# WORLD CONCERN GROWS OVER BACTERIAL RESISTANCE: Intro To The A.P.U.A.



## Mike NoLomotil (Jun 6, 2000)

An issue that has been discussed from time to time in the community of IBS sufferers here and elsewher, the symptoms of IBS are at times misdiagnosed pathogenic responses, or IBS patients are among those whose underlying disease can be complicated by infection.As concern in the worldwide medical community grows, many organizations are trying to increase thee awareness of the problems stemming from decades of antibiotic overuse and antimicrobial agent environmental overuse. This is a subject of interest and concern to all.This is a brief introduction to the Alliance For The Prudent Use of Antibiotics (APUA) and their webiste is at www.healthsci.tufts.edu/apua/home.html I encourage memebers of this community to the need for awareness and self-education, as these organizations encourage the medical profession to take corective action.Another excellent source of current info is the World Health Organization Antimicrobial resistance Info Bank at http://oms2.b3e.jussieu.fr/arinfobank Here is a brief explanation of the APUA and its mission FROM THE APUA:--------------------------------WHAT IS THE APUA?We're dedicated to curbing antibiotic resistance.Antibiotic resistance is one of the major public health threats of the 21st century. Since 1981, APUA has been the premier organization dedicated to promoting proper antibiotic use and curbing antibiotic resistance worldwide. We promote global public health by raising public awareness through education and research projects on proper antibiotic use and antibiotic resistance With members in over 90 countries and international chapters, we support country-based activities to control and monitor antibiotic resistance. We facilitate the exchange of up-to-date information by forging international partnerships among scientists, healthcare providers, consumers and policy makers.We have a professional staff with expertise in medicine, microbiology, health education, policy analysis, development and advocacy, ecology, international program development and communications, with leadership from recognized medical and scientific experts, including Nobel laureates and members of national academies of medicine and science.---------------------------------------------OUR ProgramsWorking in collaboration with organizations such as the World Health Organization, US Agency for International Development, Centers for Disease Control & Prevention, local Departments of Public Health and Foreign Ministries of Health, APUA reached thousands of consumers, healthcare practitioners, researchers and policy makers worldwide with our ongoing programs.Education & AdvocacyThrough educational programs and advocacy efforts, we build awareness among healthcare practitioners, policy makers and consumers about improving antibiotic use to preserve antibiotics for future generations. Conducted workshops and major conferences in the developing world to promote the prudent use of antibiotics. Presented lectures on antibiotic resistance to over 9,000 primary care practitioners at major regional and national healthcare conferences throughout the US. Distributed our quarterly scientific newsletter to over 10,000 individuals in more than 90 countries. Developed website with an intuitive interface to meet the varied needs of our growing audiences. Developed a small grants program to provide seed money to support projects conducted by our foreign-affiliated chapters. Presented testimony and served as advisors at meetings held by public health groups such as the World Health Organization, US Institute of Medicine, US Food & Drug Administration, US National Institutes of Health and several US Congressional hearings. Conducted interviews with journalists and writers, resulting in television appearances, radio segments, press conferences, and newspaper and magazine articles on the problem of antibiotic resistance and our efforts to improve the use of antibiotics. Research & SurveillanceThrough research and surveillance projects, APUA defines trends in antibiotic prescribing and resistance patterns, and develop strategies to curb antibiotic resistance and improve antibiotic use. Convened international roundtables on antibiotic resistance surveillance with participants from regulatory and scientific groups. Conducted a pilot test to integrate data from the major surveillance systems to determine the feasibility of developing a global databank to monitor antibiotic resistance trends. Surveyed the attitudes of physicians in Massachusetts to determine reasons for prescribing antibiotics that will enable us to develop tools to improve prescribing habits. Conducted regional survey regarding antibiotic use in Latin America to determine how to maintain antibiotic efficacy in the region. Developed first international research network and website on antibiotic resistance in non-pathogenic bacteria._________________________________________MNL_________________________________________ www.leapallergy.com


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## moldie (Sep 25, 1999)

Sounds like a great organization long over-due but at least now in existence. Thanks for posting it Mike. It is too bad that better controls couldn't have put into place before the epidemic proportions. I believe the CDC knew about this at least by 1995 when they began to alert the medical profession.I especially enjoyed this News Page Mike: http://www.healthsci.tufts.edu/apua/News/news.html [This message has been edited by moldie (edited 10-01-2000).]


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## flux (Dec 13, 1998)

> quote:I believe the CDC knew about this at least by 1995


I think this idea has been bandied about for a few decades.


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## Mike NoLomotil (Jun 6, 2000)

MOLDIE:What FLUX said is interesting and truer than most people realize.When I entered college in 1970 to start basic sciences until i decided where I wanted to go in the medical field (I was trying to pick betwee RT and Nursing) in my first semester of college I took microbiology.The only lecture of his that I never forgot in 30 years was his lecture on the overuse of antibiotics, specifically using antibiotics for viral infections...usesless except to create dnagerous bacterial resistance. Every professor I had that semester (esp. the introductory pharmacology guy) said the same damn thing.Then I watched it being ignored in the hospital and out for the next 30 years... and so here we are.MNL


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## moldie (Sep 25, 1999)

I figured as much. The reason I mentioned the year 1995 is because I just saw an article about this in the newspaper a couple of weeks ago. I suspect that is just another year that they decided to inform the medical profession again. Of course there have been studies and info going on since the 70's, as I am aware of some in the books I have read in the past. Mostly, the real indication was from actual drug books that list possible side-effects. Do you think it was pressure from the pharmaceutical companies whose salespeople tended to leave out/minimize the possible side-effects in their conversation with the physicians (and maybe the docs didn't take the time to read all the small print?). Perhaps it was that doctors didn't take into account the long-range effect, overided by their immediate success rates of antibiotic usage in the past? Perhaps a little of both. Seems a quick fix is not always so in the end.Here is another interesting page I found there: http://www.healthsci.tufts.edu/apua/Newsle...sletterTOC.html I'd be interested in seeing more articles that warned of prolonged antibiotic therapy as early as the 70's and 80's, specifically the side-effects of such therapy. If you have any on these flux, let me know.


