A question for JREF doctors re: Antibiotics

[Antiquehunter]

Living in Kabul, one occasionally suffers from 'Kabul Belly' - or a general nasty G-I 'issue' with cholera-like symptoms.

When I first contracted this, I went through the suffering of seeing an army doctor on the US Base (As a Canadian civilian - this took some wheedling) and was prescribed 'Cipro' or 'Ciprofloxacin' (sp?) And, I was fixed up in no time. A lovely drug in my opinion - stopped my immediate problem, gave me nice clear skin, stopped my sniffles etc...

We have a new person on our team, and she has come down with the dreaded Kabul Belly. Rather than going through the headache of disturbing the military doctors again, I suggested she take Cipro for a couple of days and only see the doctor if that didn't fix things up.

She won't take it because she says:

"Its a broad spectrum antibiotic and I don't want to develop a resistance"

and

"People shouldn't take broad spectrum antibiotics because they only make the germs stronger"

So - she's suffering and drinking lots of fluids.

Can you please explain to me for my curiosity how antibiotics work, and if there is any truth to her assertions? Is there a magic number to the number of times I can take Cipro before it stops working? By occasionally taking a course of Cipro to clear up an infection am I contributing to the evolution of some nasty mega-bug that will wipe out humanity?

-Oke

 

[Freakshow]

Living in Kabul, one occasionally suffers from 'Kabul Belly' - or a general nasty G-I 'issue' with cholera-like symptoms.

When I first contracted this, I went through the suffering of seeing an army doctor on the US Base (As a Canadian civilian - this took some wheedling) and was prescribed 'Cipro' or 'Ciprofloxacin' (sp?) And, I was fixed up in no time. A lovely drug in my opinion - stopped my immediate problem, gave me nice clear skin, stopped my sniffles etc...

We have a new person on our team, and she has come down with the dreaded Kabul Belly. Rather than going through the headache of disturbing the military doctors again, I suggested she take Cipro for a couple of days and only see the doctor if that didn't fix things up.

She won't take it because she says:

"Its a broad spectrum antibiotic and I don't want to develop a resistance"

and

"People shouldn't take broad spectrum antibiotics because they only make the germs stronger"

So - she's suffering and drinking lots of fluids.

Can you please explain to me for my curiosity how antibiotics work, and if there is any truth to her assertions? Is there a magic number to the number of times I can take Cipro before it stops working? By occasionally taking a course of Cipro to clear up an infection am I contributing to the evolution of some nasty mega-bug that will wipe out humanity?

-Oke

I am not a doctor, but I do know a bit about pharmaceuticals. Take the following with a grain of salt...

People do not develop resistance to antibiotics. Bacteria develops a resistance to antibiotics. It is simply due to evolution. There is no magic number to the number of times you can take Cipro before it stops working. If the particular bacteria never evolves a resistance to it, then it will always work.

Yes, you might be contributing to the evolution of some nasty bacteria. But your individual part in this is so small, it couldn't be measured. It is an interesting moral stand your friend is taking, but it has no actual practical effect. The world is not going to change due to her taking/not taking antibiotics.

Anyone that has actual professional expertise in this area is free to correct me, and I won't be offended.

 

[CaveDave]

I agree, also from a non-medical background, with Freakshow. I would add that if you start a course of any antibiotic, take the whole course - don't stop when the symptoms leave. If you knock down the weak members, but don't kill the strong ones, the strong have a wide-open place to colonize. That creates something that might be immune the next time, And it is in YOU.

How would your colleague manage to get this drug without seeing a physician? Do they just hand out Cipro over there? I would call that a Bad Idea.

Just my thoughts.

Dave

 

[Antiquehunter]

Pharmaceutical distribution is completely unregulated here. I can walk into a local pharmacy and get pretty much anything I want. Dangerous, agreed. I've been here for about 18 months now and haven't needed anything more than cough syrup and Cipro - but if I wanted say... percodan... it wouldn't take me long to find it.

It is also revealing how CHEAP pharmaceuticals can be! 10X500mg Cipro = 45 Afghanis or a little less than a buck. My folks take various diabetic medications and save about 60% over CANADIAN prices by having me bring them their supplies.

