The development of antibiotics in the 20th century was a major medical advancement. Hailed as wonder drugs, medications like penicillin have saved millions of lives. But 60 years of misuse and overuse has allowed mutated strains of bacteria to become resistant to the same drugs that once wiped them out. Every year, more than 2.8 million infections from bacteria that are resistant to antibiotics occur in the U.S. and more than 35,000 people die as a direct result.
During Antibiotic Awareness Week, Jonathan Fialkow, M.D. and his guests, clinical pharmacists Timothy Gauthier, PharmD and Jefferson Cua, PharmD, explain why we all need to take action to protect these precious antimicrobial drugs.
More information about Antibiotic Awareness Week is available on the U.S. Centers for Disease Control and Prevention's website.
The development of antibiotics in the 20th century was a major medical advancement. Hailed as wonder drugs, medications like penicillin have saved millions of lives. But 60 years of misuse and overuse has allowed mutated strains of bacteria to become resistant to the same drugs that once wiped them out. Every year, more than 2.8 million infections from bacteria that are resistant to antibiotics occur in the U.S. and more than 35,000 people die as a direct result.
During Antibiotic Awareness Week, Jonathan Fialkow, M.D. and his guests, clinical pharmacists Timothy Gauthier, PharmD and Jefferson Cua, PharmD, explain why we all need to take action to protect these precious antimicrobial drugs.
More information about Antibiotic Awareness Week is available on the U.S. Centers for Disease Control and Prevention's website.
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Dr. Jonathan Fialkow:
Hello, Baptist Health Talk Podcast listeners. I'm your host, Dr. Jonathan Fialcow. I'm a practicing preventative cardiologist and lipidologist at the Miami Cardiac and Vascular Institute at Baptist Health South Florida, as well as chief population health officer at Baptist Health. The development of antibiotics is one of the major advances in medicine in the 20th century. Drugs like penicillin made it possible to treat infections that previously claimed millions of lives. They've been hailed as wonder drugs, but for the past 60 years, antibiotics have been widely and too often irresponsibly prescribed and used and now we're facing serious consequences. According to the Centers for Disease Control, antibiotic resistance is one of the most urgent global threats to the public's health. This is national antibiotic awareness week, and I've invited two colleagues to the podcast to talk about the fight against antibiotic resistance. Timothy Gauthier, Pharm. D, Antimicrobial Stewardship Clinical Program Manager for Baptist Health South Florida, and Jefferson Cua, Pharm. D, a clinical pharmacist with Baptist Health. Welcome to the podcast guys.
Timothy Gauthier:
Thank you. We're happy to be here.
Dr. Jonathan Fialkow:
So let's talk about a couple of things. I mean, I know we as clinicians, certain, we use certain terms that to us become innately obvious, but maybe to the listeners that may not be as evidence. So let's start with some basics and Tim, I'll ask you, what are antibiotics and what do they specifically treat? How do they work? Let's talk a little bit first about what antibiotics are.
Timothy Gauthier:
And so antibiotics are special because they're not like other drugs. Antibiotics treat bacteria, they kill bacteria, they target bacteria. Whereas a lot of the other drugs we use, they target cells in our body. And so when we use an antibiotic, it impacts bacteria rather than impacting our cells to maybe reduce our blood pressure or reduce our cholesterol. So the mechanism of how they work is really to target the specific bacteria and different antibiotics have different targets on those bacteria. And so we've tried to pick the right bug for the right drug, depending upon what infection we're talking about.
Dr. Jonathan Fialkow:
So a great point to start out with they treat conditions by directly killing, if you will, the bacteria, the harmful bacteria that leads to these conditions. Jefferson, let's talk a little bit about what they are not. I mean, there's a lot of confusion between viruses like influenza, coronavirus, which even as COVID is also the form of cold viruses. I can't tell you to this day, 30 years, plus in practice, I get calls regularly from friends, "Hey, I'm traveling and I have a scratchy throat and can I get a Z-Pak or an antibiotic?" Or every little low grade fever people want antibiotics for. So let's talk about what the bacterial illnesses are that antibiotics work against versus things like viruses. Can you elaborate on that a little bit?
