. Since antibiotics are
very expensive, the poor parents do not bother to
give them to their children for minor illnesses. This
helps the poor child to fight the infection with the
help of its own immune system and, in the bargain,
the child develops immunity against major
infections. This has another very dangero u s
ramification to it. Antibiotics given to minor viral
illnesses of childhood make the immune system
change its response to infection in such a way that
the cytokine response to infections, based on their
genes, changes from TH1 to TH2[4]. The latter is the
most important trigger for asthma in later life. The
slum dwellers’ kids, when they have enough to eat,
have very robust health and have a very low
incidence of asthma and many other common
illnesses. Whenever they do not thrive, it is only
because they do not get enough nutrition in their
diet.
The other dangers of antibiotics are in
c o m m e rcial fields like farming and the diary
industry. Broiler sheds use a lot of antibiotics to not
only treat the infections in chicks but, also in the
fond hope of preventing infections in them. The
amount of antibiotics used in cattle and broiler
sheds far outweighs all that is used in hospitals and
operation theatres! Today it only takes six weeks to
get a bird on the dining table from the egg stage,
about half the time normally required. The farmers,
therefore, make double money and the birds come
cheaper. But it means that we get a huge dose of
antibiotics each time we bite a chicken lollypop!
This does not take into account the added hazards
of excessive hormones fed to fatten the birds. In
short, we are only eating a slow poison[5].
Mastitis in cows is another danger. The
incidence is around 10% of the cows in a dairy on a
given day! The huge amount of antibiotics, like
ciprofloxacin, injected into the udder (one udder
dose costs $ 250) makes the milk not potable for a
week. But the farmers might use the milk earlier to
reduce loss of money. So the milk that we drink
from large pools in larger dairies might also contain
unacceptable doses of antibiotics[6].
The House of Lords in Britain was worried
about the large-scale abuse of antibiotics in farming
and spoke of a “vicious circle repeatedly witnessed
in which the value of each new antibiotic has been
p ro g ressively eroded by resistance.” Very dangero u s
indeed! In a shocking incidence recently at the
Prince Edward Hospital in Wales a patient had an
infection in his leg wherein the germs were
resistant to all the antibiotics available. Doctors had
to go back to Nature to get maggots to help cure
that infection! [7]. Now they are routinely culturing
maggots to treat resistant infections. In Nature, this
is a very common way of controlling bacterial
infections, evident even during the Second World
War and earlier.
Minor wounds could be smeared with fresh,
clean honey. Honey gives a coating to the wound to
prevent germs getting in and the germs already
there are prevented from multiplying, as honey
stops the nutrition needed for growth and multiplication
in the germ world. Therefore the existing germs die
out and the new ones cannot get in.
The time bomb of tuberculosis is threatening to
burst anytime now. The West is in the middle of the
worst TB epidemic in the last twenty years.
Tuberculosis never went away. It was only lying
low because we depended on the powers of the
anti-TB antibiotics too much and did away with the
methods to enhance the capacity of the immune
system as we used to do before the advent of
antibiotics. Sanatoria, good food, complete rest, and
a healthy environment were given up as useless.
Surgery, which in the olden days, helped to get rid
of the infected part of the lung, thereby reducing
the risk of death and bleeding, took a back seat.
Now we are threatened by the MDR, multiple
d rugs resistant germs, of this deadly disease,
waiting to produce another epidemic of the white
death. Thomas Dormandy in his treatise ‘The White
Death’[8] gives us the horror stories of the hoary past
with even people like Napoleon Bonaparte having
suffered its ravages.
TB is no respecter of status, position or even
money power for that matter. Many were the
victims such as leaders, poets (Keats was the
leading one), writers, soldiers, beggars, children,
adults, mothers and also the medical and nursing
p rofessionals. Many careers had to be either
terminated or changed in mid-waters when TB
struck. Things could be gloomier with the added
b u rden of AIDS reducing the potency of the
immune system of man. Vaccination against TB
came and went without much fanfare. May be we
need to look more carefully into this aspect of TB
prevention.
This article should alert all good Samaritans
about the time bomb ticking away threatening to
explode any time now. While I am sure the
situation is worse in India, I have no scientific data
June 2005 KUWAIT MEDICAL JOURNAL 81
for the whole country to give you the true picture.
The earlier we wake up from our deep slumber, the
better for our progeny. We have never been using
antibiotics scientifically for well over half a century
and the results could be disastrous to say the least.
Professor J R Bignall of the Institute of Chest
Diseases (Brampton Hospital, London) was
requested by Nehru’s government in India in 1956
to study the TB situation in the country. He came,
he saw and then he gave a very sane suggestion.
The anti-TB drug situation at that time was very
pathetic with very few drugs trickling into the
country and being abused by even quacks. Dr
Bignall wrote to the government suggesting that
the 2,50,000 odd TB patients in the country at that
point in time should be allowed to have the
conventional treatment available then. The use of
anti-TB antibiotics should be banned in the country
for ten years! His scientific reasoning was that those
that die of the disease would die anyway and take
the germs with them to be burnt or buried, ending
the germ’s life cycle. Rest of the patients who
survive, their immune system would kill the germs.
In the following ten years, India would have been
rid of TB germs. With hindsight, it looks like God’s
advice.
The same advice could have worked even for
the West. Leaders of the time in India ridiculed this
report in the Parliament and rejected it. The results
are there for all of us to see. “Truth” said Aristotle,
“could influence only half a score of people in a
given time or age, whereas falsehood and mystery
would drag millions by the nose”. How true?
There is also the brighter side of antibiotics.
Many have been saved from the jaws of death by
antibiotics but, the number is dwindling daily. The
famous story of the great British Prime Minister,
Lord Winston Churchill, the son of a Nobleman, is
very interesting. As a boy Winston was drowning
in a marshy patch and was struggling for his life
with no help in sight. Afarmer in the neighborhood
heard the cries of the desperate boy and went over
to help him. Thus saved, Winston thanked the
farmer pro f u s e l y. The following day Wi n s t o n ’ s
father came by to compensate the poor farmer for
his noble deed. The modest farmer refused any
money and told the elder Churchill that he was
only doing his duty. However, the elder Churchill
insisted in helping the son of the farmer, same age
as Winston, to get good education in Oxford ,
which, in the normal course, the farmer’s son could
not have afforded. Later in life when Sir Winston
C h u rchill was seriously ill with pneumococcal
pneumonia it was the same farmer’s son, by then
Nobel Laureate Alexander Fleming, who came with
his penicillin to help pull Sir Winston from the jaws
of death. Irony of fate indeed! But the story now is
totally different. Arecent report from the US shows
how nosocomial infections alone kill more than
80,000 people in American hospitals in one year[9].
This is the long and short of the story of the
germ and man, the two friends, that depend on one
another for better or for worse.
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2) Breathnach AS, de Ruiter A, Holdsworth GM, et. al. An
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hospital. J Hosp Infect 1998; 39:111-117.
3) Garrett L. Betrayal of Trust-The collapse of the Global
public health. 2000. New York, Herpion.
4) Culpepper L, Froom J. Routine anti-microbial treatment for
otitis media-is it necessary? JAMA1997; 278:1643-1645.
5) Doolittle WF. You are what you eat: a gene transfer rachet
could account for bacterial genes in eucaryocytic nuclear
genomes. Trends Genet 1998; 14:307-311.
6) Davies J. Inactivation of antibiotics and dissemination of
resistance genes. Nature 1997; 389:924.
7) Handworth B. Maggots treat as they eat. National
Geographic Newsletter. 2003, October 24.
8) Dormondy T. The White Death. 1999, Hambledon Press,
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