Germs find a way to fight back

FIRST OF FIVE PARTS
Sunday, June 20, 1999

Drug-resistant bacteria have area health officials mobilizing

By Ron Sylvester
News-Leader

When Michelle Albrecht took 1-year-old Aaron to the doctor for an ear infection, she shocked friends and family by returning without a prescription for antibiotics for her son.

“They all said, `What kind of quack do you have?’” Albrecht said. “It was the old school of `your child is sick, so you have to have medicine.’”

By the end of this year, however, more Springfield doctors will be doing what Dr. Robert Steele did: limiting access to antibiotics.

Because of medicinal misuse by patients and overuse by doctors, the nation’s health-care community finds itself battling new forms of “superbugs” capable of fighting off some of the most powerful medicines. From simple ear infections in children to more serious ailments such as staph and tuberculosis, new strains of old diseases are threatening to invade our bodies.

In response, Steele and other area health professionals are joining a task force of pediatric and infectious disease specialists to find ways to protect the public, making Springfield one of only a handful of communities in the nation to mobilize.

Their mission: to map out a strategy for teaching the dangers of misuse and overuse of antibiotics.

Increasing resistance to drugs is a problem in Springfield, where in the last year 20-35 percent of strep pneumoniae – the bacteria that cause most ear infections – could defeat penicillin.

Just last week, researchers in Memphis reported on a potentially unstoppable strain of strep pneumoniae that could tolerate vancomycin, doctors’ last line of defense.

“It’s a public health crisis, an emergency,” said Dr. Bernadette Albanese, infectious disease specialist with Johns Hopkins University in Baltimore.

And from Maryland to Missouri, few people know anything is wrong.

“It’s like the Titanic sinking – the band is playing on and everyone thinks things are fine, then everything crashes,” said Dr. Alastair Haddow of St. John’s Health System. “That’s where we are now.”

Haddow and Dr. Wolfe Gerecht, infectious disease specialists for Springfield’s two largest health providers, are seeing patients’ health sinking in a sea of overprescribed drugs that people don’t use as directed.

“We’ve got patients dying of these infections right here in Springfield,” Haddow said. “They don’t respond to anything.”

And we have ourselves to blame.

The U.S. Centers for Disease Control and Prevention in Atlanta estimates half the prescriptions for antibiotics are unnecessary.

Pressured by patients clamoring for relief, doctors have been prescribing antibiotics for illnesses the drugs weren’t meant to treat, such as viruses.

“People think the common cold is cured by antibiotics, and it’s not – it’s bacteria that antibiotics kill,” said Dr. Diane Nitta of Springfield’s Pediatric Center. “A majority of illnesses kids come into the office for are viruses. If you just give them time, the fever will be gone and they’ll have fought it off on their own.”

But distinguishing a bacterial sinus infection from a viral cold can be tricky, even for seasoned doctors.

“Most of the snotty noses that people have – where they blow the green-yellow stuff up – are viruses,” said Gerecht, with Cox Health Systems. “But when we keep giving antibiotics, we keep exposing bacteria to them, and over time they become smart and learn how to become resistant.”

It’s simple evolution. To survive the onslaught of drugs, bacteria build armor to protect themselves, then pass those traits to the next generation. The new bugs, now fully resistant, can be spread among people.

Even children who’ve never taken antibiotics end up in the hospital with resistant infections, said Albanese at Johns Hopkins.

“They obviously got it from another kid,” she said. “That’s when it becomes a community problem.”

When children go to day care, their chances of catching a resistant infection increase dramatically.

The pneumococcal bacteria can be passed through runny noses. Children wipe their noses and touch one another. They share toys crawling with germs.

“So the fact that someone else is getting antibiotics also puts your child in danger,” said Steele, a pediatrician at the Children’s Clinic in Springfield.

Aaron Albrecht’s first ear infection cleared up without antibiotics. But he likely caught subsequent infections, already immune to medication, from someone else.

By the time Michelle Albrecht took her son back to see Steele with a new infection in his other ear, Aaron had picked up a bug that the antibiotic Augmentin couldn’t nip. Neither could three generations of cephalosporins, a step up from penicillin.

“Basically, his infection was resistant to everything I have,” Steele said.

Albrecht’s baby was not getting any better.

