Antibiotic prescriptions have been the mainstay of modern life since they were put to widespread use in early 1940s. While antibiotics are an amazing addition to modern medicine, they also come with substantial risks. Public health agencies have warned medical professionals and the general public about risks associated with the excessive use of antibiotics for years now, but it seems those warnings have fallen on deaf ears. A recent survey conducted by the World Health Organization found people misinformed about antibiotics, with two thirds (64%) of those surveyed believing that antibiotics can treat colds and flu.(1) Antibiotics make up ¼ of the medications prescribed to children, so this deserves much more discussion. With more and more research pointing to the risks that antibiotics pose, especially for our babies and children, let’s recap what antibiotics do and why they should be saved for when absolutely necessary.
Antibiotics are a type of prescription medicine that goes into the body and mounts an attack against bacterial infections. They do this by either killing or blocking the reproduction of bacteria by targeting various parts of the bug. Antibiotics do not treat viral infections, which are responsible for the common cold, flu, most coughs, sore throats and many ear infections. They aren’t helpful during a viral infection and can often lead to more harm than good. While appropriate antibiotic use is one of modern medicine’s miracles and absolutely has its place, it has too many risks to use without serious thought.
There are really two main areas of concern with antibiotic use. One of the main issues with antibiotic use is antibiotic resistant bacteria. This is a major and growing public health issue as more bacteria strains are becoming resistant to more varieties of antibiotics. Each year as many as 2 million people in the US become infected with an antibiotic resistant bacteria resulting in at least 23,000 deaths and the numbers are rising worldwide.
Our understanding of how antibiotics interact with bacteria is changing. Even the traditional wisdom of finishing the entire antibiotic prescription has come into question. Numerous studies comparing longer versus shorter antibiotic treatments have found shorter rounds of antibiotics just as effective. (2,3,4,5,6,7) Taking antibiotics puts pressure on the beneficial bacteria in our bodies along with the harmful ones. In addition to eradicating bad bugs that could become resistant, antibiotics can encourage good bugs to develop drug-resistant genes, which can then be transmitted to bad bugs. Killing drug-susceptible bacteria in infections too quickly makes it easier for drug-resistant bacteria to multiply due to less competition for resources. The gut ecology works as a system, the good bacteria keep the bad bacteria in check. When you wipe out too many of the good bugs with antibiotics then the more resistant are left to flourish and multiply. This means more chance of transmitting the resistant bacteria to another person which is exactly what we want to avoid. A recent study found this very thing in mice infected with both drug-susceptible and drug-resistant malaria. When the infected mice were treated less aggressively, they were 150 times less likely to pass on the resistant pathogens. (8) This is not to say don’t finish your antibiotic prescriptions but this is something to discuss with your healthcare provider the next time you receive an antibiotic prescription.
The other major concern with antibiotic use is what happens to each person’s gut microbiome and immune system after a round of antibiotics. More and more recent research shows that early exposure to antibiotics leads to long term health risks. Antibiotics alter the gut microbiota by killing both good and harmful flora. This is a problem because once you wipe out a beneficial strain of flora, the benefit also disappears. A study out of the University of Minnesota in 2015 found that antibiotic use in infancy increases the risk for certain diseases later in life. (9) The study highlights how the use of antibiotics may eradicate key gut bacteria that help immune cells in the prevention of allergies or how antibiotic-induced changes in the gut microbiota resulted in increased levels of short-chain fatty acids that affect metabolism, increasing obesity risk. This was also a key finding in a recent study out of the University of British Columbia in 2014 where researchers found that different antibiotics killed different strains of gut flora which in turn, resulted in different diseases because of the lost strain. (10) These studies show the importance of all the different individual strains of gut microbiota. Remove or decrease just one strain and the body suffers. Interesting research from the University of Helsinki in 2016 looked at 142 Finnish children, aged 2 to 7 years. Researchers investigated how many courses of antibiotics the children had received in their lifetime and how the use of antibiotics impacted their intestinal microbiota. They found that the more rounds of antibiotics, particularly the class of antibiotics called macrolides, such as azithromycin or clarithromycin, a child has in the first two years of life the greater the risk for asthma, obesity and metabolic diseases. (11) Encouraging news from these researchers highlights how that it takes about one year for the gut microbiota to recover from a course of antibiotics but those who had heavy use of antibiotics in early life and then avoided antibiotics for two years had gut microbiota similar to children with low lifetime antibiotic use. With all the news about the importance of our gut microbiota, it is nice to see that recovery from the damage that antibiotics can inflict is possible.
