Last month, I was in the emergency room for a cellulitis infection with abscess. The attending physician examined me and declared that I didn’t need an ultrasound and drainage, just an antibiotic. He prescribed Clindamycin, about which I was ignorant. Subsequent research informed me that this drug was more associated with Clostridium difficile infection, Stevens-Johnson Syndrome (aka toxic epidermal necrolysis) and colitis than most other antibiotics. I also learned that ultrasound and drainage of an abscess constituted “best practice”. So I returned to the following day to complain. I got another ER doc who complied with my request for those procedures plus doxycycline (also indicated for the condition) which I had taken without incident several years earlier for a hand infection. My research also told me about how easily untreated cellulitis can turn into sepsis. This post will be about those two topics: antibiotics and sepsis. (I suppose a third issue could be physician incompetence, but I think I’ll save that one for another time.)
Overall, these “miracle drugs” have clearly been a boon to humankind, although side effects seem to be glossed over in general discourse on the subject. Earlier, I mentioned colitis (a serious inflammation of the colon), and also C. difficile. This bacterium of the Clostridium genus, which includes the species for tetanus and botulism, is potentially fatal, causing severe watery or bloody diarrhea, fever, anorexia, abdominal pain, and electrolyte disturbances. Then, finally Stevens-Johnson Syndrome: a systemic skin disease producing severe, widespread rash, fever, and lesions. Skin loss may lead to dehydration, infection and death. These are fairly rare reactions, but ones which must be kept in mind. The more common side effects of antibiotics are mild rash, diarrhea, nausea with or without vomiting, loss of appetite, and photophobia. (With the doxycycline, I experienced no side effects whatsoever.) And then, of course, there is the potential for a serious allergic reaction (anaphylaxis).
Nature can produce its own antibiotics, but the first man-made one was synthesized in the laboratory of Paul Ehrlich in 1909. This was called Salvarsan, the “magic bullet” that cured syphilis. Alexander Flexing discovered penicillin by chance in 1928, but commercial development had to wait until the 1940s. For those with penicillin allergies, tetracycline was discovered in 1948 and erythromycin the following year. Vancomycin was discovered in 1952, rifampin in 1957, and metronidazole in 1962. In 2001, a new drug to treat MRSA (methicillin-resistant staphyloccus aureus) reached the market: linezolid. New soil technology enabled the development of teixobactin in 2015.
Then there is the serious issue of antibiotic resistance. In the U.S. alone, resistant bacteria cause more than 2 million infections and 23,000 deaths per year. Nothing about this phenomenon: the existence of bacterial resistance genes has been documented in permafrost sediments in the Yukon from 30,000 years ago. Three genes encoding resistance to B-lactam, tetracycline, and glycopeptide antibiotics have been identified. Even so, the problem is exacerbated by numerous modern factors, including both clinicians who prescribe antibiotics unnecessarily as well as agribusiness’ use of the drugs to promote animal growth. For many years now, antibiotic resistance has been recognized by health authorities as a global crisis.
“Without urgent, coordinated action by many stakeholders,” says Dr. Keith Fukida, the WHO’s Assistant General Director for Health Security, “the world is headed for a post-antibiotic era in which common infections and minor injuries which have been treatable for decades can once again kill.”
An often deadly sequela of an infection is sepsis, defined by Taber’s Medical Dictionary as “a systemic inflammatory response to infection, in which there is fever or hypothermia, tachycardia, rapid breathing and evidence of inadequate blood flow to internal organs.” A mnemonic for remembering the symptoms: S (shivering, fever, or very cold); E (extreme pain or general discomfort (“worst ever”)); P (pale or discolored skin); S (sleepy, difficult to rouse, confused): I (“I feel like I might die”); S (shortness of breath). Complications of sepsis include septic shock, metastatic abscess formation, and organ failure. The old term for “blood poisoning” (“septicemia”) has mostly been replaced by “bacteremia”. The risk of sepsis can be reduced by preventing infections, practicing good hygiene, and staying current with vaccinations. The leading cause of death in U.S. hospitals, sepsis is also the leading cause of readmissions to the hospital with 19% of people hospitalized with sepsis needing to be re-hospitalized within 30 days. As many as 87% of sepsis cases originate in the community. Approximately 6% of all hospitalizations are due to sepsis, and 35% of all deaths in-hospital are due to sepsis. As many as 80% of sepsis deaths could be prevented with rapid diagnosis and treatment. Mortality increases by as much as 8% for every hour that treatment is delayed.
The 21st Century Cures Act of 2016 authorized $6.3 billion, mostly for the NIH, to streamline the approval process for drugs and devices. The problem is, these items are being approved on weaker evidence, bypassing randomized controlled trials. The legislation has been opposed by consumer organizations that are trying to protect the public from dangerous, ineffective treatment. This would include antibiotics. To put it bluntly, capitalists are trying to push these dubious substances through to the public for quicker profits. Some of these new antibiotics are tigecycline (Tygacil), bedaquiline (Sirturo), dalbavancin (Dalvance), and ceftazidime-avibactam (Avycaz). As Sarah Sorscher, a lawyer for Public Citizen has noted, “[This bill] will be bad for patients and public health. In exchange for an ephemeral boost in research funding, the bill will pressure the FDA to approve dangerous new antibiotics and institutionalize a hospital payment system and other measures that promote antibiotics overuse and speed the development of drug resistance.”
A final note: September 2019 is Sepsis Awareness month.
~ Wm. Doe, Ph.D. – August 2019
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