[HN Gopher] What was the Golden Age of Antibiotics, and how can ...
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What was the Golden Age of Antibiotics, and how can we spark a new
one?
Author : surprisetalk
Score : 60 points
Date : 2024-12-23 15:24 UTC (3 days ago)
(HTM) web link (ourworldindata.org)
(TXT) w3m dump (ourworldindata.org)
| chiph wrote:
| Stop administering them whenever anyone gets a sniffle so they
| stay effective longer. Also firmly separate veterinary antibiotic
| classes from human antibiotics so that the ones intended for
| humans stay effective longer.
| Spivak wrote:
| The problem with a policy like this is that in practice rich
| people will get antibiotics whenever they (we? hn is well off
| enough to cont as rich for this perk) want and everyone else
| suffers. It will for sure also summon the racist underbelly of
| the US where doctors will believe white sympathetic patients
| when they say how long they've been sick and question everyone
| else. This will deal double damage if you try to enforce any
| kind of quota.
|
| I can afford to go to a nice doctor who will prioritize my
| comfort and who will literally tell me what to say to meet the
| criteria but anyone with less choice will have to fight.
| whatshisface wrote:
| Judging the need for antibiotics is not some kind of
| personality quiz, bacteria can be cultured. (I'm not sure why
| they don't usually do it.)
| trallnag wrote:
| Takes time and costs money. Problematic for an already
| strained health care system. And as a patient I prefer to
| get treated immediately for my painful skin infection
| instead of waiting a day or so for results to arrive
| queuep wrote:
| Sure, but on a global scale the rich are a small percentage
| of the world population.
|
| Some countries are very restrictive on prescribing
| antibiotics (almost too strict) and it feels like it falls
| flat as you can get it over the counter in a lot of places.
| _zoltan_ wrote:
| In Switzerland it's tough to get antibiotics unless you
| absolutely need them. Even when I had a lung issue for 2
| weeks I had to beg to get antibiotics. Weird. And they are
| not available over the counter.
|
| In Hungary, on the other hand, they hand them out like
| candies.
|
| So yes, the solution was to import them from Hungary. :-)
| epcoa wrote:
| > get antibiotics unless you absolutely need them.
|
| Yes that's exactly how it should be. They are not at all
| benign misprescribed.
|
| > Even when I had a lung issue for 2 weeks I had to beg
| to get antibiotics.
|
| Was there any evidence of a bacterial infection or did
| they just give in? 2 weeks is not a long time for a viral
| respiratory illness either.
| _zoltan_ wrote:
| they didn't give in, but I actually checked hospital
| internal guidelines for doctors, and it states 3 weeks.
|
| They could have done some more tests or whatever, as it
| was maybe the worst lung issue I've had and I was really
| miserable. I knew that antibiotics would help, and they
| did. I sourced them myself.
|
| You could say lucky guess, but after I complained to my
| health insurer about the bad doctor's visit, they covered
| the cost fully without any dispute, so they must have
| agreed with me with at least about maybe running some
| more tests...
| gus_massa wrote:
| If it was "only" [1] a viral disease, it should dissapear
| even without antibiotics after a week or two. So perhaps
| your body solved the problem alone, while you took
| antibiotics that had no effect.
|
| This is a real posibility and is a real problem to test
| how useful the medicines are. So all serious studies use
| a control group [2] to compare the rate of spontanous
| healing with the rate of healing with the antibiotic.
|
| [1] Some virus are very nasty and can kill you. People
| confuse the common cold andd the flu, but usualy the flu
| is much worse.
|
| [2] Preferabely a preregistered double blind randomized
| control group, becuse there are a lot of other problem
| that can cause a false result.
| dillydogg wrote:
| I find this is so frustrating to describe to patients.
| There really is a limited scope of appropriate outpatient
| antibiotic use.
| trallnag wrote:
| What kind of evidence are you expecting? Many diseases
| are treated with antibiotics without definitive evidence
| via some kind of test. Often, evaluating symptoms is
| deemed sufficient. For example, in the case of
| Erysipelas, an infection of the skin
| epcoa wrote:
| The commenter did not expound on any specific evidence
| that would suggest a bacterial lung infection. 2 weeks of
| malaise and non specific upper respiratory symptoms is
| not strong evidence of a bacterial pneumonia, sorry.
|
| For external infections, observation by visible
| inspection is still evidence, a sign, not a symptom. So,
| not sure what your point is. Erysipelas is invariably
| diagnosed by signs, not symptoms. Very rarely are
| bacterial infections diagnosed by symptoms alone.
