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"Bacteria becoming completely resistant to treatment - also known as the antibiotic apocalypse - could plunge medicine back into the dark ages." Probably not,

"Bacteria becoming completely resistant to treatment - also known as the antibiotic apocalypse - could plunge medicine back into the dark ages." Probably not, for a number of reasons. The arms-race strategy of antibiotics vs drug resistance was doomed to fail from the start, as many know. The solution is counter intuitive: stop the arms race of stronger and stronger antibiotics completely, and the bacterial resistance to weaker antibiotics will be reduced over time. It's expensive for bacteria to keep antimicrobial genes around, and once the selective pressure of an antibiotic environment decreases, they'll lose the traits that confer resistance. It may even be possible to phase out one drug resistance trait at a time in multiple-drug-resistant populations. The horizontal gene transfer that the article mentions is really cool, but ultimately a non-sequitor when it comes to population-level infection control. This solution means temporarily accepting uncontrolled drug-resistant bacteria in some narrow cases, which is unpalatable, but this strat works in the petri dish.

iamthepieman 11y ago
This sounds like a great idea but your last line is a death sentence to it. I think it would take the apocalypse you are dismissing before the solution you are recommending could be implemented.
- stupidcar 11y ago
  You'd take an apocalypse where no antibiotics work, and everybody dies, against a solution where some antibiotics work, and some people die? Are you sure you've thought this through?
  - iamthepieman 11y ago
    My comment was not an opinion on the proposed solution. It was an opinion on the likelihood of such a solution actually being implemented by society.
mooreds 11y ago
Does "this strat" work when your father/mother/son/daughter is in the hospital? Or are you (and I include in "you" any human being with the choice) going to want every antibiotic available for your loved one? Maybe I miss the point of your comment, but if not, I doubt it is a viable strategy.
- zasz 11y ago
  This is one of the few fairly clear cases in real life where you could make a utilitarian argument, though. Sacrifice a few lives now to save more in the long run. I wouldn't want to be the government that has to dictate this policy, though. The guilt would be too much.
  - th0waway 11y ago
    You first! Seriously though, how do you chose who has to die, so that others may live?
  - cryoshon 11y ago
    Yep, that's my angle. Utilitarianism is king in epidemiology. We can pretend otherwise, but frequently our hand will be forced anyway. I don't know if we're going to need to "sacrifice" people who have poly-drug resistant bacteria, but I'm guessing it won't be in our control anyway, if the option is between doing nothing and the patients dying versus doing everything we can and still having the patient die. Damage control is critical, and sentimentality can't get in the way. FWIW, I wrote an in depth report on controlling poly drug resistant tuberculosis in poor countries when I was in college... the conclusion was that quarantine was not only necessary, it was the only effective course of action for people with full spectrum drug resistant TB. Of course, TB is far more infectious and lethal than garden variety "bacteria".
- arethuza 11y ago
  We had a very nasty experience where my teenage son got a bad eye infection and they had to try about five different antibiotics before falling back on something that is basically a simple antiseptic that eventually fixed the problem.
gus_massa 11y ago
Many of the antibiotics are variations of the natural antibiotics produced by fungus and other bacteria, so it's not a new arm race. It's clear that not all the bacteria become resistant to all the natural antibiotics, because it usually increase the metabolical cost. I think that in the long term this will be a draw, we will need to discover new antibiotics, some bacteria will discover new resistance. (For the more nasty variants we can have to use other tools like vaccines.)
- abandonliberty 11y ago
  After an explosion in the 80s and early 90s, antibiotic development ground to a halt as we 'won' the war. [1] Researchers and funding moved on to sexier things. From a capitalist perspective, it's much better to wait for resistant bacteria than produce yet another antibiotic in a crowded field. It's starting to pick up again. My money is on a continued battle until we develop nanomachines or wipe ourselves out. [1]https://en.wikipedia.org/wiki/Timeline_of_antibiotics https://en.wikipedia.org/wiki/Timeline_of_antibiotics
  - refurb 11y ago
    Only two truly new (new mechanism of action) antibiotics have been developed in the last 30-40 years. A number of new antibiotics were approved in the 80's and 90's, but I wouldn't say people thought we had won the war. The really challenging thing with antibiotics (as a reply below notes) is that if you create a great new antibiotic, nobody will use it unless they have to. There is resistance out there, but for most infections, the 40+ year old antibiotics work just fine. It's not like almost every other disease where the best drug gets used first line. Unless the financial incentives are fixed, it's unlikely there will be enough incentive to do the R&D to create new antibiotics.
    - kbenson 11y ago
      There was an interesting radiolab episode recently[1] about this. The information in this discussion is somewhat contradictory to it, but it paints both an interesting history of antibiotics, and has an interesting story about the possible future. 1: http://www.radiolab.org/story/best-medicine/ http://www.radiolab.org/story/best-medicine/
noir_lord 11y ago
Not entirely, we have a far better understanding of disease control, quarantine and aseptic practices. It's going to suck though for those people who have anything that is resistant to multi-spectrum antibiotic treatment.
JPKab 11y ago
This is a classic comment from someone who forgets that societies and governments don't work like cleanly controlled complex systems. In order for us to "stop the arms race for stronger and stronger antibiotics", we have to let people infected with resistant bacteria die. In droves. You would be all for this strategy until it's you, or your spouse or child sitting there being eaten alive by MRSA. You could tell your toddler that she's not dying for no reason, and that a few years from now the bacteria won't be as deadly. That'll make her feel better. Do you really think that this is even remotely realistic in any democratic society?
- sliverstorm 11y ago
  What about regulating which "classes" of antibiotics get used at least in the gross majority of cases? Different antibiotics have different pathways, much like barbituates and amphetamines have different pathways, despite both getting you high. Perhaps if we use only pathway "A" for a decade, bacteria will lose resistance on pathway "B" (and vica versa)?
  - howlin 11y ago
    Similar issue though. When class A fails, do you let your patient die, or do you try class B even though it's not supposed to be used this decade?
