I think the UN or governments themselves should get into the business of bad business medicine. The fact drug companies are prioritizing research of chronic medications is an obvious outcome of our current structure. The government or quasi governmental organization can continue to subsidize industry research and buy licenses for discoveries they then productionize at cost. This wouldn’t directly compete with industry and it would incentivize public private research across large areas of otherwise unprofitable areas of medicine such as this.
We also need regulation (and effective enforcement) as much as research.
Even if you discover a groundbreaking new antibiotic under current incentives it's going to get fed to pigs in China until it's useless.
Arguably the kinds of antibiotics we need the most are ones with significant side effects; effective enough that they can save humans but with side effects that are severe enough that they are not over-prescribed or fed to livestock.
> Arguably the kinds of antibiotics we need the most are ones with significant side effects
I don’t think there can be a better example of perverse incentives than this.
This is what the Turkish government has been up to and it has driven drug costs, and therefore overall costs of healthcare provision and insurance, down. More countries should nationalise production of generics, it works.
Does the cost of letting everyone see a specialist whenever they want cancel that out?
Overuse and misuse of antiobiotics isn't really a US thing. https://resistancemap.onehealthtrust.org/AntibioticResistanc... is a nice, interactive map showing where the majority of the resistant strains are found. Any effort to curtail the emergence of antibiotic resistant bacteria will require coordinated global action, which means it's highly unlikely to happen.
Agricultural overuse is also a major vector.
So why is India such a resistance hotspot?
Sad that the article is not talking about bacteriophages[1]. Basically viruses that infect other bacteria. The world is full of them (and even virophages: viruses that infect other viruses). The soviet union started experimenting them, and they seem to be used to treat hard-to-cure infections like Staphylococcus aureus, but I guess it died down somehow?
From the bits and pieces I've heard, the problem is one of scaling. Bacteriophages had to be made bespoke for a specific patient.
I've heard that for stubborn cases it works really well. It's true it does not lend itself to mass manufacture the way antibiotics do but I believe, a typical lab with the right knowledge/equipment/resources should be able to do it. I saw a documentary a long time back where they do it Georgia, not sure how legit it is.
>but I guess it died down somehow?
I've heard that it lives on in Georgia.
Stop administering them whenever anyone gets a sniffle so they stay effective longer. Also firmly separate veterinary antibiotic classes from human antibiotics so that the ones intended for humans stay effective longer.
In most of the world, by population, the regulatory structure of society is so weak that there is no way to achieve this. Antibiotics are available without prescription, licensed doctors of skill are rare, and patients are insistent on antibiotics for everything. In most developed countries doctors are already parsimonious with antibiotics and generally won’t prescribe them unless an infection is observable. But in most of the developing world it’s prevalent to over administer antibiotics either through clinics are directly at the unregulated pharmacies.
> In most developed countries doctors are already parsimonious with antibiotics and generally won’t prescribe them unless an infection is observable.
Antibiotics as 'consolation prizes' is definitely a thing.
Yeah ive seen it myself, and part of it is driven by people's demands and expectations to receive treatment when they go to a doctor. Even if they go for very minor sniffles, many people will not return to the same doctor later if they are given nothing other than what boils down to "stop being a wimp and rest for a few days because nothing I do is going to actually help." Especially when the visit itself comes at a decent cost to the patient (in the US atleast). So doctors who overprescribe medication are more profitable for their owners and have higher demand from patients and are incentivized to do so, while doctors following the science more closely will be less profitable and have lower demand.
Better education on health and healthcare would help, but certainly not come anywhere near eliminating the incentives to over prescribe versus under prescribe antibiotics and medications. Perhaps more placebo medications could help, but that has its own litany of problems in making people believe they are receiving a medication when they are not, and numerous patients might view it as being scammed even if a placebo is the best thing that could be given to them.
At least in the EU they have reduced prescriptions a lot. They don't write antibiotics prescriptions if you have bronchitis unless you have a fever or if it does not improve over a span of days. 10 years ago they would just give you a wide spectrum antibiotic.
They still suck on just taking a swab and culture.
> Stop administering them whenever anyone gets a sniffle
This hasn't been true for most of my life and it remains a serious concern.
Not to mention antibiotics often come with seriously nasty side effects of their own, so you as the patient even wanting the best outcome shouldn't even necessarily want antibiotics.
