The great antibiotic debate
A noted medical researcher was recently asked what we will likely see first: a cure for cancer or a cure for bacterial infections. While confident that cancer will eventually be defeated, he believed the battle against bacteria may never be won. He explained that cancer cells begin when healthy cells mutate, and may even evolve as they grow and spread, but die when the patient is cured or succumbs to the disease. Their evolutionary path ends there. *
Bacteria, on the other hand, have the ability to pass from one individual to another, allowing them to continue their evolutionary journey. In fact, many of the bacterial species we are facing today didn’t exist twenty years ago, and the bacteria of the future will be even more evolved, and more difficult to defeat. Antibiotics have served as a potent weapon, but the war is far from over.
The history of antibiotics started in 1928 with the discovery of penicillin by Alexander Fleming. Although groundbreaking, it wasn’t widely produced until America’s entry into WWII. With memories of WWI soldiers dying almost as much from infection as they did from gunshot wounds, production methods were rapidly increased after the attack on Pearl Harbor in 1941.
Interestingly, Fleming’s later discoveries turned out to be equally as crucial, and prophetic as well. In 1945 Fleming noted that when too little penicillin was used, or for too short a time, the bacteria would adapt and survive. This ‘antibiotic resistance’ as he called it was observed early on in his clinical studies and rendered his penicillin useless.
Of course today we’re well aware of resistant bacterial species, and despite continued development of new antibiotics, some have evolved beyond our ability to treat. Perhaps the most notable example is MRSA, which stands for Methicillin Resistant Staph Aureus. MRSA and other resistant species are referred to as ‘superbugs;’ in the US they are responsible for one death every 15 minutes. And just as Fleming predicted, it was irresponsible prescribing, overuse, and poor patient compliance that led to their emergence.
Recognizing the potential epidemiological effects, the medical community is working diligently with prescribers to be much more judicious in their use of antibiotics. No longer do you get penicillin for the common cold, or amoxicillin for the flu. These are, after all, viral infections. Changes such as these were easy to adopt, but others have been much more difficult due to conflicting evidence, patient demands, and old-fashioned stubbornness.
For patients undergoing dental procedures, the medical community has long recommended premedication with antibiotics for conditions such as joint replacements, certain heart disorders, and for those with a compromised immune system. The rationale is that dental procedures can cause bacteria in the mouth to enter the bloodstream and lead to infection susceptible areas. However, as research continued to broaden our understanding of these processes, we learned that joint and heart infections weren’t caused by bacteria from the mouth, and prostheses developed a protective layer around them soon after implantation.
Over time, the recommendations for premedication were periodically scaled back, reducing the amount of antibiotic taken, conditions for which coverage is recommended, and timeframe of susceptibility for certain procedures. In fact, in a 2014 report conducted jointly by the American Dental Association and the American Academy of Orthopedic Surgeons, a panel of experts concluded that “In general, for patients with prosthetic joint implants, prophylactic antibiotics are not recommended prior to dental procedures to prevent prosthetic joint infection.” 1
If your healthcare provider is recommending antibiotics prior to dental procedures, it is important to understand why. A prior joint or heart infection can be an indication, but also are contributing health conditions (comorbidities) such as diabetes which can affect healing. Your provider should be able to provide a lucid explanation as to why he or she is prescribing them. “Well, that’s the way I’ve always done it” just won’t cut it any more.
Our knowledge will continue to evolve as more research comes in, and the evolution of the bacteria that seek to thwart our efforts will continue too. Bacterial evolution is unencumbered by dogma, bias, politics or profits. Can we do the same on our end of the fight? Can we make the right decisions regardless of conflicting pressures? Can we outsmart the bacteria?
*There are rare exceptions to this, such as the spread of Devil Facial Tumor Disease in the Tasmanian Devil population.
1 The Use of Prophylactic Antibiotics Prior to Dental Procedures in Patients With Prosthetic Joints: Evidence-Based Clinical Practice Guideline for Dental Practitioners—A Report of the American Dental Association Council on Scientific Affairs. JADA. 2015;146:11-16