Missing Microbes Part III: Potential Solutions

This is Part III of IV of my review of Missing Microbes, How the Overuse of Antibiotics is Fueling our Modern Plagues, by Dr. Martin Blaser, head of the Human Microbiome Research Project at New York University. Part I explained how the human body evolved to depend on the services of its resident bacteria, collectively the microbiome. Part II detailed why many people are missing important bacteria species from their microbiomes and the significant health problems that can occur when that happens. This week in Part III, I will discuss some of the potential solutions to those problems.

Americans overuse antibiotics. We are quick to prescribe antibiotics for children with ear infections, which are likely to resolve on their own, and for respiratory infections, 80% of which are caused by viruses and thus not treatable with antibiotics. It is clear that we can reduce our use of antibiotics at least to some extent without sacrificing our collective health. But how can we determine the correct usage rate? As is often the case when confronted with complicated questions, we may be well served by asking ourselves WWSD? What would Sweden do?

Every year in the United States 833 prescriptions for antibiotics are written per 1,000 people, compared to only 388 in Sweden. Are the Swedes being too stingy with the amoxicillin? Let’s compare some health statistics of the U.S. and Sweden to determine if their lower antibiotic usage rate has any negative consequences. As discussed in Part II, overuse of antibiotics has been a major factor driving the rate of obesity in the U.S. to over 30%. While other factors may also have an influence, lower rates of antibiotic use in Sweden are likely a key aspect of their much lower obesity rate of 9.7%. One might assume that our greater reliance on antibiotics would provide increased protection to our infants, whose immune systems are not fully developed. However, Sweden’s rate of infant mortality of 2.7 per 1,000 per year is less than half of the U.S. rate of 6.6. One statistic that leapt off the page for me was the rate of death by intestinal disease, an area of health that is inextricably intertwined with the proper function of the microbiome. It is twenty times higher in the U.S. compared to Sweden. Twenty times! Clearly we should work towards adopting an antibiotics usage rate to something near to or even below that of the Swedes.

We also need to consider some changes to our birthing procedures, both Caesarian and vaginal. As discussed in Part I, the first moments of life are critical in establishing a healthy and diverse microbiome. This is accomplished by allowing the child to ingest bacteria-rich placenta and amniotic fluid, and also by allowing these liquids to maintain skin contact after birth.  Therefore, babies born vaginally should not be washed off the moment they are born. This may seem hygienic to us, but it deprives the infant of the chance to be colonized by important species of bacteria. When a child is born via C-section, we need to try to provide them with any missing bacteria by swabbing the insides of their mouths with fluids collected from the mother’s vagina, and also, if possible, apply after-birth fluids to their skin for a period of time. Several studies have shown that this approach is nearly as effective in establishing a healthy and diverse microbiome as a vaginal birth.

We also need to develop target-specific antibiotics. Nearly all of the antibiotics available in the U.S. are broad-spectrum, such that they kill both pathogenic and beneficial bacteria.   When a patient is critically ill and there is not sufficient time to determine which species of bacteria is involved, then broad-spectrum antibiotics are appropriate and can be lifesaving. However, most bacterial infections are not particularly severe or rapidly developing. Furthermore, use of broad-spectrum antibiotics can weaken the health and vigor of the microbiome and allow a secondary pathogenic bacterial infection to develop while the first is being treated. For non-life threatening situations we should develop diagnostic tests which identify which species of bacteria is/are causing the problem, and then use an antibiotic which specifically targets only that/those species. We have all the medical technology necessary to develop these diagnosis tests and next-generation antibiotics. Furthermore, the task is made easier since the vast majority of serious infections are caused by just 40 species of pathogenic bacteria.

Now that we know what to do, how can we go about trying to achieve it? With regard to antibiotic usage and birthing procedures, we need strong advocacy from our existing and excellent public health resources at the Centers for Disease Control (CDC), the National Institutes of Health (NIH), and the office of the Surgeon General, along with cooperation from the American Medical Society and other similar organizations. The NIH should be provided with additional funding to both conduct and sponsor research on improved diagnostic tests for bacteria and also more specific antibiotics.  It’s also important that the general public be informed of the important medical findings and recommendations in Missing Microbes. That’s obviously my goal with this series. These approaches will help to bring about the necessary changes to our medical culture. In the meantime, I’d suggest raising some additional questions with your medical providers when bacterial infection or birth practices are the topic of your health care needs.

Let me conclude my review of Missing Microbes with a strong recommendation that you read this book. Next week I will publish an epilogue to this series in which I cover some thoughts I have on the implications of Dr. Blaser’s book. See you next week.

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