| trallnag wrote:
| The difference between symptoms and signs was unclear to
| me. Just checked. Thanks
| epcoa wrote:
| > I can afford to go to a nice doctor
|
| If your doctor is giving you antibiotics for clearly viral
| illnesses they are doing a disservice to you, it isn't
| actually nice. It's not like I've ever seen some systemic
| withholding of antibiotics when they are clearly indicated -
| quite the opposite, some of the worst areas for resistance
| are the poorest. They aren't without other side effects,
| resistance being only one.
|
| Also you have it backwards, the racist thing to do is to just
| prescribe the antibiotics, since they are dirt cheap, cost me
| (the provider) nothing, and makes the person whose skin color
| I possibly don't like get out of my office faster (if not
| racism, pragmatism to see too many patients). Racism alone is
| not necessarily the only explanation, but antibiotic over
| prescription/use tends to be associated with poverty.
|
| Well run antibiotic stewardship is a conceit of the most
| affluent health systems.
| PessimalDecimal wrote:
| > It will for sure also summon the racist underbelly of the
| US where doctors will believe white sympathetic patients when
| they say how long they've been sick and question everyone
| else.
|
| You're trying to shoehorn an unfounded accusation of racism
| into a discussion about antibiotics. This sh*t is tiresome.
| Spivak wrote:
| We're not talking about antibiotics, we're talking about
| policy. And any discussion of policy requires systems level
| thinking. I'm not accusing anyone of racism, I'm white and
| reasonably affluent idgaf, I genuinely believe the policy
| being proposed would be selfishly better for me personally.
|
| This is the reality of medical care _right now_ in the US
| what are you talking about?
|
| https://www.hopkinsmedicine.org/news/articles/2021/06/physi
| c...
|
| The existing bias in the medical system along with policy
| that asks doctors to doubt more patients has a pretty damn
| predictable outcome.
| HeatrayEnjoyer wrote:
| That isn't true at all.
| chmod775 wrote:
| > I can afford to go to a nice doctor who will prioritize my
| comfort
|
| If they actually do, they'll probably not give you
| antibiotics, which are associated with many undesirable short
| and long-term health outcomes.
|
| Taking antibiotics for mere short-term "comfort" is utterly
| insane.
| PittleyDunkin wrote:
| > Stop administering them whenever anyone gets a sniffle
|
| This hasn't been true for most of my life and it remains a
| serious concern.
|
| Not to mention antibiotics often come with seriously nasty side
| effects of their own, so you as the patient even wanting the
| best outcome shouldn't even necessarily want antibiotics.
| foobiekr wrote:
| It is not an issue in the US.
|
| It is a massive, massive issue in some very large countries.
| PittleyDunkin wrote:
| Ahh yes, very fair.
| ipaddr wrote:
| It is still a big issue in the US even if it is more
| massive elsewhere plus we use it in the meat industry to
| the point where certain types of antibiotics cannot be used
| anymore.
| fnordpiglet wrote:
| In most of the world, by population, the regulatory structure
| of society is so weak that there is no way to achieve this.
| Antibiotics are available without prescription, licensed
| doctors of skill are rare, and patients are insistent on
| antibiotics for everything. In most developed countries doctors
| are already parsimonious with antibiotics and generally won't
| prescribe them unless an infection is observable. But in most
| of the developing world it's prevalent to over administer
| antibiotics either through clinics are directly at the
| unregulated pharmacies.
| AyyEye wrote:
| > In most developed countries doctors are already
| parsimonious with antibiotics and generally won't prescribe
| them unless an infection is observable.
|
| Antibiotics as 'consolation prizes' is definitely a thing.
| AngryData wrote:
| Yeah ive seen it myself, and part of it is driven by
| people's demands and expectations to receive treatment when
| they go to a doctor. Even if they go for very minor
| sniffles, many people will not return to the same doctor
| later if they are given nothing other than what boils down
| to "stop being a wimp and rest for a few days because
| nothing I do is going to actually help." Especially when
| the visit itself comes at a decent cost to the patient (in
| the US atleast). So doctors who overprescribe medication
| are more profitable for their owners and have higher demand
| from patients and are incentivized to do so, while doctors
| following the science more closely will be less profitable
| and have lower demand.
|
| Better education on health and healthcare would help, but
| certainly not come anywhere near eliminating the incentives
| to over prescribe versus under prescribe antibiotics and
| medications. Perhaps more placebo medications could help,
| but that has its own litany of problems in making people
| believe they are receiving a medication when they are not,
| and numerous patients might view it as being scammed even
| if a placebo is the best thing that could be given to them.
| christkv wrote:
| At least in the EU they have reduced prescriptions a lot.
