On Antibiotic Resistance

I completed my family practice residency in Latrobe in 1999. In my last year our practice admitted three cases of rheumatic fever to hospital. I was the senior resident on two of those cases. Rheumatic fever comes from an untreated strep throat infection. The bacteria can cause damage to the nervous system, the joints, and the heart. My first admission was an 11 year-old girl with chorea, that is she could not control the movement of her arms which swung involuntarily in broad arcs. My second admission was a 14 year-old junior state wrestling champion with valvular heart damage; upon discharge the cardiologist on the case advised the family that he should wrestle no more. In the age of antibiotics rheumatic fever is rare, so at this point our residency director was in a panic, and he requested an investigation into how we practiced medicine from the Infectious Disease Department at The University of Pittsburgh Medical Center (UPMC). We were a cutting edge residency that practiced modern medicine which meant that we followed the advice of the Infectious Disease experts against “overprescription” of antibiotics as this led to the rise of antibiotic resistance. Resistance was such a major problem that we were not allowed to prescribe certain antibiotics, particularly Cipro, without authorization from an attending physician.

Not surprisingly. UPMC gave us a dean bill of health as we were prescribing in the fashion they recommended. But the residents knew there was something wrong; the community physicians around us never saw rheumatic fever because they ignored the advice of the experts. The patients in our residency were trained not to come in with cold symptoms because they were not going to get antibiotics, so they stopped wasting their time. But the patients could not tell the difference between a viral illness and a strep infection, hence strep was left untreated to a much higher degree in our residency than in the surrounding community. A century ago another strep infection called scarlet fever was a common killer of children. The reason we no longer see thing such scarlet fever, and rheumatic fever, and mastoiditis from chronic ear infection is due to the “overprescription” of antibiotics.

Yes , we are in a race with the germs, and the bugs will ultimately win as they evolve quickly, unless genetic medicine really fulfills its potential. But are doctors really to blame? The drug companies invest almost nothing in antibiotic research as there is little money in it. The NIH wants to cure cancer and AIDS to achieve politically correct renown, so there is little money for bacterial infection research. And why Cipro? We do not prescribe it nearly as much as say Amoxicillin or Bactrim. The answer occurred to me in 2012 while reading a report on the chemicals found in drinking water from the Potomac River. At the top of the list was an antibiotic used in industrial farming that is almost identical to Cipro. In 2012 more than 28 tons of antibiotics were used for livestock compared to less than 7 tons prescribed by physicians. And what about the steroids used to plump up the livestock before slaughter? Are they the cause of the early puberty that we are seeing?

– Gary Gallo, MD