It is not an issue in the US.
It is a massive, massive issue in some very large countries.
It is still a big issue in the US even if it is more massive elsewhere plus we use it in the meat industry to the point where certain types of antibiotics cannot be used anymore.
Ahh yes, very fair.
The problem with a policy like this is that in practice rich people will get antibiotics whenever they (we? hn is well off enough to cont as rich for this perk) want and everyone else suffers. It will for sure also summon the racist underbelly of the US where doctors will believe white sympathetic patients when they say how long they've been sick and question everyone else. This will deal double damage if you try to enforce any kind of quota.
I can afford to go to a nice doctor who will prioritize my comfort and who will literally tell me what to say to meet the criteria but anyone with less choice will have to fight.
> I can afford to go to a nice doctor
If your doctor is giving you antibiotics for clearly viral illnesses they are doing a disservice to you, it isn’t actually nice. It’s not like I’ve ever seen some systemic withholding of antibiotics when they are clearly indicated - quite the opposite, some of the worst areas for resistance are the poorest. They aren’t without other side effects, resistance being only one.
Also you have it backwards, the racist thing to do is to just prescribe the antibiotics, since they are dirt cheap, cost me (the provider) nothing, and makes the person whose skin color I possibly don’t like get out of my office faster (if not racism, pragmatism to see too many patients). Racism alone is not necessarily the only explanation, but antibiotic over prescription/use tends to be associated with poverty.
Well run antibiotic stewardship is a conceit of the most affluent health systems.
> It will for sure also summon the racist underbelly of the US where doctors will believe white sympathetic patients when they say how long they've been sick and question everyone else.
You're trying to shoehorn an unfounded accusation of racism into a discussion about antibiotics. This sh*t is tiresome.
We're not talking about antibiotics, we're talking about policy. And any discussion of policy requires systems level thinking. I'm not accusing anyone of racism, I'm white and reasonably affluent idgaf, I genuinely believe the policy being proposed would be selfishly better for me personally.
This is the reality of medical care right now in the US what are you talking about?
https://www.hopkinsmedicine.org/news/articles/2021/06/physic...
The existing bias in the medical system along with policy that asks doctors to doubt more patients has a pretty damn predictable outcome.
Sure, but on a global scale the rich are a small percentage of the world population.
Some countries are very restrictive on prescribing antibiotics (almost too strict) and it feels like it falls flat as you can get it over the counter in a lot of places.
In Switzerland it's tough to get antibiotics unless you absolutely need them. Even when I had a lung issue for 2 weeks I had to beg to get antibiotics. Weird. And they are not available over the counter.
In Hungary, on the other hand, they hand them out like candies.
So yes, the solution was to import them from Hungary. :-)
> get antibiotics unless you absolutely need them.
Yes that’s exactly how it should be. They are not at all benign misprescribed.
> Even when I had a lung issue for 2 weeks I had to beg to get antibiotics.
Was there any evidence of a bacterial infection or did they just give in? 2 weeks is not a long time for a viral respiratory illness either.
I find this is so frustrating to describe to patients. There really is a limited scope of appropriate outpatient antibiotic use.
they didn't give in, but I actually checked hospital internal guidelines for doctors, and it states 3 weeks.
They could have done some more tests or whatever, as it was maybe the worst lung issue I've had and I was really miserable. I knew that antibiotics would help, and they did. I sourced them myself.
You could say lucky guess, but after I complained to my health insurer about the bad doctor's visit, they covered the cost fully without any dispute, so they must have agreed with me with at least about maybe running some more tests...
If it was "only" [1] a viral disease, it should dissapear even without antibiotics after a week or two. So perhaps your body solved the problem alone, while you took antibiotics that had no effect.
This is a real posibility and is a real problem to test how useful the medicines are. So all serious studies use a control group [2] to compare the rate of spontanous healing with the rate of healing with the antibiotic.
[1] Some virus are very nasty and can kill you. People confuse the common cold andd the flu, but usualy the flu is much worse.
[2] Preferabely a preregistered double blind randomized control group, becuse there are a lot of other problem that can cause a false result.