| They don't write antibiotics prescriptions if you have
| bronchitis unless you have a fever or if it does not improve
| over a span of days. 10 years ago they would just give you a
| wide spectrum antibiotic.
|
| They still suck on just taking a swab and culture.
| PessimalDecimal wrote:
| Overuse and misuse of antiobiotics isn't really a US thing.
| https://resistancemap.onehealthtrust.org/AntibioticResistanc...
| is a nice, interactive map showing where the majority of the
| resistant strains are found. Any effort to curtail the emergence
| of antibiotic resistant bacteria will require coordinated global
| action, which means it's highly unlikely to happen.
| api wrote:
| Agricultural overuse is also a major vector.
| bsder wrote:
| So why is India such a resistance hotspot?
| samarthr1 wrote:
| Lax enforcement on class H drugs (the non otc, but not
| addictive stuff), which spans combiflam to augmentin...
|
| We also have pharmacists who act as doctors in a pinch and
| reccomend drugs.
| fakedang wrote:
| > We also have pharmacists who act as doctors in a pinch
| and reccomend drugs.
|
| Honestly this is a very granular problem I think, simply
| because doctors are so expensive in quite a few
| locations. Wherever doctors are affordable or accessible,
| I've never seen a pharmacist play doctor and push their
| medication. Kerala, Himachal, Goa, places with good
| accessible govt clinics and hospitals, etc.
| metalman wrote:
| wrong the over prescribing and agricultural use of antibiotics,
| started and was definitly more prevelant in the US. Largely due
| to wealth and availibility. And in fact ALL of the modern
| chemical agriculture practices that have "unintended
| consequences" got started in the US. Over use of pestisides,
| herbisides, and fertilisers. That other countrys followed
| after, at the prompting of US govrnment trade policy , and to
| the benifit of US industry, is hardly grounds to shift blame.
| What would be relevant, is a map, a nice interactive one, that
| overlayed profit flow, from the areas where "resistent strains"
| are found. This and many other of the worlds problems can be
| summed up, under the heading of "exporting contradictions" and
| reaping the profits. DDT is still made in the US, for export
| only.
| nimish wrote:
| Do we need one? Quarantine them from the countries that can't or
| won't enforce discipline on prescription and the problem solves
| itself.
| bigmadshoe wrote:
| Insane take. What about the people with life threatening
| infections in those countries? Just collateral damage?
| voidfunc wrote:
| Sucks to be them?
| Findecanor wrote:
| You could argue that in that case the people deserving the
| most blame would be the people in charge for that country's
| medical system not having implemented proper antibiotic
| discipline to qualify for the antibiotic.
|
| The same rules would have to apply to all.
| BriggyDwiggs42 wrote:
| Why would we condemn a population of innocents on the basis
| of bad leaders. This is very bad logic; it leads to very
| bad things.
| old_king_log wrote:
| This poster has +2551 karma. Stay classy HN.
| aurizon wrote:
| Doctors and their 'fee for service' mentality are, in part, at
| the roof of this. They know an antibiotic is a waste of $$ for a
| viral disease, but the money meter ticks upwards.
| nradov wrote:
| There are problems with the fee-for-service financial model but
| this isn't one of them. The doctor will be paid the same for
| the office visit regardless of whether they prescribe or not.
| The money for any antibiotic goes to the pharmacy, pharmacy
| benefit manager, and pharmaceutical company.
| eszed wrote:
| You're neglecting customer loyalty, and patient throughput. A
| doctor who (correctly) says "there's nothing I can do for
| you; ger some rest and you'll get better" will be seen as
| "uncaring" and patients will de-register from their practice.
| They'll also have to spend time arguing / "educating"
| obstreperous patients, and earn less. A doctor who writes a
| (perhaps unwarranted) prescription finishes the visit faster,
| and gets better patient reviews.
|
| I'm not making this up. A medical provider up-thread made
| this point.
| nradov wrote:
| That's a separate issue unrelated to the fee-for-service
| financial model. The same issue would still exist under any
| model where patients can pick their providers, including
| capitated VBC.
| aurizon wrote:
| Makes me wonder why there is such a death grip on the fee
| for service model?
| nradov wrote:
| Fee-or-service is the simplest and lowest risk model for
| providers. Anyone can submit a claim using a standard EDI
| transaction or paper form. Capitated models only work for
| larger health systems that can deliver most common
| services under one roof, and that have the necessary IT
| and actuarial competence to price risk for a patient
| population accurately. There is an emerging set of
| technical standards which can make this a bit easier.
