The Antibiotic Resistance Problem Revisited

Abstract

Mr. C was a wealthy 49-year-old Argentine businessman who was generally too busy to see a physician when he felt ill, preferring to treat himself with antibiotics and other drugs he purchased at his local pharmacy. He experienced intermittent periods of coughing, fever, and fatigue for several weeks, finally consulting his physician who found small bleeds under Mr. C's skin, and decided to run blood tests. The diagnosis was leukemia, and Mr. C sought treatment in Boston. The diagnosis was confirmed, and appropriate treatment for his leukemia and a bacterial infection, the source of the high fever, was begun. After 10 days of chemotherapy for the leukemia, no abnormal cells were seen in his blood. A bone marrow test on Day 17 showed that he had responded to the leukemia treatment and was on his way to remission. However, the Escherichia coli infection responsible for his high fever was proving intractable. Lab results revealed that it was resistant to eight different antibiotics, including the newer cephalosporins. On Day 20 Mr. C lost consciousness due to an intracranial bleed, and on Day 22 he died. Autopsy results showed no trace of leukemia, but multiple sites of E. coli infection. His intestinal tract had become an incubator for the development of antibiotic resistant organisms, including the E. coli which led to his death (Levy, 2002). Mr. C obviously had no difficulty in simply walking in to a pharmacy and purchasing over-the-counter antibiotics, and most likely received little guidance as to antibiotic selection and course of treatment. In his case, this practice undoubtedly was a significant factor in his death. Over-the-counter (OTC) availability of antibiotics is a problem in nations other than Argentina. Amabile-Cuevas (2003) estimates that approximately 30% of antibiotic purchases in Mexico City drugstores are OTC, and in the U.S. soldiers often buy antibiotics intended for treating aquarium fish to save money. E. coli is by no means the only microbe associated with antibiotic resistance. The Centers for Disease Control and Prevention list several other diseases and pathogens associated with this public health problem (see Table 1). The problem remains a serious public health concern responsible for two million nosocomial (hospital-acquired) infections/ year in the U.S. at an excessive treatment cost of six billion dollars/year (Vecchione & Sipkoff, 2007) and resulting in 100,000 deaths/year. Compared with hospital-acquired infections, the numbers of community-acquired infections from antibiotic resistant organisms are much more difficult to estimate. While Mr. C's story illustrates the serious nature of the antibiotic resistance problem, similar tales of the significance of infection with antibiotic resistant organisms abound in the literature. * Shane Matthews, former Chicago Bears starting quarterback, underwent surgery for a hernia repair in 1999. He acquired a methicillin-resistant Staphylococcus aureus (MRSA) infection while in the hospital, spending three months in the hospital fighting the infection. He survived, but lost 30 pounds and much of his strength in the battle. It took him almost two years to regain his strength (Levy & Fischetti, 2004). * Salmonella typhimurium DT104, has been responsible for three major human outbreaks in the U.S. since 1996, all of animal origin. This organism often carries multiple resistance determinants, evidenced by the Food and Drug Administration's isolation of one strain carrying resistance to 12 different antibiotics (Walters, 2003). * More than two billion of the world's six billion population have latent tuberculosis, including 10-15 million Americans. Eight million active cases are diagnosed globally each year. In the tuberculosis epidemic in New York City from 1979-92, over one-third of the cases were multi-drug resistant (MDR-TB). The city's response included local screening programs, Directly Observed Therapy-Short Term (DOTS) clinics, improved health care in city jails, plus quarantine for some patients (only 11 % completed therapy voluntarily) at a total cost of over a billion dollars (Markel, 2004). …