    - sliverstorm 11y ago
      So long as you can keep usage of class B very low, especially if you can quarantine anyone being treated by class B until they are not contagious, you don't have to prohibit all use.
- cryoshon 11y ago
  It's called quarantine. It's a valid tactic, though it's quite unpleasant for everyone. If the issue is really as serious as the article details, my plan is not so much of a "we can solve this problem if we do X" as much as a "this is the extreme approach required to mitigate the problem". The government will naturally default to this strategy if things are actually in danger of getting bad. Getting bad is defined as a drug resistant bacteria's ability to occasionally fell healthy normal people. I guess the alternative is to hand wave that us scientists can magically solve the decades-building problem that big-agriculture and doctors caused. Sure, we'll get right on it, but there needs to be a plan for the time between when research starts and when a new group of antibiotics is tested and ready for the market. Staged rotating/phasing out certain antibiotics so that they will be usable again after a period of time would ensure that there's something left in reserve for people who actually need it.
rwj 11y ago
The solution does not need to be that drastic. Stop using antibiotics as a placebo, stop using antibiotics in your household cleaning supplies, stop dosing livestock with antibiotics as a prophylactic, .... Part of the problem is that since antibiotics have been so beneficial we now over use them. This creates an environment saturated with antibiotics, which in turns drives evolution of resistance in bacteria. (tldr; household cleaners with antibiotics mean that when you do get sick, it won't be something that can be cured)
- adamwong246 11y ago
  antibiotics... in household cleaning supplies?! I don't think antibiotics work like that. Source?
  - secabeen 11y ago
    They're probably referring to Tricolsan, which does show up in hand soaps and other products: https://en.wikipedia.org/wiki/Triclosan https://en.wikipedia.org/wiki/Triclosan
    - adamwong246 11y ago
      http://ec.europa.eu/health/scientific_committees/opinions_layman/triclosan/en/index.htm#2 http://ec.europa.eu/health/scientific_committees/opinions_la... Ok, I see how the use of Tricolsan could lead to bacterial resistance. But just to point out what jeremyt said above, Triclosan is definitely not an antibiotic. But the effect is the same.
- jeremyt 11y ago
  I think you're confusing antibiotics with antibacterials. Using hand soap with triclosan has antibacterial properties, none of which contribute to antibiotic resistance. There are lots of reasons to quit using antibacterials in your house, and I have stopped, but contributing to the antibiotic resistance problem is not one of them.
  - 11y ago
mikeash 11y ago
How long does this temporary phase last, exactly?
clock_tower 11y ago
Short of such measures, I would wonder about using bacteriophages. They're creepy as anything, but they're less creepy than dying of untreatable bacterial infections...
Cass 11y ago
All these "back to the dark ages" worst case scenarios seem to assume that we'll wake up one day and realize that every single one of our antibiotics has stopped working on anything. That's not how it's going to happen. It only takes a few years for most strains of bacteria to lose their resistant traits, and we're going to have years of undeniable warning signs. (As opposed to the deniable warning signs we have now.) What's actually going to happen: We're going to have an epidemic of some sort of drug-resistant bacteria in the Western world--maybe that incurable TB that's going around, maybe something else. A few thousand Westerners are going to die--people the Western world actually cares about, as opposed to them poor people in them third world countries that are always dropping like flies anyway. There'll be a media hysteria similar to the Ebola crisis. People will suddenly realize that antibiotic resistance isn't just a problem affecting poor people in third world countries, but that it is now a problem threatening them and their children. The resulting media blitz will educate even the average idiot about the importance of taking the full course of antibiotics even if you feel much better already. Antibiotic use on lifestock will be banned. Western governments will pressure China and India into stopping the unrestricted sale of antibiotic. Western doctors are finally going to realize that prescribing antibiotics like candy just to shut a patient up is a mistake even if the patient is yelling really loudly. Developing a new antibiotic is sudenly going to be a lucrative or at least PR-relevant strategy for Big Pharma, instead of a likely fincancial loss. Hospitals are going to be forced to actually deal with the problem of MRSA. (Right now, many patients that should be tested and isolated aren't tested because there's no room to isolate them in case of a positive result.) Within a few years, drug resistance will taper off sharply, without antibiotics ever losing their use except in the case of a few rare resistant diseases, which will be tested for and isolated. Problem solved. These are all things we could do right now, if we wanted to, we just don't care about the problem enough. The moment it becomes big enough to interest the majority of the population, we know how to solve this.
JoeAltmaier 11y ago
Losing resistance is theoretical - bacteria have resistances to things that have been extinct for millennia. Knowing that, once there is resistance to an antibiotic, its no longer useful to restrict its use. The horse has left the barn; locking the door won't help. Yet folks continue to harp on 'restrict antibiotic use'. What have I overlooked?
crpatino 11y ago
This is factually incorrect. Even if antibiotics become less effective (they are not becoming ineffective, is just that resistant bacteria require higher doses, which start to become problematic from the side effects point of view). First of all, we will still have the Germ theory of Disease. Much of the early gains in lifespan from modern medicine came from the awareness of the correlation between cleanness and healthiness. For as long as we can support infrastructure for proper sanitation and disposal of dangerous agents, those gains will persist. Second, we will still have vaccination. Many dangerous diseases are kept at bay not by heavy use of drugs but by immunization the population instead. This technique is also subject to diminishing returns due to bacteria evolution, but the dynamics are different. Over use antibiotics and you end up with resistant diseases; reach full immunization and you root out the disease out of your population. Third, we have better palliative care now. Even if everything else fails, we are better prepared now to keep people alive long enough for their own antibodies to fight off most diseases. This will be shitty for our current expectations - to be able to take a pill and bounce back in a day or two. But it does not mean either that half of our children are going to die of colds or tummy aches or anything like that.

