In order for us to "stop the arms race for stronger and stronger antibiotics", we have to let people infected with resistant bacteria die. In droves. You would be all for this strategy until it's you, or your spouse or child sitting there being eaten alive by MRSA. You could tell your toddler that she's not dying for no reason, and that a few years from now the bacteria won't be as deadly. That'll make her feel better.

Do you really think that this is even remotely realistic in any democratic society?

80% of antibiotic use in the USA goes to farm animals, not people. We could therefore significantly reduce the amount of antibiotics in our environment without affecting human lives.

You could make another very significant reduction by keeping doctors from prescribing antibiotics so often to placate patients who really don't need them.

This would go a long way towards reducing bacterial resistance without changing what treatments are available for truly sick people.

Good luck with that. This would mean regulation, and that would mean going up against corporate farms and their lobbyists as well as the Senators and Congressmen they have in their pockets. America's legislative branch is actively hostile to science and anything that could impact the bottom line of their campaign donors.

I guess the alternative is to hand wave that us scientists can magically solve the decades-building problem that big-agriculture and doctors caused. Sure, we'll get right on it, but there needs to be a plan for the time between when research starts and when a new group of antibiotics is tested and ready for the market. Staged rotating/phasing out certain antibiotics so that they will be usable again after a period of time would ensure that there's something left in reserve for people who actually need it.

Tuberculosis is a prime example of why this is such an intractable problem. 1 in 3 people globally are infected with the TB bacterium. That's >2 billion people!

It is usually dormant, but there's a 10% chance it will flare up into the active - and deadly - state in a healthy individual's lifetime, so it really needs to be treated. It is the top infectious disease killer every year (>1.5 million people, including 140,000 children).

The current treatment regime requires daily doses of multiple kinds of antibiotics for 9 months, and that assumes you're lucky enough to have a strain that is vulnerable to first line drugs. In practice many treatment regimes require multiple antibiotics administered at once, and can take up to 24 months to clear from the body. Second line drugs have severe side effects.

Every time someone misses a dose, they risk creating a resistant strain. In fact, even if you're taking it regularly, there's a chance it will still develop into a resistant strain.

There is simply no way to ensure all of the 2 billion infected people around the world, mostly in low and middle income countries, will (1) be identified, (2) have access to these drugs, (3) consistently take them for 9-24 months even if faced with severe side effects, and (4) be monitored by a professional that can decide when to move to a second or third round of treatment.

A certain percentage of the population will never be treated, abandon treatment too early, or simply have terrible luck and not fully respond to treatment. You just can't identify and quarantine them all. Besides, even if you did, where would you house them? For how long, the 24 months of treatment? The rest of their lives?

It's also important to remember the human element here. We can't cycle/phase out antibiotics, even if you did manage to get every doctor in all 190+ countries of the world to agree to do so. What would you do if you or your baby needed treatment, but a doctor told you "no, we won't prescribe the most effective treatment because we're worried in 30 years it won't be effective anymore." Without effective treatment, an active case of TB has a 45% chance to lead to death. It's also in everyone's interest that that infected person be cured asap.

Finally, it's highly doubtful draconian containment or drug cycling restrictions would even work. Drug resistant genes are already in the natural environment. Life finds a way. In 2012, doctors found a strain of TB in India that is entirely resistant to =all= known treatment. They found 12 cases in one hospital alone. Most facilities don't know how to identify it, so it's spreading out there, right now.

Quarantine and treatment can slow the progression of resistance, but it simply can't be reversed. 3.5% of new cases every year are already resistant to =multiple= drugs. We will need to develop an entirely new model over the next century to eliminate these bacterial infections.

Different antibiotics have different pathways, much like barbituates and amphetamines have different pathways, despite both getting you high. Perhaps if we use only pathway "A" for a decade, bacteria will lose resistance on pathway "B" (and vica versa)?

(tldr; household cleaners with antibiotics mean that when you do get sick, it won't be something that can be cured)

Using hand soap with triclosan has antibacterial properties, none of which contribute to antibiotic resistance. There are lots of reasons to quit using antibacterials in your house, and I have stopped, but contributing to the antibiotic resistance problem is not one of them.

http://online.liebertpub.com/doi/abs/10.1089/mdr.2006.12.83

(as far as I know, antibiotic and antibacterial are largely synonymous)

Not really.

Antimicrobial: an agent that kills bacteria or fungi.

Antibiotic: an agent that kills bacteria or fungi in the body.

This is a crucial distinction. Phenols have been around as antimicrobial disinfectants for over a century and a half, but you really don't want to take them internally. Whereas something like penicillin VK -- alas, no longer very useful due to widespread resistance -- is pretty much safe to take in large doses, unless an immune response arises.

We've got plenty of antimicrobial agents; what we're short on are ones that don't poison us along with the target organisms when we take them.

Ok, I see how the use of Tricolsan could lead to bacterial resistance. But just to point out what jeremyt said above, Triclosan is definitely not an antibiotic. But the effect is the same.

I think that in the long term this will be a draw, we will need to discover new antibiotics, some bacteria will discover new resistance. (For the more nasty variants we can have to use other tools like vaccines.)

