We’ve all heard by now that the post antibiotic apocalypse is coming if we don’t do something to preserve our antibiotic supply. Whether you’re a medical professional or a member of the public, you’ve been impacted by the concept of antibiotic stewardship (a fancy term for ensuring we have effective antibiotics to treat our grandkids with).
A classic headline warning us all of the post antibiotic apocalypse. Source: https://www.cbc.ca/news/health/superbug-deaths-1.4429406
Antimicrobial stewardship promotes the judicious use of antimicrobials to limit the development of antimicrobial resistant organisms. Antimicrobial stewardship programs support coordinated interventions designed to improve and measure the appropriate use of antimicrobials including selection, dosing, duration of therapy and route of administration. source: https://www.publichealthontario.ca/en/health-topics/antimicrobial-stewardship
As a pharmacist, I’ve spent many hours learning about the spectrum of action of antibiotics such that given a particular infection, we choose an antimicrobial with the narrowest spectrum of action first, preserving the hard hitters for more severe and dangerous bugs. As the last person to see a potential prescription before it gets to a patient, it’s important for me to know how to spot inappropriate antibiotic use.
The logo for the professional resource and educational group Do Bugs Need Drugs Source: http://www.dobugsneeddrugs.org/
As a member of the public you’ve likely been impacted as well. Popular educational campaigns by the website http://www.dobugsneeddrugs.org/ can be found on the back of buses in cities and plastered all over the walls of doctor’s clinics and hospitals. Or perhaps you’ve been to the doctor in awful condition assuming you’d get an antibiotic only to be told that the infection is viral and you’d have to wait out the symptoms?
Every year the Canadian government spends a staggering amount trying to tackle the problem of antimicrobial resistance. The current figure is $1.4 Billion per year, spent funding projects to study resistance patterns, educate members of the public, lawmakers and healthcare professionals alike. That cost is expected to increase if we don’t change the way we approach this problem substantially.
“The Canadian report’s findings on the economic and social toll of antimicrobial resistance are stark. Currently, the problem costs the national health-care system $1.4 billion a year, and by 2050, that figure is projected to grow to $7.6 billion, the report says. The cost to GDP is expected to jump from $2 billion to up to $21 billion annually.”
As an engineer, taught to rigorously study systems problems and find effective solutions, here’s what I see:
The current antimicrobial stewardship program is Odie, I am Garfield.
The current antimicrobial stewardship program is producing some results, no doubt. But given the predicted increase in cost referenced above, it’s not doing enough. In my humble opinion, we’re focusing too much on the wrong part of the system-the prescription of drugs. We’re just blindly accepting that our population will get a certain amount of infections per year, and then spending our time educating prescribers about recognizing viral infections, and prescribing the most narrow spectrum agent when appropriate. But what if we looked a bit more upstream for a solution?
we should be focusing more on reducing the need for antibiotics, rather than solely focusing on the downstream process of prescribing those antibiotics.
The relationship between an unhealthy population and increased antibiotic use, which begs the question: Shouldn’t we take a look at those burgers?
In the image above, I point out the relationship between an unhealthy population and antibiotic use, employing the image of a tasty burger to represent the myriad of factors that are contributing to lowered immune status in our population. Other important factors are the impact of stress and sleep to name a few, but in the interest of time, I’m going to focus on food choices.
The western diet and the immune system:
The paper referenced below does a great job of explaining the effect of food choices on the immune system. The author even breaks the evidence down between human studies and animal studies. The image taken from the same paper shows how poor food choices lead to the down regulation of our immune system through gut inflammation and dysbiosis leading to leaky gut.
A particularly powerful statement from the study explains that obese individuals actually have fewer, and less effective white blood cells available to fight infection:
Obese individuals have fewer white blood cells to fight infection and those cells they do possess have reduced phagocytosis capability [11,12]. While a complex interplay of hormonal, metabolic, and immunologic processes contribute to the biologic responses in the obese the resultant immune dysfunction increases the risk of infections of the gums, respiratory system, and of surgical sites after an operation
What does the data say about our antibiotic use?
Now that we’ve reviewed the mechanisms through which poor food choices contribute to lowered immune status, we can look to the data to see if those mechanisms show up in our population. To do that, I looked to the following paper from the Journal of Antimicrobial Chemotherapy:
This paper, published in 2017 sheds some unnerving light on the use of antibiotics in our western culture. The study, performed by the UCL Institute of Health Informatics looked at the frequency of antibiotic prescribing amongst different patient groups in the UK. They surveyed the data from ~1.9 million people across more than 300 medical clinics and found that over half of the antibiotics prescribed in primary care were for only 9 percent of patients!
“Individuals with heart failure, asthma or peripheral arterial disease were prescribed 53%–69% more antibiotics than individuals without these conditions. Compared with the general population, diabetics and individuals with coronary artery disease were prescribed 47% more antibiotics. Obesity, stroke and chronic kidney disease were all associated with more than a one-third increase in rates of antibiotic prescribing compared with individuals without these conditions.”
What patients, made up those 9%? Patients with comorbidities including asthma, coronary artery disease, chronic kidney disease (CKD), COPD, diabetes, heart failure, obesity, stroke, peripheral arterial disease (PAD), and smokers. The paper cites that individuals with diabetes and coronary artery disease ALONE, were prescribed 47% more antibiotics than the general public.
Note that obesity, while represented as it’s own medical condition in the paper, contributes greatly to most of the other 10 conditions listed. The only two conditions not directly related to obesity are are smoking and asthma. But wait! Asthma is an autoimmune condition! Refer back to the image from the Western Diet article and you will see autoimmunity being driven by poor food choices leading to dysbiosis!
conclusion: the most effective antibiotic stewardship begins with the diet.
The bad news: The burden of obesity far outstretches our waistlines, leading to increased antibiotic prescribing and threatening the longevity of our antimicrobial supply.
The good news: We have a clear upstream target to focus on: nutrition!
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