iamthepieman 11y ago

This sounds like a great idea but your last line is a death sentence to it. I think it would take the apocalypse you are dismissing before the solution you are recommending could be implemented.

stupidcar 11y ago
You'd take an apocalypse where no antibiotics work, and everybody dies, against a solution where some antibiotics work, and some people die? Are you sure you've thought this through?
- iamthepieman 11y ago
  My comment was not an opinion on the proposed solution. It was an opinion on the likelihood of such a solution actually being implemented by society.

mooreds 11y ago

Does "this strat" work when your father/mother/son/daughter is in the hospital? Or are you (and I include in "you" any human being with the choice) going to want every antibiotic available for your loved one? Maybe I miss the point of your comment, but if not, I doubt it is a viable strategy.

zasz 11y ago
This is one of the few fairly clear cases in real life where you could make a utilitarian argument, though. Sacrifice a few lives now to save more in the long run. I wouldn't want to be the government that has to dictate this policy, though. The guilt would be too much.
- th0waway 11y ago
  You first! Seriously though, how do you chose who has to die, so that others may live?
- cryoshon 11y ago
  Yep, that's my angle. Utilitarianism is king in epidemiology. We can pretend otherwise, but frequently our hand will be forced anyway. I don't know if we're going to need to "sacrifice" people who have poly-drug resistant bacteria, but I'm guessing it won't be in our control anyway, if the option is between doing nothing and the patients dying versus doing everything we can and still having the patient die. Damage control is critical, and sentimentality can't get in the way. FWIW, I wrote an in depth report on controlling poly drug resistant tuberculosis in poor countries when I was in college... the conclusion was that quarantine was not only necessary, it was the only effective course of action for people with full spectrum drug resistant TB. Of course, TB is far more infectious and lethal than garden variety "bacteria".
arethuza 11y ago
We had a very nasty experience where my teenage son got a bad eye infection and they had to try about five different antibiotics before falling back on something that is basically a simple antiseptic that eventually fixed the problem.

