Resisting Resistance: all's not well with antibiotics

I would argue that the most important invention of the last 200 years is the Uncrustable. The fact that it tastes divine as both a frozen and air-fried food, to me, demonstrates its largess in the halls of human ingenuity.

However.

Some would argue that antibiotics could potentially best the Uncrustable. I guess I can (begrudgingly) see their point. So, we’ll leave the Uncrustables discussion for another day.

The first antibiotic ever developed was called Salvarson and began use in 1910. Then in 1928, Sir Alexander Fleming discovered the antibiotic that would begin the antibiotic revolution, Penicillin. From 1928 to the 1970s, antibiotic discovery thrived and humans benefitted hugely. At the beginning of the 20th century, the average life expectancy of someone in an industrialized nation was 47. By 1980, the average life expectancy in the US was about 74. That’s an increase of 27 years. Antibiotics were largely responsible for this.

Antibiotics made it possible to treat diseases such as typhoid fever, pneumonia, cholera, smallpox, tuberculosis, and syphilis. They also opened up whole new avenues of medical treatment, such as open-heart surgery, some cancer treatments, and organ transplants. Essentially, antibiotics changed life on Earth for the better. They made our lives longer and healthier.

However, there’s something amiss in the world of antibiotics these days. The 1960s-1970s were considered the golden era of antibiotics, but since then, there have been comparably few significant antibiotic discoveries. T add to this, antibiotic resistance is starting to have its moment. I’m not super excited about it.

Resistance to antibiotics is…well, really not good. Imagine when the Death Star destroyed Princess Leia’s home planet, Alderaan. Antibiotic resistance is…ok, it’s not as bad as that, but it is still definitely bad. In 2019, there were an estimated 1.27 million deaths directly attributable to forms of antimicrobial resistance - with antibiotic resistance being the largest contributor - and a total of 4.95 million deaths where AMR was a factor. That’s like two Chicagos, or four Austins, or 19 Salt Lake Cities.

And it’s getting worse each year. The bacteria keeps getting smarter, bit by bit.

How does this happen? A couple ways:

In the US, we’ve implemented rules and regulations around antibiotic use to (hopefully 🤞 ) stop the madness. Or at least slow it down and give the science geniuses time to science and find new drugs. Overall, we’re doing significantly better with our antibiotic use than we were 20 years ago.

With humans.

We’re doing well with human antibiotic use.

I guess I forgot to mention that we’re doing fantastically poorly with animals 🤷 and it is starting to be a problem.

The term “animal agriculture” seemed unnecessarily clinical a term for raising livestock when I first read it. That was until I came across the term “factory farming,” which feels much colder, but, if I’m being honest, is closer to the truth of what’s going on.

Now, I want to preface this. I am not against eating meat. Do I think we as Americans eat too much meat? Sure. That’s just kinda known. I believe there are ethical ways of raising animals for food. Some of you may disagree and that’s ok. But whether you agree or disagree, the way we raise approximately 99% of livestock in the US is cruel in many ways.

It’s also self-destructive.

You see, use of antibiotics in animals doesn’t just affect animals. Antibiotic resistance that develops in animals can spread to humans, and quite quickly. For example, in 2013, a specific type of resistance was discovered in E. coli isolated from a pig. Within 5 years, that same strand of resistance was found in samples collected from humans across the globe. Analysis of the resistance showed that it had first developed in 2006, meaning that the time“from its first emergence to its global distribution in humans was less than ten years.”

In the United States, of all the antibiotics sold, about 80% are used in animal agriculture. Nearly 70% of these are classes of antibiotics that are important in human medicine. Yes, there are more animals raised for food in the US than there are humans, but the issue goes beyond simply the total quantities sold.

Intensity of use, which is essentially how much is being used per kilogram of animal, is increasing. From 2017-2020, while the intensity of antibiotic use in humans decreased by 26%, milligrams of antibiotics used per kilogram of livestock weight (mg/kg) increased from 162.0 mg/kg to 170.8 mg/kg. This is despite active efforts by the FDA to ensure appropriate use of antibiotics in animal agriculture.

Starting in 2012, the FDA began an effort to improve antibiotic use in animal agriculture. They began with some basic guidelines that included veterinary oversight and consultation as a key principle. They followed this up in 2017 with guidelines that required that antibiotics important in human medicine would require veterinary oversight. Essentially, moving them away from being over the counter but not quite at the level of prescription medication.

The FDA feels this has been a huge success! But a statement I found made me question this. In 2016, the American Farm Bureau Federation, one of the largest groups representing farmers in the US, stated they “would accept veterinarian oversight of antibiotic use, where veterinarian oversight is defined as a working relationship with a licensed veterinarian.” A “working relationship” is a loosely defined term that essentially means that a vet has some degree of involvement in a farmer’s operations.

Whenever the industry getting regulated suggests or says that would accept certain regulations, it makes me think that perhaps those regulations aren’t going to do much (I’m looking at you OpenAI).

Turns out, this is (sort of) the case. The regulations the Farm Bureau said they would accept were pushed out by the FDA in 2017, increasing the requirements of veterinary oversight over antibiotic use. The 2017 guidelines initially had a positive affect. They’ve reduced antibiotic use by 50% since the peak sales/use in 2015. However, from 2017 until 2022 (the most recent year with published data) antibiotic use has started increasing.

And, ultimately, the intensity of antibiotic use in animal agriculture is still so far above use in humans that it feels like we’re playing with fire. And while these regulations - a new one came out in 2023 giving veterinarians more oversight - have moved the needle a bit, I think more can and should be done.

I see arguments for and against factory farming often get broken down into two thoughts:

Neither is the whole picture. The issue is much more nuanced.

The bottom line is that factory farming isn’t the best we can do. It creates environments where animals often need significant doses of antibiotics simply to live long enough to make it to slaughter. As talked about above, this is adding to the very real and very import issue of antibiotic resistance, an issue that could make simple cuts life threatening injuries. It is also a ripe environment for other diseases to develop and spread such as viral or fungal infections.

Interestingly, this is a space where most people across ideologies agree, and so feels like an area we should focus on to make change. In a 2020 article published in National Review, author Spencer Case makes a compelling argument that “factory farms are hazardous work environments, and they produce enormous amounts of untreated animal waste that we have to deal with. But of the many anthropocentric considerations against factory farms, the most compelling is that they elevate the risk of pandemic diseases.”

Ultimately, there are a lot of reasons factory farming should reform. But biggest among them, to me, is the possibility that are negligent use of antibiotics could forever change our ability to live long, healthy lives.

And don’t worry. I promise the next issue discussed will be a little less of a downer 😅