Can Antibiotic Resistance Cause an Antibiotics Shortage?

A bit like climate change, small effects accumulate. Changes go unnoticed and then they tsunami.

Such is the case with antibiotics. If we all use the same drugs again and again without being careful, bacteria can just collect genes that resist the antibiotics we have. Because of this, bit by bit, the antibiotics we thought we could rely on may stop working, making common infections dangerous.

Keeping antibiotics working protects a common good.

Using lots of antibiotics, especially when not needed, may use up a shared resource—antibiotics that work. The more we use and misuse them the more we risk a day when antibiotics just won't work anymore.

What Is Antibiotic Resistance?

Antibiotics are drugs used to treat bacterial infections. They do this by inhibiting further growth and expansion of the bacteria or by killing them directly.

Antibiotic resistance means that bacteria have the capacity to continue to grow in the presence of a drug that would normally kill or limit their growth. This makes it harder for us to fight off infections. In this case, antibiotics, which would normally help us fight off the bacteria, do not help us—or do not help us as much as we need them to.

Drug resistance does not mean that the bacteria are now suddenly stronger. They do not become "Super Bugs" that are super strong. They just become drugs that antibiotics can't touch - or at least, can't do enough to stop.

 Sometimes resistant bacteria are actually weaker; sometimes they are the same. Resistance just means that the bacteria can now continue to spread despite a drug being deployed that would usually eliminate or hold back these bacteria. 

What does Antibiotic Resistance mean for us?

We've relied on antibiotics since the 1940s to treat infections caused by bacteria.

 Infections that used to be deadly, but now are just a nuisance, could return. A simple UTI or mild pneumonia could kill. Gonorrhea might just last and last. A mild injury or a simple cut could become a debilitating bone infection. Diseases now mostly in children's story books can come roaring back. 

The worry is that 10 million people a year could die across the world by 2050 from antibiotic-resistant infections. That's more than are lost to cancer each year. This would lead to all sorts of problems. There could be a drop in the GDP. We could be left unable to provide other medical care, like surgery or chemotherapy, that rely on antibiotics.

Already, there's a big problem. In the U.S. alone, each year, two million are infected with drug-resistant bacteria. At least 23,000 die yearly in the U.S. from such infections.

    How Do Resistance Develop and Spread?

    • Not all Antibiotics kill all Bacteria. To begin with, there are many, many types of bacteria. Some bacteria live on our skin. Some sit in our stomachs. Others tend to end up in our intestines. Some can spread in our blood. Others can infect our throats. Some cause sexually transmitted infections. Still others sometimes make it into the area surrounding our brains, causing meningitis.

      Some are called gram-negative, some are called gram-positive. This depends on how their outer surface appears and how they absorb dye when viewed under a microscope. The classification explains how the bacteria will respond to antibiotics. Certain classes of antibiotics just don't ever work on certain types of bacteria. This is without the bacteria acquiring any resistance genes; this resistance is intrinsic to the bacteria.
    • Bacteria Can Pick Up Resistance: In other cases, antibiotics can become ineffective and "resisted" when bacteria have a chance mutation - or receive a gene - that allows them to carry on, despite the presence of an antibiotic. ​
    • These mutations can just be the result of chance mutations. Some antibiotics just need a simple (non-harmful) mutation for them to be useless; bacteria may rapidly gain mutations and resist these antibiotics. Not all drugs easily become obsolete. Some require more complex mutations or collections of mutations; these drugs may last longer.
    • Resistance genes can - by natural selection - become more common. Sometimes some bacteria, but not all of the bacteria, carry resistance genes. When bacteria are exposed to a treatment, those bacteria that have the resistance genes will multiply, while the bacteria without the genes do not do as well. As a result, suddenly, the population of bacteria includes many bacteria that can resist the drug used, while not as many that can succumb to it. 
    • Resistance genes can also spread from bacteria to bacteria. They can spread from mother to daughter cell or when bacteria have sex and spread antibiotic resistance genes from one to another. The genetic material that contains resistance can be on the main chromosomes or on plasmids, separate pieces of genetic material. Sometimes genes spread by seemingly jumping from bacteria to bacteria through transposons, jumping genes that can insert themselves into a new place in the genome.
    • There's a whole ecosystem of bacteria out there with all sorts of genes. Resistance genes can exist and persist in bacteria without being "under pressure" from any antibiotics. The resistance genes can appear among bacteria before the antibiotic does. This means that it's important to stop less dangerous bacteria from developing resistance, as these bacteria can spread resistance to more dangerous bacteria. It also means that in sewage systems or even our own guts—places where there are many different types of bacteria—that bacteria can mix and match resistance genes, developing new patterns of resistance to antibiotics.

    How Does Resistance Spread? 

    Resistance among people can also spread in several ways.