If only shipping was more reliable from Kabul, one could start a web-based business...

 

[Rolfe]

Frankly, if there's a lot of indiscriminate antibiotic-taking going on in the area, avoiding the antibiotics personally isn't going to do an individual the slightest bit of good. The wider practices will probably result in resistant strains appearing, and then anyone can get infected even if they've never allowed an antibiotic to pass their own lips in their lives.

If you have a significant infection with an organism known to be sensitive to a particular antibiotic, for goodness sake take it! And complete the course. That's what they're for. If you never take an antibiotic, then what the hell, it's of no consequence whether resistance develops or not because you're not getting any benefit at all (by choice) in any case!

Try asking her that. Why do you care if antibiotic resistance develops if you never take them anyway?

This isn't an individual thing, it's a societal thing. Responsible use of antibiotics, targeted only at significant infections by known susceptible organisms, has to be society-wide. One person getting on her high horse will have precisely zero effect. All she's doing is depriving herself of the antibiotics during their useful period!

Rolfe.

 

[MRC_Hans]

Antiquehunter:

I suggested she take Cipro for a couple of days and only see the doctor if that didn't fix things up.

Rolfe:

And complete the course.

Note these two statements. The best way to provoke resistance is to stop the medicine as soon as you improve: Those bacteria that survive will be those with most resistance. Darwinism in function. Therefore it is important to achieve overkill, in other words, be sure that they ALL are dead. No survivers=no resistance. There are other problems, like remains entering the sewage system, but that's another matter.

So, if the label says take them for 8 days, do it, even if you feel much better after 3.

ETA: Oh, and disclaimer: I'm not a doctor. ....still..........

Hans

 

[roger]

What MRC_Hans said.

Plus, I'm a mountaineer, so we tend to travel to out of the way places with our own, extensive medical kits (hard to find a doctor half way up K2). The latest advice in these situations is to take a Cipro "bomb". That is, you take a triple dose all at once the first day, then continue with the normal course. The thinking here has nothing to do with making you healthy, but to guarantee 100% kill of the bacteria as soon as possible. Otherwise, you'll be crapping/vomiting/whatever resistant bacteria all over the landscape, making the problem worse.

Note I am not a doctor, only relating what doctors have told me. As I haven't left the country for this sort of activity in 2 years, perhaps the thinking has changed. I.e., don't act on my advice w/o talking to a professional.

 

[Roboramma]

Try asking her that. Why do you care if antibiotic resistance develops if you never take them anyway?

Maybe she cares about other people or something...

Not that I'm saying that her stance makes that much sense. I might be wrong, but isn't it true that using antibiotics responsibly isn't the problem? It's things like the others were mentioning - cutting your course when the symptoms go away. Also, isn't it true that indiscriminate use of antibiotics is also part of the problem? Like taking antibiotics when to treat a viral infection and whatnot?

And I do think that people who knowing will cut their course short when the symptoms first disappear are wrong to do so. Is the effect microscopic? Sure, maybe, but that doesn't mean there can't be a moral stand there. But maybe I should avoid starting a debate on morality here...


As an aside to all this, I have a little anectodal story to share about antibiotic use.
In hong Kong, where I used to live, and my girlfriend currently does, there seems to be a tendancy amoung doctors to underprescribe antibiotics - that is the course will be maybe two days. Then you have to go back to the doctor to get another prescription. It seems to me that this practice will only serve to increase antibiotic resistance there.

That said, this information only comes second hand. I've never been prescribed antibiotics in HK. My girlfriend has mentioned it a few times, and uses the point to argue that it's better if you can just go out and buy your own without a prescription. I don't agree - the doctors should just prescribe a full dose the first time.
So, anyway, take it with a grain of salt. But maybe someone else can comment presence or absence of this practice.

 

[Eos of the Eons]

As others have stated, you won't develop resistance.
It doesn't make the microbes stronger either.