gus_massa 11y ago

Many of the antibiotics are variations of the natural antibiotics produced by fungus and other bacteria, so it's not a new arm race. It's clear that not all the bacteria become resistant to all the natural antibiotics, because it usually increase the metabolical cost. I think that in the long term this will be a draw, we will need to discover new antibiotics, some bacteria will discover new resistance. (For the more nasty variants we can have to use other tools like vaccines.)

abandonliberty 11y ago
After an explosion in the 80s and early 90s, antibiotic development ground to a halt as we 'won' the war. [1] Researchers and funding moved on to sexier things. From a capitalist perspective, it's much better to wait for resistant bacteria than produce yet another antibiotic in a crowded field. It's starting to pick up again. My money is on a continued battle until we develop nanomachines or wipe ourselves out. [1]https://en.wikipedia.org/wiki/Timeline_of_antibiotics https://en.wikipedia.org/wiki/Timeline_of_antibiotics
- refurb 11y ago
  Only two truly new (new mechanism of action) antibiotics have been developed in the last 30-40 years. A number of new antibiotics were approved in the 80's and 90's, but I wouldn't say people thought we had won the war. The really challenging thing with antibiotics (as a reply below notes) is that if you create a great new antibiotic, nobody will use it unless they have to. There is resistance out there, but for most infections, the 40+ year old antibiotics work just fine. It's not like almost every other disease where the best drug gets used first line. Unless the financial incentives are fixed, it's unlikely there will be enough incentive to do the R&D to create new antibiotics.
  - kbenson 11y ago
    There was an interesting radiolab episode recently[1] about this. The information in this discussion is somewhat contradictory to it, but it paints both an interesting history of antibiotics, and has an interesting story about the possible future. 1: http://www.radiolab.org/story/best-medicine/ http://www.radiolab.org/story/best-medicine/

noir_lord 11y ago

Not entirely, we have a far better understanding of disease control, quarantine and aseptic practices. It's going to suck though for those people who have anything that is resistant to multi-spectrum antibiotic treatment.

JPKab 11y ago

This is a classic comment from someone who forgets that societies and governments don't work like cleanly controlled complex systems. In order for us to "stop the arms race for stronger and stronger antibiotics", we have to let people infected with resistant bacteria die. In droves. You would be all for this strategy until it's you, or your spouse or child sitting there being eaten alive by MRSA. You could tell your toddler that she's not dying for no reason, and that a few years from now the bacteria won't be as deadly. That'll make her feel better. Do you really think that this is even remotely realistic in any democratic society?

sliverstorm 11y ago
What about regulating which "classes" of antibiotics get used at least in the gross majority of cases? Different antibiotics have different pathways, much like barbituates and amphetamines have different pathways, despite both getting you high. Perhaps if we use only pathway "A" for a decade, bacteria will lose resistance on pathway "B" (and vica versa)?
- howlin 11y ago
  Similar issue though. When class A fails, do you let your patient die, or do you try class B even though it's not supposed to be used this decade?
  - sliverstorm 11y ago
    So long as you can keep usage of class B very low, especially if you can quarantine anyone being treated by class B until they are not contagious, you don't have to prohibit all use.
cryoshon 11y ago
It's called quarantine. It's a valid tactic, though it's quite unpleasant for everyone. If the issue is really as serious as the article details, my plan is not so much of a "we can solve this problem if we do X" as much as a "this is the extreme approach required to mitigate the problem". The government will naturally default to this strategy if things are actually in danger of getting bad. Getting bad is defined as a drug resistant bacteria's ability to occasionally fell healthy normal people. I guess the alternative is to hand wave that us scientists can magically solve the decades-building problem that big-agriculture and doctors caused. Sure, we'll get right on it, but there needs to be a plan for the time between when research starts and when a new group of antibiotics is tested and ready for the market. Staged rotating/phasing out certain antibiotics so that they will be usable again after a period of time would ensure that there's something left in reserve for people who actually need it.