“It was frightening,” she said.

Aaron faced surgery. Then spring arrived. Kids stopped getting sick and spreading infections. Aaron’s ears cleared up.

Antibiotic abuse in the community, however, didn’t go away.

“This is a monumental problem,” said Harold Bengsch, director of the Springfield-Greene County Health Department. “This is for public health the equivalent of the Y2K for computers.”

Albrecht doesn’t need convincing.

“Going without antibiotics is always an option for me,” she said. “We’re just going to play it by ear.”

But experts agree more doctors and patients have to adopt that attitude to stem the risk of setting medicine back 60 years.

If not, illnesses now taken for granted will be able to beat all antibiotics.

They will become incurable.

People could get strep throat and die, as they did before penicillin arrived in the 1940s.

“If we’re not careful, by the time our grandchildren need antibiotics, we’re going to be back to a pre-1940s era,” said Cox’s Gerecht. “In 20 years, we’re going to be in real trouble.”

CLOSER LOOK: THE MICROBES’ WAR ON DRUGS

Microscopic bugs that make us sick also use an impressive arsenal to battle drugs we take to make ourselves well. Here are some of the most common ways microbes defend against human medicine:

AGENT DNA

DNA carries the genetic design for every life form, and it floats freely in the small world of microbes. Bits of DNA can travel in tiny space capsules called plasmids.

By sharing DNA, microbes can make chemical weapons or protective armor against drugs. Some DNA packs codes to produce enzymes that neutralize drugs like penicillin. Or it can strengthen a cell’s surface, barring the antibiotic from getting inside to do its work.

FLAK JACKETS

Microbes, and even fungi, can shield themselves from harmful elements – including adverse temperatures and chemicals – by wrapping up in protective layers of membranes and protein.

Inside these spores, the microbe goes to sleep. It can remain dormant for a long time – a century or more if it must. When the environment becomes less threatening, the microbe sheds its armor and resumes normal activity.

E. coli and the bacterium that causes Legionnaire’s disease use this method to survive chlorine in water supplies.

SMALL SCAVENGERS

Bacteria such as strep and staph can actually transform by changing the very makeup of their DNA.

They do this by picking up particles of DNA from other sources, even from dead cells, and adapting them to their own uses. E. coli, for example, can snatch DNA from other E. coli cells or from unrelated bacteria.

They may use the new DNA to produce stronger strains able to withstand drugs that might have previously killed them.

SEXUAL HEALING

The most common way microbes build resistance is through sexual contact. Microbes engage in sex by stretching their membranes to touch other organisms and transfer DNA via plasmids.

JUMPING GENES

Genes called transposons can hop along strands of a DNA molecule, picking up pieces of the code. Like bees flying among flowers, these genes can hop within the same cell, to other cells or even jump to other species of organisms, pollinating them with resistance.

IT’S CONTAGIOUS

Bacteria can catch viruses, through which they can pass DNA to one another. The recipient blends the new DNA with its own.

THE HUMAN TOUCH

Humans help create new ways to make themselves sick by taking only enough medicine to kill off the weakest microbes, leaving the strongest alive.

Because bacteria can duplicate as often as every 20 minutes, it takes as little as eight hours to reproduce a billion new microbes able to fight off future doses.

That’s why doctors instruct patients to finish all prescribed antibiotics – and leave no survivors.

Rising resistance

Pneumococcal bacteria, the most common cause of ear infections and pneumonia, are growing increasingly resistant to antibiotics. Here are national figures breaking down the number of cases by type of infection and the rate of resistance among total infections from 1991 to 1997.

Infection numbers

Infection type/Cases per year

Ear infection/7,000,000
Pneumonia/500,000
Bloodstream/50,000
Meningitis/3,000

Resistant infections rising
’91-’92 – 7 percent
’93-’94 – 14 percent
’95′-’96 – 21 percent
’96-’97 – 25 percent

Source: Centers for Disease Control, Johns Hopkins University News-Leader

ABOUT THE SERIES: As dangerous bacteria resistant to drugs become more common, Springfield is beginning a communitywide response – one of only a few places in the nation to do so.

INSIDE TODAY: Disease detectives ever on the lookout / 4A

MONDAY: Doctors feel pushed to answer patient demands.