Jefferson Cua:
Yeah. So like Tim said a lot of our antibiotics, the way that they were designed to attack the bacteria directly. And so of course, if we look at what a bacteria and what a virus may have, they have different components. And so sometimes the target that antibiotics try to attack are not on the virus. And so using antibiotics for viral infections, it's not going to be effective. So a lot of our common infections that we see in our outpatient and also inpatient population, they're going to be a common cold and that for instance are, most of them are due to a respiratory viruses. So your common cold, for instance, could be caused by a virus. And the way that we would treat that would not be with antibiotics because antibiotics, again, would target bacteria versus a viral infection would not be effective in treating with an antibiotic.
Dr. Jonathan Fialkow:
So if one has symptoms of an infection, arguably, we would want that person to know if it's a potential bacterial infection or more likely a viral infection. Certainly they can know on their own. They can call Care on Demand. They can go to their primary care doctor to help guide them. But we could say, well, if antibiotics are otherwise okay, and you're not sure why don't we just use them, give me an antibiotic anyway, cause maybe, maybe it's a bacterial infection, but obviously we're not here to talk about why that's not good policy for an individual and for the population. So let's start Tim, Antibiotic Awareness Week. I mentioned it in the introductory comments. What is it and why is it certainly something very cogent towards current times?
Timothy Gauthier:
Yeah. So US Antibiotics Awareness Week actually corresponds with the World Antibiotics Awareness Week. The World Health Organization facilitates really great graphics and media information about World Antibiotic Awareness Week and the CDC, Center for Disease Control and Prevention provides a number of excellent content that people can use for Antibiotic Awareness Week in the United States. Antibiotics can save lives and are critical tools for treating a number of common or more serious infections that can lead to very serious infections like sepsis and US Antibiotic Awareness Week is an annual observance that always happens November 18th through 24th and it highlights the steps that everyone can take to provide antibiotic prescribing end use that as rational. And so a lot of it is generated towards using antibiotics when we need to it's okay to use antibiotics when you need to, but when you don't need antibiotics, we do not want to give them because there can be consequences.
Dr. Jonathan Fialkow:
So I think that's also well said it's and I use the analogy of statins for cardiac prevention. They're great in the right people, but let's not use them where they don't, where they're not necessarily beneficial. So the Antibiotics Awareness Week is not just, hey, antibiotics are great and let's use them. It's also as going back to the stewardship of where not to use them. And I guess that speaks a little bit and I'll turn it over to you, Jefferson, the concept of antibiotic resistance. Let's dive a little deeper into that. Speak a little bit about antibiotic resistance.
Jefferson Cua:
Yeah. So antibiotic resistance basically refers to when the antibiotics we use for certain bugs, all of a sudden, the bugs out smart start the antibiotics and what used to work for them no longer it's going to work. And that happens usually if we give antibiotics to people who don't need it. If patients are on it for a long period of time, or if we're not dosing the antibiotic correctly. So we're probably using a lower dose of that antibiotic that gets bugs to grow and then develops sort of their way of defeating this drug. And so the drugs that we are commonly using are no longer affective.
Jefferson Cua:
So we were talking about statins earlier, and of course how you would prescribe it to one patient is only going to affect that patient, but that we're worried more about like public health. Cause what you choose for one patient eventually could affect multiple patients. Because if they're, if they develop bugs that are resistant to certain antibiotics and other people might catch this bug and it becomes a public health problem. So that's why it's very important that we make sure the right people get the right antibiotics.
Dr. Jonathan Fialkow:
And to follow that up, I guess that's the concept you're bringing to the forefront, which is when we use antibiotics, especially if we don't use the proper doses or we use them with their own belong, there will be some bacteria that will survive an antibiotic and maybe adapt to no longer being sensitive to that antibiotic. One of the other components and we brought this up in a previous podcast is when antibiotics are prescribed, the individuals should complete that dose. Right? If they're feeling better after a few days, they shouldn't just stop the antibiotic because there still may be some residual bacteria. So that would be another recommendation I would expect.