rwj 11y ago

The solution does not need to be that drastic. Stop using antibiotics as a placebo, stop using antibiotics in your household cleaning supplies, stop dosing livestock with antibiotics as a prophylactic, .... Part of the problem is that since antibiotics have been so beneficial we now over use them. This creates an environment saturated with antibiotics, which in turns drives evolution of resistance in bacteria. (tldr; household cleaners with antibiotics mean that when you do get sick, it won't be something that can be cured)

adamwong246 11y ago
antibiotics... in household cleaning supplies?! I don't think antibiotics work like that. Source?
- secabeen 11y ago
  They're probably referring to Tricolsan, which does show up in hand soaps and other products: https://en.wikipedia.org/wiki/Triclosan https://en.wikipedia.org/wiki/Triclosan
  - adamwong246 11y ago
    http://ec.europa.eu/health/scientific_committees/opinions_layman/triclosan/en/index.htm#2 http://ec.europa.eu/health/scientific_committees/opinions_la... Ok, I see how the use of Tricolsan could lead to bacterial resistance. But just to point out what jeremyt said above, Triclosan is definitely not an antibiotic. But the effect is the same.
jeremyt 11y ago
I think you're confusing antibiotics with antibacterials. Using hand soap with triclosan has antibacterial properties, none of which contribute to antibiotic resistance. There are lots of reasons to quit using antibacterials in your house, and I have stopped, but contributing to the antibiotic resistance problem is not one of them.
- 11y ago

mikeash 11y ago

How long does this temporary phase last, exactly?

clock_tower 11y ago

Short of such measures, I would wonder about using bacteriophages. They're creepy as anything, but they're less creepy than dying of untreatable bacterial infections...

Cass 11y ago

All these "back to the dark ages" worst case scenarios seem to assume that we'll wake up one day and realize that every single one of our antibiotics has stopped working on anything. That's not how it's going to happen. It only takes a few years for most strains of bacteria to lose their resistant traits, and we're going to have years of undeniable warning signs. (As opposed to the deniable warning signs we have now.) What's actually going to happen: We're going to have an epidemic of some sort of drug-resistant bacteria in the Western world--maybe that incurable TB that's going around, maybe something else. A few thousand Westerners are going to die--people the Western world actually cares about, as opposed to them poor people in them third world countries that are always dropping like flies anyway. There'll be a media hysteria similar to the Ebola crisis. People will suddenly realize that antibiotic resistance isn't just a problem affecting poor people in third world countries, but that it is now a problem threatening them and their children. The resulting media blitz will educate even the average idiot about the importance of taking the full course of antibiotics even if you feel much better already. Antibiotic use on lifestock will be banned. Western governments will pressure China and India into stopping the unrestricted sale of antibiotic. Western doctors are finally going to realize that prescribing antibiotics like candy just to shut a patient up is a mistake even if the patient is yelling really loudly. Developing a new antibiotic is sudenly going to be a lucrative or at least PR-relevant strategy for Big Pharma, instead of a likely fincancial loss. Hospitals are going to be forced to actually deal with the problem of MRSA. (Right now, many patients that should be tested and isolated aren't tested because there's no room to isolate them in case of a positive result.) Within a few years, drug resistance will taper off sharply, without antibiotics ever losing their use except in the case of a few rare resistant diseases, which will be tested for and isolated. Problem solved. These are all things we could do right now, if we wanted to, we just don't care about the problem enough. The moment it becomes big enough to interest the majority of the population, we know how to solve this.

JoeAltmaier 11y ago

Losing resistance is theoretical - bacteria have resistances to things that have been extinct for millennia. Knowing that, once there is resistance to an antibiotic, its no longer useful to restrict its use. The horse has left the barn; locking the door won't help. Yet folks continue to harp on 'restrict antibiotic use'. What have I overlooked?

crpatino 11y ago

This is factually incorrect. Even if antibiotics become less effective (they are not becoming ineffective, is just that resistant bacteria require higher doses, which start to become problematic from the side effects point of view). First of all, we will still have the Germ theory of Disease. Much of the early gains in lifespan from modern medicine came from the awareness of the correlation between cleanness and healthiness. For as long as we can support infrastructure for proper sanitation and disposal of dangerous agents, those gains will persist. Second, we will still have vaccination. Many dangerous diseases are kept at bay not by heavy use of drugs but by immunization the population instead. This technique is also subject to diminishing returns due to bacteria evolution, but the dynamics are different. Over use antibiotics and you end up with resistant diseases; reach full immunization and you root out the disease out of your population. Third, we have better palliative care now. Even if everything else fails, we are better prepared now to keep people alive long enough for their own antibodies to fight off most diseases. This will be shitty for our current expectations - to be able to take a pill and bounce back in a day or two. But it does not mean either that half of our children are going to die of colds or tummy aches or anything like that.