What could happen if you don't complete the series is that you could leave behind the survivors. Then only those survivors (who have so far not been killed by the antibiotic) are left to re-populate the infected area. At first there were only a few, now suddenly there are bazillions left to reproduce. If these survivors survived because they DID have some sort of resistance, then you've let resistant bacteria take on a strangle hold without any antibiotic hindering them, so the likelihood of them surviving another dose of antibiotic is suddenly wildly increased. If they survived because they were just lucky enough to be left behind so far, then you just have the same problem on your hands as before, and they can be easily killed off by an antibiotic.

So take the antibiotic, all of it. Kill off all the bacteria or help the body fight it off more easily so it can take care of the ones that might be better surviving the antibiotics.

The ironic thing is that silly woman is allowing them to breed, and she could breed out a strain that has mutated in a way that is resistant as well. Maybe resistant to antibiotics or maybe resistant to her own body's immune system. It's less likely they resist an antibiotic (not having that selection factor), but letting huge numbers like that survive and ravage her insides for days could allow any number to mutate and find a way to resist her body's attempts to kill them too.

How long are people usually sick if they don't get treatment?

 

[Antiquehunter]

How long are people usually sick if they don't get treatment?

Good question. When I went to the Dr. my tests came back positive for E.Coli - so I don't want to guess what happens if you leave this untreated. I was sicker than a dog until I got the Cipro into me. Apparently Kabul has the highest airbone human coliform count of any major city - dunno if this is true or apocryphal but I can imagine its close. There is no sewage treatment here of any kind.

If she hasn't seen a quack or started to take some kind of stance by tomorrow AM I'm going to personally take her to the base.

Kabul is not a pleasant place to be ill. I can't imagine being SERIOUSLY ill here...

-Oke

 

[Rolfe]

Good question. When I went to the Dr. my tests came back positive for E.Coli - so I don't want to guess what happens if you leave this untreated.

Hmmm, don't jump to too many conclusions here. If you don't have E. coli in your guts, there's something wrong. It's one of the five principal commensal bowel flora organisms.

However, there are certain substrains of E. coli which are pathogenic. Of which O157 is probably the best known and most lethal. The likelihood is that you tested positive for a known pathogenic strain. However, without knowing that for sure, and which strain it was, there's no telling what would happen if you went for the benign neglect option. (And there are still clinicians who look at a faecal bacteriology report and flip when they see the very words Escherichia coli, without remembering that unless otherwise stated these are harmless, indeed necessary commensals.)

It's a thought, when treating diarrhoea, that while you may want to kill off the pathogen, you really would rather not kill off the commensal flora. Sometimes there's no option, if you have a really evil pathogen. But then, sometimes it's better to let the organisms settle the issue among themselves, as the commensals will almost always win in the end.

But in a hot climate, with questionable water, and known pathogens floating around - me, I'd probably take the tablets!

Rolfe.

 

[Deetee]

The usual cause of traveller's diarrhoea is infection with a strain of E. coli that produces a toxin which inflames the bowel wall, causing diarrhoea. This is EnteroToxigenic E. coli (aka ETEC), as opposed to other forms of nasty E coli such as 0157 (see what Rolfe said).

The standard course of therapy with a quinolone like ciprofloxacin for this infection is 3-5 days, but I have heard of it being prescribed for 48 hours only and there is certainly evidence that this duration may be clinically sufficient, and there are studies even looking at a single dose.(http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=7983954&dopt=Citation)

However, as others have pointed out, shorter courses can predispose to the selection of resistant strains.
http://aac.asm.org/cgi/content/full/44/6/1731

 

[Ohmer]

Hmmm, don't jump to too many conclusions here. If you don't have E. coli in your guts, there's something wrong. It's one of the five principal commensal bowel flora organisms.

So what are the effects of Cipro killing these bacteria? It’s obviously not nearly as bad as Kabul Belly but it seems to me that there must be some consequence to killing off commensal bowel flora.

This leads me to another question somewhat related to the OP. What do you think of “preventative” antibiotics? For example, my dog got a small laceration on her shoulder that required a couple sutures. The vet who did the work prescribed a course of antibiotics to prevent infection. We gave her the pills, the cut healed and she is doing well.