Dr. Jonathan Fialkow:
So antibiotic resistance, it's a big problem. It's a big problem internationally. And the issue is we are now getting bacteria that don't respond to antibiotics, leaving people at risk for worsening infections that we can't really help. But why alter... I'll ask both you guys, maybe Tim start. Why can't we just develop new antibiotics? Why can't we just, okay, here's a bacteria. Let's find some drugs to, to, to kill it. What goes into that to limit that?
Timothy Gauthier:
That's an excellent question and if you think about an antibiotic, it's kind of a miracle drug in a way, because most antibiotics cure infections, rather than treating the symptoms of a disease for a long period of time. So the return on investment for a pharmaceutical company isn't near what it is for developing a new heart medication or a new lipid lowering medication. And so because of that return on investment being reduced, there used to be about 20 pharmaceutical companies engaged in research for new antibiotics. And that is down to about three currently. And so pharma is not putting money into it because they're not seeing money come out of it. And there are organizations that have been developed in order to facilitate drug development, but unfortunately it's not going very well. In fact, no new approved classes of antibiotics have been discovered since 1962, but the most dangerous type of bacteria, which is gram negatives, like E coli, Klebsiella and pseudomonas, for example.
Timothy Gauthier:
And so what we see is drugs that come to the market and they're new drugs, but they have the same mechanism as old drugs that we already have on the market. And so it's been a big, big gap in antimicrobial drug development over the years. And that's one of the major reasons why we don't see new drugs coming to the market. And if they do come to the market, many times they're intravenous only they have specific toxicities or they're first specific bacteria that most people do not have. So they're very, very niche drugs. So that's, those are some of the challenges that we face.
Dr. Jonathan Fialkow:
Which also further supports the fact that we, as people in the community and a population have to be stewards of taking antibiotics appropriately. So we don't wind up having these medical problems where there are no new drugs to be able to support for the reasons that you described. Jefferson what specifically are you and Tim and then with your colleagues, what are we doing at Baptist to fight the fight of anti-microbial resistance? Which as we've ascertained is a significant problem in our country and in the world.
Jefferson Cua:
Yeah. So I am part of the team called the AntiMicrobial Stewardship Program here. And I'm joined by my colleagues, Kelsey Williams Nehemiah at our Miami Cancer Institute and Olga [inaudible 00:10:45] here at Baptist Hospital. But we also have other stewardship pharmacists all across the system. And what we do is we make sure again, that we are using our antibiotics judiciously. So just making sure that all the right patients are getting their antibiotics. And we talked about choosing a right duration of therapy for each patient, so just making sure that everyone completing their courses appropriately. And if there's any opportunities for us to optimize their dosing again, because dosing is a big component into how resistance may develop in our patients, we work closely with our providers just to make sure that our doses are optimized, the correct drugs are being used based on the labs that we get every day. So sometimes the patient may have a culture that comes up and we can narrow a big gun antibiotic that we may start off with a patient to something that may be [inaudible 00:11:45] cover less bugs than what we start off with. So just making sure that all antibiotic to optimize for each patient.
Dr. Jonathan Fialkow:
So a precision approach, as opposed to just throwing everything against the wall, to see what may kill bacteria more specific towards the best antibiotic for that particular one so we're not exposing the person and the other bacteria to antibiotics, which is wonderful.
Jefferson Cua:
Exactly.
Dr. Jonathan Fialkow:
So let's talk a little bit now what, what we can do in the community. I'll ask you guys a little bit of a tricky question, but there's some concerns that a lot of the use... the use of bags of antibiotics, especially indiscriminately over the course of a person's life might affect their bowels or the way they absorb foods and maybe even create colonies of sinusitis and stuff like that. That's a lot of exploration now in the antibiotic use, killing healthy bacteria. Can either of you address that at a very high level, just really just for a concept for the listeners, the idea of taking bacteria, taking antibiotics without the proper indications or for the full count can actually kill healthy bacteria and leave you with other types of medical problems. That's something you're comfortable talking about?