|
| https://www.hl7.org/about/davinci/
| aurizon wrote:
| Yes, ignorant clients 'beg' the magic bullet.
| aurizon wrote:
| Practices are usually very granular and are tracked in
| detail, so increments for this/that abound. I suspect they
| would gather this low hanging fruit.
| fnordpiglet wrote:
| I think the UN or governments themselves should get into the
| business of bad business medicine. The fact drug companies are
| prioritizing research of chronic medications is an obvious
| outcome of our current structure. The government or quasi
| governmental organization can continue to subsidize industry
| research and buy licenses for discoveries they then productionize
| at cost. This wouldn't directly compete with industry and it
| would incentivize public private research across large areas of
| otherwise unprofitable areas of medicine such as this.
| evrimoztamur wrote:
| This is what the Turkish government has been up to and it has
| driven drug costs, and therefore overall costs of healthcare
| provision and insurance, down. More countries should
| nationalise production of generics, it works.
| selimthegrim wrote:
| Does the cost of letting everyone see a specialist whenever
| they want cancel that out?
| sfn42 wrote:
| It's well known that the US healthcare system costs more
| for the taxpayer than single payer systems, while also
| bankrupting those unfortunate enough to get hurt/sick and
| requiring ridiculous monthly payments for the individual on
| top.
|
| So I wouldn't worry about that. Healthcare is not nearly as
| expensive as US providers make it. Single payer systems
| aren't perfect either but from my perspective having lived
| with one my entire life it works fine. I have always gotten
| the help I need in reasonable time. I also have private
| options if I want to spend money, and they're far cheaper
| than private options in the US. But so far I haven't felt
| any need for it. A colleague was recently diagnosed with
| testicular cancer, he was admitted for surgery within a few
| days and back to work in a few weeks. Didn't cost him
| anything.
|
| And just to reiterate - this is cheaper _per capita_ , just
| comparing tax costs, than the US system and that's ignoring
| insurance premiums and copays etc.
| selimthegrim wrote:
| I was talking about Turkey specifically where it's
| driving specialists to leave the country
| ajmurmann wrote:
| If everyone did this, how would it impact creation of new
| drugs?
| evrimoztamur wrote:
| New drugs to solve new problems or old problems better
| would continue receiving protections, and the incentives
| would remain in place.
|
| How do you think about the nationalisation of generics of
| existing drugs being detrimental to new drugs' development?
| xyzzy123 wrote:
| We also need regulation (and effective enforcement) as much as
| research.
|
| Even if you discover a groundbreaking new antibiotic under
| current incentives it's going to get fed to pigs in China until
| it's useless.
|
| Arguably the kinds of antibiotics we need the most are ones
| with significant side effects; effective enough that they can
| save humans but with side effects that are severe enough that
| they are not over-prescribed or fed to livestock.
| dartos wrote:
| > Arguably the kinds of antibiotics we need the most are ones
| with significant side effects
|
| I don't think there can be a better example of perverse
| incentives than this.
| raincole wrote:
| > the kinds of antibiotics we need the most are ones with
| significant side effects
|
| What? Absolutely not. The patients would have a very strong
| incentive to not finish the whole course of treatment.
| shellfishgene wrote:
| These are typically only used in the hospital after all
| else fails.
| duskwuff wrote:
| Right. Only a small fraction of antibiotics are regularly
| prescribed for outpatient use; a lot of the more
| "serious" antibiotics (like vancomycin, for instance) are
| primarily given as IV infusions in an inpatient setting.
| skyyler wrote:
| Why call out Chinese pigs specifically? American meat farms
| also overuse antibiotics...
|
| Do Chinese farms do it more / worse?
| mft_ wrote:
| Agree, on two fronts.
|
| Firstly, while pharma collectively spends a lot of money (many,
| many billions) on drug discovery and development, in the grand
| scheme of collective global governmental spending, it's not so
| very much. If the (e.g.) 20 richest nations got together and
| shared out the cost according GDP it wouldn't be too much for
| them to bear at all.
|
| Secondly, as a race we're currently very bad at 'global'
| cooperation, especially if it requires 'vision'. Even when
| there's a strong incentive to cooperate across borders (like,
| say, an immediate threat from a global pandemic) we mostly
| sucked. And even relative success stories coming out of the
| pandemic, like the development of mRNA vaccines spectacularly
| quickly, had less to do with global coordination and
| cooperation than might have been the case. It would be
| wonderful to start to address this broad topic, and the
| constant threat from antibiotic resistance would seem like a
| great place to start, before we get to the stage that any
| operation brings the threat of death by untreatable infection
| with it.
| johnea wrote:
| #1 thing that could be done in the US would be to stop using so
| many of them.