I’m a minimalist when it comes to pharmaceuticals so I didn’t feel quite right about giving her drugs to treat something that may not exist. I suppose it really comes down to weighing the risks. Thoughts?

 

[Rolfe]

So what are the effects of Cipro killing these bacteria? It’s obviously not nearly as bad as Kabul Belly but it seems to me that there must be some consequence to killing off commensal bowel flora.

It's a risk/benefit call. And some species are less prone to antibiotic-induced screw-ups of bowel flora than others. Even between people, there is marked variation. But basically if the pathogen isn't to aggressive it might be better to let the commensal organisms fight it themselves. Also with Salmonella species you're better not touching antibiotics because that's likely to lead to a carrier state and that is serious bad news. Instead, bland high-fibre diet and maybe something probiotic, and wait it out.

But if you have a really vicious infection of something that's hard to clear by other means, then use the antibiotics and worry about the commensal flora later. Ideally, you should have a culture and sensitivity done before going that route.

This leads me to another question somewhat related to the OP. What do you think of “preventative” antibiotics? For example, my dog got a small laceration on her shoulder that required a couple sutures. The vet who did the work prescribed a course of antibiotics to prevent infection. We gave her the pills, the cut healed and she is doing well.

I’m a minimalist when it comes to pharmaceuticals so I didn’t feel quite right about giving her drugs to treat something that may not exist. I suppose it really comes down to weighing the risks. Thoughts?

Tough call. An injury like that could well heal fine on its own. Many things do. A woman on the radio last week was championing homoeopathy by saying that it had cured her cat of a nasty abscess within a week. (Oh yes, she didn't clean it or bathe it or drain it or use antiseptics on it?) My own cat bit me ten days ago and I've only used topical antiseptics on the wound, which is doing fine. It's stories like that that make you realise how well the body does indeed heal itself given the right support. But on the other hand all vets have seen plenty lacerations like that go horribly septic. And while I can keep a close eye on my bitten hand, and clean it as necessary (and wear tough gloves when gardening), dogs are a lot harder to keep clean, dry and disinfected. So it's hard to argue with a "better safe than sorry" approach. Especially with people queueing up to sue if something isn't done, then for want of that, things go wrong.

Rolfe.

 

[stup_id]

Hello guys...

I'm a fifth year medical student in mexico so the topic interested me...

As with the original post of the stance in not taking antibiotics, in general terms I think is a wise approach.. let me explain: generally people wants to take antibiotics (specially in poorly supervised drug seling countries) for EVERYTHING.. we have a huge problem in our hospital with people developing infections resistant to antibiotics, because they use to take them for even viral infections (which won't work).

So a wiser stand is to not take them until you have seen a health care professional.. now, particularly with the case of the thread, if she's completely sure it is a bacterial infection then taking the antibiotics is certainly the best thing to do but is not excempt from risks. Strong antibiotics can alter the normal flora in the intestine and "wipe-out" the comensal bacteries which help with the normal process of digestion. Since i'm not familiar with the particularities of the disease in that country, I wouldn't dare to give an strong advise of what she should/shouldn't do, but everybody knows their own bodies and the way they react to diseases, sometimes even myself when i've got a gastrointestinal infection, sometimes I prefer to check a few days if my body can take it, and then take the antibiotics (of course this is not something i suggest to anyone.. it is just that i have the posibility of monitoring myself in the hospital if i need it), sometimes i don't even need them...

And about making a difference in not taking the antibiotics to contribute with stronger bacteria, is a matter of publich health which is very concerning, and sometimes individual stance matter for some diseases. For instance Tuberculosis, is a big health issue, since is an infection which needs long treatment (with the best Direct Observation Treatment Shortening...3 months), and the antiTB drugs ban strictly the use of alcohol (because of hepatotoxicity), it is a great concern that a single indivual can develop a multiresistant TB which can't be cured (I've seen myself 2 cases of this in our hospital) and also since the disease is very infectous it carries an extra risk of starting an epidemia.... so i think this is a case where the single stance in the regime of antibiotics can make a huge difference (of course for TB is foolish to take a stand of "NOT TAKING THE ANTIBIOTICS")

Well... I hope I didn't say just stupid things on this topic.. hahaha I'm falling sleep after a traumatology 24 hours ward...