Timothy Gauthier:
Yeah, absolutely. So there's something called your microbiome and your microbiome is what bacteria live on and inside your body and it's perfectly normal to have bacteria and fungi actually living within your GI cavity, within your mouth, the genital-urinary area and on your skin. And actually, if you were to take all the cells in and on your body and assess them, you'd find the only one in about 10 is actually a human cell. That's how many bacteria and fungi are colonizing our bodies. Every time we expose ourselves to an antibacterial or an antifungal medication that drug is going to kill a certain number of those books and that can have long-term implications and it can have short-term implications. For example, every single antibiotic can cause diarrhea, right? And as you wipe out some organisms that live in your stomach, some of those are more friendly organisms that won't cause diarrhea, and it can, when you wipe them out, it leaves room for the non-friendly organisms to start causing diarrhea.
Timothy Gauthier:
So that's a short-term consequence of antibiotic use. Long-term impacts on the microbiome have been studied in a large number of disease state. And there's a lot of hypotheses out there about what the impact is. But I think the take home message is you don't want to take antibiotics if you don't need to, because they can be harmful. And it goes beyond just diarrhea. I mean, if you pick an antibiotic out, I could probably list five or six potential side effects beyond diarrhea that it can cause, and again, antibiotics are different because of resistance. With other drugs, like for blood pressure and cholesterol, we don't worry about resistance in our bodies to those drugs. With antibiotics. We do worry about that. And so one of the things that we say is that the more you use antibiotics, the more you lose antibiotics because we pressure the organisms to become resistant the more we use them.
Timothy Gauthier:
And so it goes back to when we need use them, we should, but let's be smart, the right drug at the right dose and the right duration. But when we don't need to use the drug, we should not use the drug. And part of that also goes along with following the advice of your physician. Antibiotics should not be taken without the supervision of physicians. And so for example, sharing antibiotics that are left over from five or 10 years ago is a really bad idea because you could cause a toxicity to the person you're sharing with it. And it may be the wrong drug for that particular bug. And so we should always seek healthcare provider guidance when taking antibiotics.
Dr. Jonathan Fialkow:
These are prescription medications, they have a specific indication, they are validated to be safe, to take for that indication. And when we go around, we'll go beyond that or around that we put ourselves and others at risk, which is I guess a, again, another important point. Before we wrap up on a couple of other community related type of components, as you just spoke about. What about antibiotics in, in food? What about in our livestock being given antibiotics to avoid infections based on the close breeding and the way their food is administered. Any impact that you could see or any impact that's been reported in the population based on antibiotics given to our food sources?
Timothy Gauthier:
I can speak to that. So antibiotics are used sometimes within animal, animal, I guess, farms and agriculture as growth promoters. And so they're given to animals so that the animal will grow faster and grow larger. Consumers can purchase meat that is produced without using antibiotics as a growth promoter. And when you buy meat that is not used... from an animal raised using antibiotics as a growth promoter you're endorsing that I don't agree with that practice. And so that's something that we can do to avoid that. The other thing is that these animals they live in farms and then they, of course are animals and so they are defecating into the environment. And then the environment has rivers and streams, which carry bacteria to other places and other animals can pick up those bacteria. And if we're giving antibiotics to these cows or pigs or sheep, or what have you, there is then also the opportunity for the bacteria to pressure to become resistant to those drugs.
Timothy Gauthier:
And then we have spread of the bacteria through the environment, which can happen in a number of different ways. So it's not necessarily that it's going to be drug resistant organisms on the meat that you bought, but there may be consequences of environmental spread because of the use of these drugs in agriculture. And also some of the drugs that we use in agriculture or that are used in agriculture for growth promotion, for example, are the same classes that we use in humans to treat infectious diseases. And so that's something that is a very big concern given we know, again, that the more we use these drugs, the more we lose these drugs, we want to preserve them because they are a precious resource.
Dr. Jonathan Fialkow:
So I'm going to say something provocative in the early parts of your comment, which might be valuable for another podcast. They give antibiotics these livestock animals to help them gain weight, which again is very provocative because it does suggest the antibiotics changing something having to do with that microbiome will affect food absorption and might actually have a component in our society of relevance. So I'll leave it at that for another conversation regarding nutrition, diets, maybe obesity. Well, this is great guys. So I love the take, which is not something I actually had a fully baked in my mind that the stewardship is really to defend our antibiotics. It's the antibiotics that, where we're protecting so that they continue to function for those in need based on their bacterial infections.