    • Food Animals: Antibiotics used in humans, or similar antibiotics, are often used in animals. Antibiotics are often given as growth promoters. That is to say, they are given in small doses to many animals, but not for any specific infection. This means a lot of bacteria are exposed to a small level of antibiotics. Those bacteria that can resist the antibiotics are selected out. This results in drug resistance in bacteria among farm animals. Bacteria resistant to antibiotics can spread to those who handle these animals and those who prepare and cook the meat produced (and if not properly prepared and cooked, those who eat the meat as well).
      Even when not the exact same drugs are used in animals, bacteria often develop and collect resistance genes that work against the antibiotics in people.
    • Using Antibiotics when Antibiotics aren't needed: Antibiotics are often given "just in case." A viral infection that won't respond to antibiotics is given an antibiotic. At the end of life, antibiotics may be given in an Intensive Care Unit even when they serve likely no benefit to the patient. Around the world, street side pharmacists hawk antibiotics; people buy them to self-treat or to treat friends and family members. The antibiotics used may have little impact on the infection if the wrong antibiotic is chosen or if the infection were not bacterial. However, this constant exposure to antibiotics increases the chance that of the millions of bacteria we carry with us, those with drug resistance will be selected and multiply. These bacteria may be harmless (or helpful) but the genes these bacteria carry can spread to other bacteria that are actually harmful and now drug resistant. The more we expose people to antibiotics, the more we risk losing this important tool.
    • Using the Wrong Antibiotic when Antibiotics are needed Resistance can also develop when infections are treated empirically. That is to say, a doctor might examine a patient and based on symptoms give a standard antibiotic - but without actually having a laboratory ensure that this is the bacteria being treated. Without testing to double check, we may be giving antibiotics that aren't needed. It may be that a different bug caused the illness than the one the doctor thought. It might be that the bug has developed resistance - or is less responsive to the antibiotic chosen. As such, we may be increasing the chance of developing resistance without actually helping the patient.
    • Using the Right Antibiotic But Not for Long Enough It's hard to take medications. It's easy to forget them. Sometimes folks don't finish their antibiotics, taking only a few days. They may stop because they felt better or because they didn't better. They may want to save the drug. They might not understand the instructions. They might also not want anyone to know they are taking drugs. There's a lot of reasons but not everyone takes antibiotics they way they should have. Under-dosing antibiotics - from a short course or not enough doses - can allow resistant organisms to be selected for.
    • Spreading Resistance from One Patient to Another It's easy to spread bacteria. Our hands are covered in bacteria. Our guts are full of bacteria. If health professionals, other caregivers, or family, friends, and visitors do not follow the proper precautions, resistant bugs can spread from one patient to another. This means washing our hands to make sure we don't spread infections. This can mean using alcohol disinfectants and soap and water. It also may mean using gloves, as well as gowns, gloves, and masks depending on the bacteria present.
    • Using Antibiotics we need Antibiotic resistance can even occur when drugs are used exactly as they should. Antibiotics make people better. They can treat Life-threatening infections and annoying ones like acne and skin infections. They can prevent infections - like malaria and certain infections in AIDS patients or those with certain heart conditions.  These frequent - though needed - uses will also lead to the possibility of developing drug resistance. We need to always be on guard to avoid watching resistance spiral out of control.

    Antibiotic Resistance Can Be Natural

    In the environment, bacteria and other microorganisms are sometimes at war. Their weapons naturally can actually be antibiotics. We have commandeered these tools. The first antibiotic we used was penicillin - which mold used against bacteria. But sometimes these natural means of resisting bacteria can be a problem. These genes can spread in the environment.

    Antibiotic Resistance Can Be Reversed

    Bacteria without resistance can predominate again. Sometimes, when antibiotics are no longer given, the population returns to normal—or seemingly so. It's possible that a small percentage of resistant bacteria remain. 

    New Antibiotics Can Be Developed

    Sometimes new antibiotics, which require different resistance genes to be overcome, are needed. Developing new antibiotics is expensive. It's not easy to develop a totally new chemical that can stop an infection and not harm the person. 

    Investment and commitment are needed for the expensive and intense process of developing a new drug. Increasingly, governments and large-scale donors are realizing the need to develop the environment in which drug development will flourish.

    Some think other innovative approaches, like the use of Phages, may be the answer, instead of looking for more and more drugs.

    Antibiotic Resistance Worldwide

    Although antibiotic resistance is found where antibiotics are used—and not everyone has access to antibiotics—resistance is a global phenomenon.

    It is thought that by 2050, the countries hardest hit by drug resistance will include those in Africa and Asia. Of the 10 million who might die from drug-resistant infections, it would be expected that both Africa and also Asia would see over four million deaths each. No other continent would be expected to have even one million deaths.

    Antibiotic sales, often in private clinics or by a roadside salesman, are not regulated in much of the world. They may not require a prescription; the increasing use of antibiotics has led then to high rates of antibiotic resistance.

    Even cholera, a type of bacteria that disproportionately affects the poor as it attacks those who don't have access to clean water and good sanitation, has been found to have drug resistance genes to the most expensive of antibiotics.

    This calls for a global collective effort to control the management of this limited resource.

    Drug Resistance often requires specific laboratory testing for us to even know it's there. Oftentimes, this testing is not available or not accessed. As a result, we don't even know the full magnitude of the problem. In many parts of the world, there is little known about how much drug resistance there is; as we learn more, we realize how terribly common antibiotic resistance is. To fix the problem, we'll need a real investment. 

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