The World Health Organization has issued a rare health alert on a flu-like respiratory illness that has killed at least nine people and sickened 500 others, most of them in Asia. Experts working on the surveillance teams report that Severe Acute Respiratory Syndrome, or SARS, as it is known - has not responded to antibiotics.
If SARS turns out to be caused by a bacterium, public health officials will face an even larger problem - the declining effectiveness of antibiotics in the fight against bacterial infections.
University of Michigan medical historian Howard Markel says that when an antibiotic is used incorrectly, when people take too small a dose, for example, or for too short a time, bacteria can mutate or import drug resistance from other bacteria.
"So that if you prescribe them in a 'willy-nilly [haphazard fashion] or teat yourself, very frequently people will get a virus for which antibiotics do nothing," he said. "Antibiotics kill bacteria, not viruses. What you are doing [with misuse] is that you are creating resistant strains. Or [you are] helping to create resistant strains of bacteria which then can spread throughout the community which can cause more problems because we no longer have antibiotics that will work or be effective against those new strains of germs."
Before antibiotics became available, millions of people died routinely from staph, strep and tuberculosis infections. Penicillin, introduced during the Second World War treated battlefield infections like gangrene, septicemia and pneumonia. Within a few years, resistant bacteria began to appear. Easy access to these drugs is partially to blame. Antibiotics are readily available over the counter at pharmacies in many countries. Even in the United States, where the law requires a doctor's prescription illegal trade,in antibiotics is a growing problem.
About 1,000 patients a week seek medical care at Settlement Health, a clinic that serves Spanish Harlem, a New York City neighborhood populated by immigrants from central and south America and Mexico. Dr. Jaime Lopez-Santini has worked there for seven years. He says his patients bring with them the medical folklore from their homeland. "[They think] that antibiotics are good for everything," said Dr. Lopez-Santini. "That's what they think. Every little thing that they have they [think they] can take antibiotics, especially a common one around here is Ampitrex in their countries. They take Ampitrex for every little thing. Back pain they take Ampitrex. Earache, headache, they take Ampitrex, and they think that is what is taking care of the problems. And when you give them something like Tylenol or Motrin or Advil or any over the counter stuff, they say, 'This is not good enough. You didn't give me a prescription for it,' or they just go buy it somewhere else without prescription."
Skirble: What can you do as a doctor in this community?
Lopez-Santini : We try to educate people a lot. We try to educate them on the use of antibiotics or misuse of antibiotics. Let us say that you really have an infection and instead of ampicillin that you can get in the bodega (small market) you need something stronger. You took it for nothing and you can get sick and end up in the hospital because you took the wrong medicine. So it is good for you to come to the doctor and see the doctor when you feel sick.
Skirble: Why do you think this message is such a hard one to communicate?
Lopez-Santini : I think it has to do with a lot of things. There are myths. Family members tell them to forget about it; Ampitrex will take care of it. You don't need to see the doctor for this. There is an economic situation. People don't have money. They don't know that places like us [Settlement Health Clinic] exist. And, then the other issue is that people are scared of places like us will report to immigration and some other places and they say they prefer to go to the bodega and get it there and then I don't have to go to the doctor and show my ID [identification]. Bodegas are small Hispanic markets where drugs like Ampitrex are sold over the counter, no questions asked. Immigrants supply the bodegas with antibiotics - which they import illegally - as personal items. University of Michigan medical historian Howard Markel says U.S. customs agents - officers charged with curbing illicit drugs and crime on U.S. borders - rarely seize these medications. "It is an issue of priorities, and I would argue that this is a huge priority," he said. "That if we lose the ability to treat infections with our antibiotics because we are overwhelmed by resistant strains of germs, we have really gone backward in probably the greatest achievement in modern medicine, which is the conquest of infection."
Howard Markel says antibiotic overuse cuts across social class and education. Patients ask their doctors to prescribe these medications when they feel sick, whether or not they have a bacterial infection. "The evidence that we have for that, if you take a very common germ, Streptococcus pneumonia," he added. "That is a very commonly acquired germ. It is the leading cause of community acquired pneumonia. It is the leading cause of Strep throat. Thirty-five percent of all strains of Strep pneumonia in the United States are resistant to penicillin, ampicillin and similar drugs like that."
But Howard Markel says that over the past decade, physicians have become more reluctant to prescribe antibiotics. "For example, pediatricians: you get a million [patients coming in with] ear infections," he said. "If you don't get ear infections you shut up your practice. And, we are not treating every ear infection as we used to with an antibiotic. In fact there are good studies to show that 80 percent of all ear infections will get better without an antibiotic. So, [to sum up] the doctors are changing their practices slowly but surely."
Howard Markel says people must be educated about the proper use of antibiotics, not only for themselves but for the sake of others at risk of infection by drug-resistant bacteria.