The Age of the Superbug Is Here

> As a former boss used to say, there is no "fairly sterile" just as there is no "fairly pregnant".

This (and mrob's post) is definitely incorrect. It's the opposite, in fact, there is no "sterile" in the absolute sense. You'll never kill everything.

This is measured in multiple ways, depending on field: sterility assurance level[0] is one, similar to the way the USDA specifies cooking temperatures to hit 6- or 7-log reduction in bacteria populations. This is also why we crash probes like Cassini into Saturn to not risk contaminating any possible niches that could support life even though the probes have been built in a clean room, cleaned, and irradiated.

[0] https://en.wikipedia.org/wiki/Sterility_assurance_level

Please stop. We ban accounts that continue to violate the guidelines like this.

https://news.ycombinator.com/newsguidelines.html

Not from a medical background, but I spent some time writing hospital infection surveillance software so can share a few anecdotes.

What he's saying isn't inaccurate. The idea is antibiotic resistance generally carries some metabolic cost -- the bacteria disable or find some other way around whatever pathway is being targeted by the antibiotic. This means they operate "less efficiently" than their non-resistant peers. When the antibiotic disappears from the environment, the resistance no longer offers an advantage, so they get out-competed by their non-resistant "more-efficient" peers.

This is in fact one of the ways hospitals fight outbreaks of resistant bacteria -- they cycle antibiotics. More subtleties of course, but basically the head infection surveillance person says "alright docs, this month we're blacklisting these antibiotics, next month we're blacklisting these." (This is one of the interventions our infection software helped with.)

On the other hand, there are places where the widespread use of antibiotics extends far beyond the reaches of a hospital building. Commercial agriculture is infamous for overusing antibiotics (basically mixing them into the lot's feedstock so every cow gets it). Outbreaks like SARS and avian flu weren't antibiotic-resistance outbreaks, but they WERE caused by sizable quantities of people working in close proximity with livestock and then spreading the disease through their normal travel and social interaction vectors.

India is known for having antibiotics widely available over-the-counter for people. There are stories of people coming back from India with an infection resistant to literally everything (there's only about 50 antibiotics out there) -- when that happens, it's like the outbreak movies where the CDC comes in with plastic sheets and wearing bunny suits to quarantine the room.

So will the lower-metabolic-efficiency attribute of antibiotic resistance be self-limiting enough to prevent it from turning into another 1918 spanish flu global pandemic? Maybe. But as long as there are large city-scale pockets of heavy antibiotic over-use with people traveling in-and-out, there are going to be constant transmission vectors that will still kill people in largely preventable ways.

Bacteria mutate much quicker than fish. Generations of bacteria form within minutes. There is significant possibility in the viability of cycling antibiotics as bacteria lose resistance.

The presence of antibiotics creates what's called a selective pressure in favor of bacteria with antibiotic resistance. Removing that selective pressure (i.e. the antibiotics) can potentially lead to the growth of non-resistant bacteria like your friend points out. But that doesn't mean antibiotic resistant bacteria just 'goes away.' There was a recent paper[0] published by the ASM that suggests antibiotic resistant genes can persist even in the absence of selective pressure. While I only skimmed over it, and it's certainly not definitive, it's very much an alarming conclusion. So while I understand his general point, I wouldn't bet the farm on it.

Already, we're seeing some pretty scary bugs with CRE (carbapenem-resistant enterobacteriaceae) and XDR-TB (extensively drug-resistant tuberculosis) and others. Festering in hospitals, where patients are at a much higher risk almost by definition, can create a real nightmare scenario that spreads outward from there. Even if that's avoided, antibiotics are almost a fundamental aspect of modern medicine. When they first came out, they were quickly perceived as an almost magical cure-all by the general public. Most people aren't able to imagine a world without them, let alone support the necessary steps to fight such a scenario. Medicine pre-penicillin was a scary thing, and no one really wants to think about the possibility of returning to it.

The body count--figuratively, literally, and economically--will likely be higher than a feared superbug as a result of surgical complications, the impact on organ transplants (if they're even feasible at that point), and a host of other problems brought about by common antibiotic resistance under the worst case scenarios. It's not a scary picture, and it's already here with thousands of deaths annually.

Unless some of the many ideas already being explored start to pan out, along with the discovery of new antibiotics in the interim, we're looking at a major step backwards to the 1930s. But that's going to require a lot of public funding and support. Personally, my nightmare scenario isn't a pandemic or a drastic decrease in survival rates for routine procedures. It's that we'll wind up having to experience one or both of those before the public starts to understand the problem and change their behavior. Maybe I'm being too pessimistic, but then I look at how antibiotics are treated in foreign countries and in livestock management, and I start to wonder if I'm not being pessimistic enough.

0. https://www.asm.org/index.php/journal-press-releases/94465-a...