Too Much of a Good Thing
Everything in excess is opposed to nature. –Hippocrates.
The discovery of antibiotics in the early 20th century dramatically altered how infectious diseases impacted humanity worldwide, but particularly in developed countries. Prior to the 20th century, disease-causing organisms were the leading cause of death and average life expectancy at birth was about 47 years. Because of antibiotics, the average life expectancy in the US is now around 78 years and non-communicable diseases—cardiovascular disease, cancer—now are the leading causes of death.
Unfortunately, bacterial resistance to antibiotics has kept pace, setting the stage for potentially multi-drug resistant superbugs that simply cannot be treated. Antimicrobial resistance happens when organisms develop the ability to defeat the drugs designed to mitigate them.
The terms “antibiotic” and “antimicrobial” may appear to be used interchangeably, but there is a difference. Antimicrobial resistance is the ability of certain pathogens to resist targeted drugs meant to kill them or disrupt their growth. Microbes encompass not only bacteria, for which antibiotics are the targeted drugs, but other organisms, such as viruses, fungi, and parasites. All microbes can become drug resistant, which is only the organism’s desire to survive.
The World Health Organization (WHO) considers antibiotic resistance to be one of the largest health threats. It cautions that an increasing number of infections are getting harder to treat as antibiotics, over time, become less effective.
According to the Centers for Disease Control and Prevention (CDC), more than two million illnesses occur annually in the US due to antimicrobial resistance, resulting in approximately 35,000 deaths. In addition, patients who have been hospitalized and receive antibiotics are more vulnerable to develop potentially lethal infections, such as Clostridium difficile.
Antimicrobials are invaluable tools. However, the overuse and misuse of these medications is accelerating resistance. The CDC estimates that five out of six Americans are prescribed an antibiotic annually, but one-third of those prescriptions are not necessary.
The use of antibiotics that the WHO deems critically important for human health increased 91 percent worldwide and 165 percent among low- and middle-income countries (LMICs) between 2000 and 2015. Of note, many of these countries allow access to these medicines without a prescription.
Antimicrobial use in farming has enabled the growth of intensive animal production to meet global protein demand. However, studies indicate approximately three-quarters of all antimicrobials prescribed globally are used for animals raised for food. Of the top five countries reporting animal husbandry antimicrobial usage in 2017, China was number one, accounting for 45 percent of the medicines utilized.
Here in the US—number four on the antimicrobial usage list—up to 80 percent of the antibiotics given to livestock are administered to healthy animals to compensate for crowded and unsanitary conditions, according to the Natural Resources Defense Council (NRDC). Food and Drug Administration (FDA) data indicates not only are vast amounts of antimicrobials being used, but they are also being prescribed at much higher doses, even adjusting for the weight differentiation between animals and humans.
Human activity can contaminate the environment, exacerbating antimicrobial resistance. Fecal waste, even when treated, often contains trace amounts of antibiotics, as well as drug-resistant organisms. In many LMICs, human waste enters the watershed without treatment. Like human waste, manure from antibiotic-treated animals carries residue. Manure is often used as fertilizer, expanding opportunities for resistant organisms to spread among food sources.
Several pesticides are similar in chemical structure to certain antimicrobials. Their use contributes to antimicrobial resistance. Like humans, animals have active internal germ biomes. When slaughtered, antimicrobial resistant organisms can pass to humans if not processed or cooked correctly.
Launched in October 2015, WHO’s Global Antimicrobial Resistance Surveillance System (GLASS) provides a standardized approach to the collecting, analyzing, and sharing of antimicrobial resistance data among participating countries. GLASS is focused on eight priority bacterial pathogens in humans, considered the greatest threats globally. GLASS is also collecting information on participating countries’ progress in establishing national surveillance systems. WHO hopes to expand the data collection system to include other types of resistance-related surveillance, such as in the food chain and in the environment.