|
| Especially in agricultural animals...
| Faaak wrote:
| Sad that the article is not talking about bacteriophages[1].
| Basically viruses that infect other bacteria. The world is full
| of them (and even virophages: viruses that infect other viruses).
| The soviet union started experimenting them, and they seem to be
| used to treat hard-to-cure infections like Staphylococcus aureus,
| but I guess it died down somehow?
|
| [1]: https://en.wikipedia.org/wiki/Bacteriophage
| MoreMoore wrote:
| From the bits and pieces I've heard, the problem is one of
| scaling. Bacteriophages had to be made bespoke for a specific
| patient.
| dennis_jeeves2 wrote:
| I've heard that for stubborn cases it works really well. It's
| true it does not lend itself to mass manufacture the way
| antibiotics do but I believe, a typical lab with the right
| knowledge/equipment/resources should be able to do it. I saw
| a documentary a long time back where they do it Georgia, not
| sure how legit it is.
| dennis_jeeves2 wrote:
| >but I guess it died down somehow?
|
| I've heard that it lives on in Georgia.
| pazimzadeh wrote:
| Most new antibiotics come from soil bacteria. We got all the low
| hanging fruits, now you need to dig through tons of soil to find
| something new., Better culture methods would make it easier to
| run experiments instead of relying on genome rather than relying
| on /cloning/expression in E. coli.
| vouaobrasil wrote:
| Is there a danger that with more sophisticated antibiotics, we
| could eventually eradicate too much good bacteria?
| xandrius wrote:
| More sophisticated, I'd expect more precision not just more of
| the same (and bad) old.
|
| Now we just wreck havoc of absolutely anything which is a
| bacteria, it would be nice to be able to select the typology.
| cyberax wrote:
| This article misses several new antibiotic classes that are
| emerging: macrocyclic peptides, and a bunch of compounds from
| unculturable soil bacteria (clovibactin, teixobactin, etc.)
| christkv wrote:
| We have a whole arsenal of old antibiotics no longer in use that
| are candidates for redevelopment. As bacteria develop resistance
| to newer antibiotics they make evolution tradeoffs which bring
| back into play older antibiotics.
|
| https://pmc.ncbi.nlm.nih.gov/articles/PMC4242550/
|
| I think cocktails will be used (if they are not already in use)
| to attack the bacteria from different angles at the same time
| reducing the likelihood of developing resistance.
|
| Another thing is better protocols. More quick testing before
| prescription so you use more targeted antibiotics and reduce the
| use of wide spectrum antibiotics.
| wdwvt1 wrote:
| The comments on this article take for granted that agricultural
| use of antibiotics is a key driver of the emergence of
| antimicrobial resistance (AMR). This is an intuitive and popular
| explanation, but the magnitude of this effect is not well
| established.
|
| As an example, [0] is of the best reviews available on the
| contribution of non-therapeutic antibiotic usage in animal feeds
| to AMR. Despite the large amount of evidence cited, the authors
| can't conclude that a ban on animal use of antibiotic class X
| would lead to Y more years before resistance to X
| emerges/spreads.
|
| It seems well established that banning use of certain antibiotics
| as a feed additive would slow the emergence of resistance, but
| that magnitude of that effect seems totally unknown. There is
| perhaps a strong precautionary principle argument to be made for
| banning use of medically important antibiotics as feed additives,
| but we should be cautious in making any firm conclusions about
| how much that would impact the medically useful lifetime of
| existing or new antibiotics.
|
| In a similar vein, the idea that commercial prospects for
| antibiotic development are limited because agricultural use would
| cause fast emergence is not supported from what I can find. A
| very good recent paper [1] discussing failures of antibiotic
| development in the US in the last 20 years highlights trial,
| regulatory, and commercial hurdles as key roadblocks to
| successful commercialization of antibiotics.
|
| [0] https://journals.asm.org/doi/full/10.1128/cmr.00002-11 [1]
| https://www.nature.com/articles/s41599-024-03452-0
| at_a_remove wrote:
| I believe that this is a _technical_ issue now. In a more ideal
| world, procedure, legislation, regulation, protocols would be
| followed to slow the growth of antibiotic resistance, but there
| are just too many Defectors for that approach.
|
| It's in nerd hands now ...
| rganesan wrote:
| I posted to HN an article about 3 new antibiotics discovered in
| India and it didn't get much attention :-(.
|
| https://www.bbc.co.uk/news/articles/c80vrjkkrero
| ashoeafoot wrote:
| What need a cycle, as if a bug traverses immunity ,it looses
| resistance to the opposite of the cycle
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