 

[Antiquehunter]

Followup... Took our friend to the US Military base on Friday AM since she hadn't taken anything and was really getting ill. She had gone through 5 X 1.5l bottles of water + fruit juices & soup in the past 24hrs... and I thought she was really at risk of major dehydration since there was a trip to the restroom every 30 minutes or so.

The US Military base was too busy to see her until late in the afternoon, so she broke down and took a 750mg dose of Cipro at about 10:00am and another at 2:00pm and... everything stopped.

She's recovering nicely now and intends to complete a 5 day course.

Thanks for all the info re: antibiotics - I feel much better informed now.

-Oke

 

[Antiquehunter]

The dangers of self-medication...

A humourous story... I just asked one of my local Afghan staff to go out and get me an ointment for the treatment of eczema - having developed an itchy patch on my wrist under my watch strap.

He has just returned with a tube of "Brooks Eczema Cream Homeopathic Medicine - Most effective remedy for all type of eczema"

"Active ingredients" = "Graphites 3X, Sulpher 3X, Chrysarabinum 3X, Pix liquida 0"

Good thing it only cost me the equivalent of 25 cents.

-Oke

 

[Chris Haynes]

Re: The dangers of self-medication...

A humourous story... I just asked one of my local Afghan staff to go out and get me an ointment for the treatment of eczema - having developed an itchy patch on my wrist under my watch strap....

I got that... It was cured when I found out is was a nickel allergy, and I switched to really cheap watches that are all plastic. Nickel allergy is very common.

 

[Nobody]

Glad to here she feels better. It sounds like traveller's diarrhoea.

Personally I don't see the problem with doing without the antibiotic if you think you'll get better by yourself.also, be careful where you buy the Ciprofloxacin as abroad many chemists supply sub-standard quality pills. In her case the treatment sounds justified. If she thinks that her use of the drugs is inappropriate she should see what my cousin does. Everytime she is prescribed an antibiotic she takes it only until she feels better and she saves what's left of the course for future ailments. The other week she had a cold and started taking some Oxytetracycline tablets she had found in her cupboard that were dated last year. I pointed out to her that this was very dangerous because a cold is viral and doesn't respond to such medications, it could certainly select for resistance in bacteria and this particular drug is known to deteriorate over time into toxic by products which can cause kidney damage, hence the danger of using tablets she was given last year. This IS the dangerous misuse of antibiotics.

Whenever possible see a doctor before taking anything as several pathogens can be responsible. Although it is unlikely that cases like this would be like I'm about to describe, it isn't impossible. Some strains of E.coli such as 0157:H7 which produce Verotoxins can be very dangerous if you take an antibiotic to treat them - studies have shown that the way in which many drugs damage the bacterial cell enhances the production of toxins and greatly increases the risk of HUS.

Another problem when you are abroad is extremely drug resistant strains of virulent Shigellae. Although they are usually sensitive to Ciprofloxacin amongst very few drugs, reports of resistance are emerging and they have quickly adapted to every drug used previously. As someone said above, if the illness turned out to be due to Salmonella, drugs wouldn't be indicated unless it was a typhoidial strain or the organism had spread beyond the GI tract.

Anti-diarrhoeals such as Codeine and Loperamide may also be dangerous as they hinder the body's attempt to remove the bacteria from the gut via diarrhoea.

Taking probiotic bacteria such as Lactobacillus acidophillus is known to help as they destroy most coliforms associated with diarrhoea.

If you have a rash under your watch strap maybe you shouldn't wear it for a while.

 

[Rolfe]

Re: Re: The dangers of self-medication...

I got that... It was cured when I found out is was a nickel allergy, and I switched to really cheap watches that are all plastic. Nickel allergy is very common.

Zounds!! Gazumped!

All you need to do is paint the back of the watch with nail varnish.

Rolfe.