Too Much Of A Good Thing

LIKE ANY INTERNIST, DR. Robert Moellering of Boston's Deaconess Hospital has felt the pressure to hand out antibiotics on demand. When he served as director of student health services at Emerson College, he saw a steady stream of students with colds and flus, and many knew just which drug they wanted. Instead of dashing off prescriptions, Moellering would dutifully explain that their ailments were caused by viruses, and that no antibiotic however new or expensive can kill a virus. His campaign didn't get very far. As he now recalls, the kids would return days later waving bottles of pills in his face. "They'd tell me, 'My doctor said I almost had pneumonia'."

If the golden age of antibiotics is ending, the reasons should be no mystery. Bacteria gradually adapt to any antibiotic, and when one is misused, its power to heal is squandered. "If I give, my patient too much hypertensive medicine, I might hurt that patient but there's no way I'm going to hurt the next patient," says Dr. Frank Rhame, director of infection control at the University of Minnesota Hospital and Clinic. "If I use an antibiotic too much, I'm making it less useful for everyone." Unfortunately. doctors have been slow to act on that insight. Confronted with a miserable patient, they tend to write a prescription. Antibiotic sales are soaring as a result (sales have nearly doubled since the mid-1980s). and so are drug-resistant infections.

The misuse of antibiotics isn't a new problem. Since the 1970s, various studies have concluded that 50 to 60 percent of all outpatient prescriptions are inappropriate. Other studies have found that seven in 10 Americans receive antibiotics when they seek treatment for common colds. "Essentially," says Dr. Lee Green, a family practitioner at the University of Michigan, "we have a tradition of prescribing antibiotics to anybody who looks sick."

There's plenty of blame to go around. As Moellering has learned in Boston, Americans like quick fixes, and when a doctor doesn't offer one, they look for a doctor who will. Patients aren't the only culprits. When insurance companies fail to cover bacterial tests, they encourage sloppy prescribing. Drug companies, for their part, promote the use of their products by advertising them widely and supplying doctors with free samples. Experts in health policy agree that the latest patented medications, which can cost 10 times as much as older generics, should be reserved for uniquely stubborn infections. "The more widely you use these newer antibiotics," says Dr. David Kessler, commissioner of the U.S. Food and Drug Administration, "the greater the chances that [bacterial will develop resistance." But when a manufacturer touts a new product as a high-octane alternative that every patient deserves, doctors can feel duty-bound to prescribe it. "It's another form of defensive medicine," says Dr. Thomas O'Brien of Harvard.

Even when doctors dispense antibiotics properly, there is no guarantee they'll be used that way. Studies suggest that a third of all patients fail to use the drugs as prescribed. Many stop taking their medication after just a few days, when it has killed the most Susceptible invaders but left hardened survivors to flourish. Besides being harder to treat, those resistant germs can then spread through the community. Besides quitting treatment early, some patients save unused drugs to take later, or pass them around like vitamins. "I've heard of people on trips who take a fellow traveler's antibiotic, thinking it will protect them from illness," says Dr. Stuart Levy of Tufts University. "It just causes widespread resistance."

Drug-resistant microbes don't threaten us all equally. A healthy immune system easily repels most bacterial invaders. regardless of their susceptibility to drugs. But when resistant bugs take hold among the weak. the sick or the elderly, they're hellishly hard to control. "I believe resistant infections are present in every hospital and nursing home," says Dr. Thomas Beam of the Buffalo, N.Y., VA Medical Center, "The only question is whether the institution is releasing that information." In the past 18 months alone, Beam has seen 51 patients stricken with drug-resistant Staphylococcus aureus, a microbe that infects surgical wounds and can cause pneumonia and systemic blood infections. Twelve of those infections have been lethal.

Penicillin and tetracycline lost their power over staph back in the 1950s and '60s. Another antibiotic, methicillin, provided a backup for a while, but methicillin-resistant staph is now common in hospitals and nursing homes worldwide. "If it's not in your hospital already," says Dr. David Shlaes of Cleveland's Case Western Reserve University, "the only way to keep it out is to screen patients and keep [carriers] in some kind of holding center until you treat them." Last month officials at the VA nursing home in Sioux Falls, S.D., quarantined half of the facility's 42 residents to control an outbreak of drug-resistant staph. Two of them are still in isolation.

Like staph infections, bugs known as enterococci flourish among weak and elderly hospital patients. Shlaes recalls that when a resistant strain of enterococci took hold in a Pittsburgh liver-transplant unit, 50 people were infected over the course of two years. The only survivors were patients whose infected tissues could be removed surgically (a trick from the pre-antibiotic era), or whose infections were confined to the urinary tract, where drugs can be used in high concentrations.

Though they're concentrated in hospitals and nursing homes, the superbugs aren't confined to such settings. Out in the community, many bacterial diseases are becoming ever harder to treat. Some 20 percent of the nation's gonorrhea is now resistant to one or more antibiotics. A similar proportion of TB now resists the drug isoniazid. As any doctor who has spent a winter throwing one drug after another at a toddler's ear infection can tell you, resistance is common in other bugs as well. But because the government doesn't track drug resistance, clinicians rarely know when to expect it.

To give doctors a better sense of what germs are circulating in their communities, the Centers for Disease Control and Prevention now encourages local health officials to conduct regular surveys for drug resistance. Meanwhile, the World Health Organization is funding a global computer database that doctors can use to report drug-resistant outbreaks. Surveillance alone won't stop the erosion of the wonder drugs. "The classic response has been to develop new and more powerful antibiotics," says Moellering. With luck and perseverance, scientists will discover unimagined new weapons. But the immediate challenge is to get doctors, and patients, to stop abusing the weapons we still have.

 ANTIBIOTIC SALES 

To drugstores and hospitals*



IN BILLIONS OF DOLLARS

 1988      $3.7

 1989       4.2

 1990       4.7

 1991       5.4

 1992       5.2

 1993       5.6



*EXCLUDING SALES TO HMOS, CLINICS, ETC.
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