Researchers and funding moved on to sexier things. From a capitalist perspective, it's much better to wait for resistant bacteria than produce yet another antibiotic in a crowded field.

It's starting to pick up again. My money is on a continued battle until we develop nanomachines or wipe ourselves out.

[1]https://en.wikipedia.org/wiki/Timeline_of_antibiotics

The really challenging thing with antibiotics (as a reply below notes) is that if you create a great new antibiotic, nobody will use it unless they have to.

There is resistance out there, but for most infections, the 40+ year old antibiotics work just fine. It's not like almost every other disease where the best drug gets used first line.

Unless the financial incentives are fixed, it's unlikely there will be enough incentive to do the R&D to create new antibiotics.

1: http://www.radiolab.org/story/best-medicine/

The key information they presented was that just because bacteria evolve quickly to modern forms of antibiotics, doesn't mean they don't also reduce to their tolerance to older (in this case, 1000 years older) antibiotic-like medicines that we would dismiss outright because it wasn't created in the modern age. Old medicine was very much trial and error, but it doesn't mean it can't also be effective or worth looking into deeper for ideas.

First of all, we will still have the Germ theory of Disease. Much of the early gains in lifespan from modern medicine came from the awareness of the correlation between cleanness and healthiness. For as long as we can support infrastructure for proper sanitation and disposal of dangerous agents, those gains will persist.

Second, we will still have vaccination. Many dangerous diseases are kept at bay not by heavy use of drugs but by immunization the population instead. This technique is also subject to diminishing returns due to bacteria evolution, but the dynamics are different. Over use antibiotics and you end up with resistant diseases; reach full immunization and you root out the disease out of your population.

Third, we have better palliative care now. Even if everything else fails, we are better prepared now to keep people alive long enough for their own antibodies to fight off most diseases.

This will be shitty for our current expectations - to be able to take a pill and bounce back in a day or two. But it does not mean either that half of our children are going to die of colds or tummy aches or anything like that.

What's actually going to happen: We're going to have an epidemic of some sort of drug-resistant bacteria in the Western world--maybe that incurable TB that's going around, maybe something else. A few thousand Westerners are going to die--people the Western world actually cares about, as opposed to them poor people in them third world countries that are always dropping like flies anyway.

There'll be a media hysteria similar to the Ebola crisis. People will suddenly realize that antibiotic resistance isn't just a problem affecting poor people in third world countries, but that it is now a problem threatening them and their children.

The resulting media blitz will educate even the average idiot about the importance of taking the full course of antibiotics even if you feel much better already. Antibiotic use on lifestock will be banned. Western governments will pressure China and India into stopping the unrestricted sale of antibiotic. Western doctors are finally going to realize that prescribing antibiotics like candy just to shut a patient up is a mistake even if the patient is yelling really loudly. Developing a new antibiotic is sudenly going to be a lucrative or at least PR-relevant strategy for Big Pharma, instead of a likely fincancial loss. Hospitals are going to be forced to actually deal with the problem of MRSA. (Right now, many patients that should be tested and isolated aren't tested because there's no room to isolate them in case of a positive result.)

Within a few years, drug resistance will taper off sharply, without antibiotics ever losing their use except in the case of a few rare resistant diseases, which will be tested for and isolated. Problem solved.

These are all things we could do right now, if we wanted to, we just don't care about the problem enough. The moment it becomes big enough to interest the majority of the population, we know how to solve this.

Or are you (and I include in "you" any human being with the choice) going to want every antibiotic available for your loved one?

Maybe I miss the point of your comment, but if not, I doubt it is a viable strategy.

I don't know if we're going to need to "sacrifice" people who have poly-drug resistant bacteria, but I'm guessing it won't be in our control anyway, if the option is between doing nothing and the patients dying versus doing everything we can and still having the patient die. Damage control is critical, and sentimentality can't get in the way.

FWIW, I wrote an in depth report on controlling poly drug resistant tuberculosis in poor countries when I was in college... the conclusion was that quarantine was not only necessary, it was the only effective course of action for people with full spectrum drug resistant TB. Of course, TB is far more infectious and lethal than garden variety "bacteria".

The only thing to do is to remove the "apply antibiotics because it looks like we're doing something" and save the antibiotics to use for cases where it will actually work.

From recent experience of being hospitalized with pneumonia, they were pumping me full of antibiotics and asking questions later. The culture on my sputum never came back with a clear answer even a couple days later. But they found an antibiotic that worked. I doubt I'll ever know what bacteria ultimately caused the infection. Clearly it was resistant to a few antibiotics that weren't working. Should they instead have left me with a 104 degree fever near death for a few days while trying to figure out if antibiotics would be effective or not, even though the culturing process might not even give a clear answer?

It's going to be costly but we're "back-loading" our medical process so that we leave the problem to the next generation of healthcare providers.

It's like we want everything for free - get sick? just give out a ton of medicine! Eventually we have to pay for it.

Are you sure you've thought this through?

It's going to suck though for those people who have anything that is resistant to multi-spectrum antibiotic treatment.

Yet folks continue to harp on 'restrict antibiotic use'. What have I overlooked?