Dr. Jonathan Fialkow:
So a couple of final comments, Tim, you mentioned a couple of maybe it's worth reiterating. Jefferson what, what can we in the community do? And, and, and healthcare workers as well, and not necessarily at a hospital level, which is a hyper acute situation, which is perhaps the most relevant, but in the community, if a patient comes to a doctor and says, I have a complaint, doc says, well, let me just give you an antibiotic patient should say, okay, should the patient do I need the antibiotic? What are my options? Where would we come into play for the listeners in the community about how to handle the messages we're giving them?
Jefferson Cua:
Yeah, that's a great question. So I think for people in the community, I think just learning more about infectious diseases would be something that's helpful. And I would refer them to the CDC and also the World Health Organization, just to learn more about what type of diseases where antibiotics would be appropriate to be used versus infections, where maybe viruses are more, the more common pathogens and therefore probably would not need antibiotics. I think just learning more about what those proper indications are, would be helpful. Again, also just maintaining it and descending over the pandemic now, which makes it harder for a lot of our clinicians to determine whether someone has viral versus having a co-infection with bacteria on top of it as well, always like hand hygiene and your social distancing is also very important just to prevent getting infections in that way.
Dr. Jonathan Fialkow:
Yep. I think that's great. And this was pre COVID. It'll be post COVID. I think the concept of just let me have an antibiotic. When I travel in case I needed, if I get cold symptoms, hopefully we've made the case that's not the best decision and not the best behavior for as we said, for the reasons we discussed and any final comments guys, I think you guys really hit some very high level concepts, as well as brought it down to home for a lot of actionable type of thoughts that listeners can have. Tim, anything final, anything you want to iterate?
Timothy Gauthier:
I think it's really important and a take home is that when it comes to appropriate and safe antibiotic use, it's really a team sport. And so it's engaging with the prescriber, with the patient or the family member to understand what's going on, what is the complaint that's currently ongoing and what diagnosis goes along with that complaint? And then pharmacies, pharmacists can be involved to help pick the right drug after the prescriber has made that diagnosis. When it comes to antibiotics and patients who are requesting antibiotics, sometimes it's better to focus on the specific symptom or complaint that is at hand rather than asking for an intervention. So let the physician make the call on when antibiotics are indicated, because they can give the diagnosis that'll tell us what is likely to be causing this problem and is this problem likely to be helped by an antibiotic?
Dr. Jonathan Fialkow:
And that's very gracious of you as a provider. I will tell you, I'll tell the listeners also don't pressure your doctor to give you an antibiotic if they don't think it's appropriate, because sometimes again, it's the concept of, well, what the heck? Just take it. And so be responsible for your own health, as well as those of others. And similarly, Jefferson, any final comments or anything you want to just emphasize?
Jefferson Cua:
Yes, I just want to echo Tim's words. He mentioned it's team sport, really what anti-microbial stewardship is. And I would like to echo that. It does take a village type thing. And this is the whole reason why we think the World Health Organization and the CDC is promoting that awareness campaign. It's because everyone has a role in stewardship again, and our people in the community. It's about just learning more about the drugs and again, not pressuring our clinicians for antibiotics when they don't need it, but also for all of our other health care providers, while our nursing could also play a role like a patient doing better, maybe changing an antibiotic that's given IV to an oral medication, for instance, could also help in preventing line infections and things of that sort. So I think it's definitely, again, it takes a village to help fight resistance. And I think all of us has a role to play.
Dr. Jonathan Fialkow:
Well, thank you both very much. Your expertise is evidenced by the comments and the discussions. I always loved podcasts that I learned from, and I learned from you guys as well. To our listeners. We will have links in the show notes to the CDC webpages for information, more information about this. As usual to our listeners, please email with any thoughts, ideas, or requests for future topics. Please email us at baptisthealthtalkatbaptisthealth.net. That's baptisthealthtalk@baptisthealth.net. Thanks guys for this wonderful information and to our listeners, please stay safe.
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