Exciting animal research out of Oregon State University in 2015 demonstrated how antibiotics can kill the intestinal epithelium and impair mitochondrial function. (12) Damage to the intestinal lining has various health effects as this is the site of nutrient absorption, part of our immune system and it has many other biological functions that play an important role in our health. Impaired mitochondrial function impacts cell signaling, growth and energy production which are essential for health. And if that wasn’t enough, the study found that one of the genes affected by antibiotics is critical to the communication between the host and microbe. When this communication is impaired, dysfunctions all over the body pop up. These dysfunctions include diarrhea, ulcerative colitis, obesity, food absorption, depression, immune function, sepsis, allergies and asthma. Whew.
The bottom line:
Antibiotics are an amazing achievement of modern medicine that definitely have their place. But the decades of over prescribing and rampant use in our livestock have made a huge impact on our global and individual health. This post is not to dissuade parents from treating their family with antibiotics. This post is simply meant to give parents all the facts so they can have meaningful discussions with their healthcare provider about the proper prescription and use of antibiotics. Talk with your healthcare provider about what you can do about antibiotic resistant infections. Ask whether leaving the doctor’s office with the prescription for the antibiotic unfilled and using a wait and watch approach for a few days would be appropriate. A wait and watch approach means prescriptions for antibiotics are given and not filled while cultures are tested to see if infection is actually bacterial, as well as seeing if the infection resolves in a few days without antibiotics, as is the normal case for most infections. Ask if there are things you can do to feel better without the use of antibiotics. If you and your healthcare provider decide antibiotics are appropriate, discuss a narrow spectrum antibiotic that is very specific rather than a broad spectrum antibiotic that kills many strains of bacteria. The CDC estimates that over five years 37,000 lives could be saved from resistant bacteria with more infection prevention and proper antibiotic prescribing. (13) In 2014 the CDC launched the Get Smart campaign to help raise awareness of the threat of antibiotic resistance and the importance of appropriate antibiotic prescribing and use. The CDC Get Smart website offers lots of information about antibiotic resistance and the proper use of antibiotics and is a wonderful resource. With all of the research coming out about the risks of antibiotic use, this is an important discussion to have with your healthcare provider.
-Dr. Catherine Clinton
(2) el Moussaoui et al., 2006, British Medical Journal
(3) Haider et al., 2008, Cochrane Database of Systematic Reviews
(4) Chastre et al., 2003, Journal of the American Medical Association
(5) Pugh et al., 2011, Cochrane Database of Systematic Reviews).
(6) Sandberg et al., 2012, The Lancet).
(7) Peltola et al., 2010, The Pediatric Infectious Diseases Journal).
(9) Pajau Vangay, Tonya Ward, Jeffrey S. Gerber, Dan Knights. Antibiotics, Pediatric Dysbiosis, and Disease. Cell Host & Microbe, 2015
(10) Shannon L. Russell, Matthew J. Gold, Lisa A. Reynolds, Benjamin P. Willing, Pedro Dimitriu, Lisa Thorson, Stephen A. Redpath, Georgia Perona-Wright, Marie-Renée Blanchet, William W. Mohn, B. Brett Finlay, Kelly M. McNagny. Perinatal antibiotic-induced shifts in gut microbiota have differential effects on inflammatory lung diseases. Journal of Allergy and Clinical Immunology, 2014
(11) Katri Korpela, Anne Salonen, Lauri J. Virta, Riina A. Kekkonen, Kristoffer Forslund, Peer Bork, Willem M. de Vos. Intestinal microbiome is related to lifetime antibiotic use in Finnish pre-school children. Nature Communications, 2016
(12) A. Morgun, A. Dzutsev, X. Dong, R. L. Greer, D. J. Sexton, J. Ravel, M. Schuster, W. Hsiao, P. Matzinger, N. Shulzhenko. Uncovering effects of antibiotics on the host and microbiota using transkingdom gene networks. Gut, 2015