In 2013, the CDC published Antibiotic Resistance Threats in the United States, a first-ever snapshot of the risks posed by antibiotic-resistant organisms. Following the CDC’s 2013 seminal work, the Obama Administration issued Executive Order 13676: a national action plan which outlined steps for implementing the National Strategy for Combating Antibiotic-Resistant Bacteria. Since then, the CDC and other national policy and regulatory bodies have outlined core elements for mitigating resistance through antibiotic stewardship programs across all levels of healthcare.
Whatever progress made by these think tanks was halted and ground was lost during COVID. The CDC estimates in the first year of the pandemic, close to 30,000 individuals with COVID died from antimicrobial resistant organisms. Moreover, CDC data indicates that the pandemic resulted in more resistant infections, increased and unwarranted antibiotic use, and less data and fewer prevention actions. These points also have been reinforced internationally through WHO and Pan-American Health Organization reporting.
We all play a part in fighting antimicrobial resistance. Individually, take stock of your health and routinely use preventive health strategies: wash hands, know the sources of your food and cook food properly, and get vaccinated to minimize acquiring preventable diseases.
Healthcare providers play an essential role in preventing and managing infections. They must:
• Know community vulnerabilities to disease outbreaks, and ensure patient care is evidence-based, promptly delivered, and changed based on current conditions.
• Question patients and visitors about current health status and recent travel.
• Be judicious about prescribing antimicrobials and ensure patients fully understand how to take them.
• Know when and how to promptly forward information on communicable diseases into national databases.
Livestock and poultry producers are also key in helping to reduce the development and spread of antimicrobial resistance. Key points:
• Use antimicrobials only to treat sick animals, not to increase profit margin.
• Implement bio-security practices, techniques to prevent the introduction and spread of diseases.
• Adhere to evidenced-based animal welfare and waste management practices.
If COVID has taught anything, it is that we all must do our part to ensure the sustainability of a healthy, functioning world. It’s the only one we have.▼
CAMP Rehoboth Partnering with Yale LGBTQ Mental Health Inititiative
Increasing the number of LGBTQ+ affirming mental healthcare providers for all ages in Sussex County and throughout Delaware is a health advocacy issue that is receiving support from CAMP Rehoboth and Yale University. CAMP Rehoboth Community Center and the Yale LGBTQ Mental Health Initiative, in partnership with CenterLink, will participate in federally-funded research regarding a training program in LGBTQ-affirmative cognitive behavioral therapy (CBT).
CAMP Rehoboth has identified mental healthcare providers in Sussex County who have agreed to participate in this training and research. (A mental healthcare provider is defined as a person who is qualified to provide counseling services intended to alleviate distress or improve behavior.) This training will be led by Yale’s expert trainers, all of whom are licensed psychologists and nationally recognized developers of LGBTQ-affirmative CBT training. Once the training and research are complete, CAMP Rehoboth will have a longer referral list of LGBTQ affirming mental healthcare providers serving the LGBTQ community.
In June 2023, the Substance Abuse and Mental Health Services Administration (SAMHSA) released a report, Lesbian, Gay, and Bisexual Behavioral Health: Results from the 2021 and 2022 National Surveys on Drug Use and Health. Survey results indicated that lesbian, gay, and bisexual adults are more likely than straight adults to use substances, experience mental health conditions including major depressive episodes, and experience serious thoughts of suicide. The Trevor Project’s 2022 National Survey on LGBTQ Youth Mental Health demonstrated that rates of suicidal thoughts had trended upward among LGBTQ young people the previous three years.
CBT helps people:
• Learn techniques for coping with stressful life situations
• Identify ways to manage emotions
• Resolve relationship conflicts and learn better ways to communicate
• Cope with grief or loss
• Overcome emotional trauma related to abuse or violence
• Cope with a medical illness
• Manage chronic physical symptoms
More information on the Yale University LGBTQ Mental Health Initiative can be found here: medicine.yale.edu/lgbtqmentalhealth/
Sharon A. Morgan is a retired advanced practice nurse with over 30 years of clinical and healthcare policy background.