What kind of evidence are you expecting? Many diseases are treated with antibiotics without definitive evidence via some kind of test. Often, evaluating symptoms is deemed sufficient. For example, in the case of Erysipelas, an infection of the skin
The commenter did not expound on any specific evidence that would suggest a bacterial lung infection. 2 weeks of malaise and non specific upper respiratory symptoms is not strong evidence of a bacterial pneumonia, sorry.
For external infections, observation by visible inspection is still evidence, a sign, not a symptom. So, not sure what your point is. Erysipelas is invariably diagnosed by signs, not symptoms. Very rarely are bacterial infections diagnosed by symptoms alone.
Judging the need for antibiotics is not some kind of personality quiz, bacteria can be cultured. (I'm not sure why they don't usually do it.)
Takes time and costs money. Problematic for an already strained health care system. And as a patient I prefer to get treated immediately for my painful skin infection instead of waiting a day or so for results to arrive
The comments on this article take for granted that agricultural use of antibiotics is a key driver of the emergence of antimicrobial resistance (AMR). This is an intuitive and popular explanation, but the magnitude of this effect is not well established.
As an example, [0] is of the best reviews available on the contribution of non-therapeutic antibiotic usage in animal feeds to AMR. Despite the large amount of evidence cited, the authors can't conclude that a ban on animal use of antibiotic class X would lead to Y more years before resistance to X emerges/spreads.
It seems well established that banning use of certain antibiotics as a feed additive would slow the emergence of resistance, but that magnitude of that effect seems totally unknown. There is perhaps a strong precautionary principle argument to be made for banning use of medically important antibiotics as feed additives, but we should be cautious in making any firm conclusions about how much that would impact the medically useful lifetime of existing or new antibiotics.
In a similar vein, the idea that commercial prospects for antibiotic development are limited because agricultural use would cause fast emergence is not supported from what I can find. A very good recent paper [1] discussing failures of antibiotic development in the US in the last 20 years highlights trial, regulatory, and commercial hurdles as key roadblocks to successful commercialization of antibiotics.
[0] https://journals.asm.org/doi/full/10.1128/cmr.00002-11 [1] https://www.nature.com/articles/s41599-024-03452-0
Most new antibiotics come from soil bacteria. We got all the low hanging fruits, now you need to dig through tons of soil to find something new., Better culture methods would make it easier to run experiments instead of relying on genome rather than relying on /cloning/expression in E. coli.
Do we need one? Quarantine them from the countries that can't or won't enforce discipline on prescription and the problem solves itself.
Insane take. What about the people with life threatening infections in those countries? Just collateral damage?
You could argue that in that case the people deserving the most blame would be the people in charge for that country's medical system not having implemented proper antibiotic discipline to qualify for the antibiotic.
The same rules would have to apply to all.
Why would we condemn a population of innocents on the basis of bad leaders. This is very bad logic; it leads to very bad things.
Sucks to be them?
This poster has +2551 karma. Stay classy HN.
Is there a danger that with more sophisticated antibiotics, we could eventually eradicate too much good bacteria?
More sophisticated, I'd expect more precision not just more of the same (and bad) old.
Now we just wreck havoc of absolutely anything which is a bacteria, it would be nice to be able to select the typology.
This article misses several new antibiotic classes that are emerging: macrocyclic peptides, and a bunch of compounds from unculturable soil bacteria (clovibactin, teixobactin, etc.)
We have a whole arsenal of old antibiotics no longer in use that are candidates for redevelopment. As bacteria develop resistance to newer antibiotics they make evolution tradeoffs which bring back into play older antibiotics.
https://pmc.ncbi.nlm.nih.gov/articles/PMC4242550/
I think cocktails will be used (if they are not already in use) to attack the bacteria from different angles at the same time reducing the likelihood of developing resistance.
Another thing is better protocols. More quick testing before prescription so you use more targeted antibiotics and reduce the use of wide spectrum antibiotics.
Doctors and their 'fee for service' mentality are, in part, at the roof of this. They know an antibiotic is a waste of $$ for a viral disease, but the money meter ticks upwards.
There are problems with the fee-for-service financial model but this isn't one of them. The doctor will be paid the same for the office visit regardless of whether they prescribe or not. The money for any antibiotic goes to the pharmacy, pharmacy benefit manager, and pharmaceutical company.
#1 thing that could be done in the US would be to stop using so many of them.
Especially in agricultural animals...