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## Mike NoLomotil (Jun 6, 2000)

MOLDIE:Actually, from what I saw working in direct contact and side by side with doctors and on patients all those years, in large part the pressure actually would come from the expectations of the patients themselves.With the advent of the antibiotic revolution spawned by WWII and penicillin et al, people came to expect the doc to give them a drug-cure for every sniffle and fever. Often in the days of the 60-70's, the doctor would feel compelled to oblige, even in the face of viral infection and absent culture and sensitivity studies.Before TEFRA, remember, the healthcare system in the USA was a buyers market. "Blue Cross/Blue Shield" was synonymous with health insurance, which paid on an as-billed basis. You bill it they paid it. The market controlled pricing.So, a doctor was often forced into sensitivity about keeping a happy patient, who would jump to another doctor (across the street) at the slightest whim of dissatisfaction. So WE made it self-fulfilling ourselves in many ways (not we personally but we as customers).Once the new healthcare system evolved over the decade following TEFRA, and controls were placed upon the use of antibiotics and other drugs to a degree, and patients could not just jump doctors because Dr. Welby did not give little Bobby a penicillin shot for his sniffles, unfortunately the genie was out of the bottle.Pharmaceutical companies are like anyone else. They are not in business as altruists, they are in the business of making money for the shareholders and drugs are the vehicle. So they have, by using the system, over the years grown very powerful, influential, and have been given the leeway and even the regulatory and tax incentives to drive themselves and their industry to the top of the profit heap in the USA...to the point the entire healthcare system revolves around that axis.This is not intrinsically evil or good...it is just a matter of doing business, which is the whole point of a free-market system. The problem is that it has compromised the system so it is NOT a free-market system. That is the part that has to change, and which hurts consumers. The crummier the product (drug or otherwise) the more marketing has to be done to move it, and this industry enjoys tax breaks to move good as well as crummy products that other industries do not enjoy.This is their contribution to the problem that needs to be corrected. But they certinly did not create it, the patients actually did as I witnessed it from my perspective. They simply capitalized on the demand and built an empire upon it.Now there is this little problem coming...potential pandemics of drug-resistant pathogens. So it is time to alter the focus a bit.Have a DFDMNL______________ www.leapallergy.com


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## moldie (Sep 25, 1999)

Hi Mike, You are right that patients certainly pressure doctors into ordering the magic pill to make them well. Some don't like to be uncomfortable for long, and some also want to get on with their work, not taking too many sick days in the process for fear of repercussions from their job. On the other hand, I don't recall many doctors that actually tell patients the side-effects of medications they order, since they fear you will create them in your mind so the treatment won't work if you don't complete it. (I have witnessed this as a nurse). I certainly don't recall any warning you about the global repercussions of inappropriate use of antibiotics. Why do they just go along with the patient request and not assert what they know to be true then? Why don't they do cultures to find out what the cause might be, and if antibiotics are appropriate? They are supposed to have more access to the information. Fortunately we have the internet now so patients can have some access too. Unfortunately though, there are those that don't have access to the internet, or some that still leave it up to those "in charge" of their care. Even as a nurse, I trusted that the dermatologist was right; that if I had diarrhea, I could just quit the med. and it would go away. In the first place, I thought I had to have actual loose stooling every day for it to be considered to be from the antibiotic. None of my doctors I went to recognized my symptoms either, so I guess I shouldn't feel so bad about my ignorance. In the second place, if I were informed of the other possible side-effects, and that they could cause me years of misery, I wouldn't have risked it. I went in there looking for topicals or perhaps for her to refer me for hormonal testing. I told her my concerns over taking the antibiotic because I had IBS and also told her I had fibro. This was her first choice of treatment. I later found a cleanser on the OTC market that I use twice a day that has 10% benzoyle peroxide that helped just as much as the antibiotic did. Oh no, another "whoahs me" story. Sorry about that. I must say, when I first heard about the warnings of antibiotic resistence from their over-use, I did not consider the fact that one can have a chance for this possible infection living within them. I just thought it meant if you contracted something from the outside, the usual antibiotics might not work anymore and that more virulent micro-organisms that were harmful were beginning to show up in our external environment. I never really thought about the fact that my own internal environment contained organisms that could become harmful when the antibiotic destroyed the good ones that kept the bad ones normally in check. This was one thing that was never impressed upon me in my LPN training. When did you first find out about this Mike? Of course I knew people with immune problems were more susceptible to infections. Unfortunately, little is known about this with autoimmune conditions outside the "hosptital" crisis setting, nor do some even know which conditions actually fit in the autoimmune category. I never really was taught about the fact either that when one contracts an infection, that sometimes those with autoimmune problems develop sensitivities as their immune system goes haywire and attacks those things that one would normally tolerate in a healthy state. Is this how you understand it Mike, and is this an accepted theory by most of the medical field? I would guess not, just as the majority seem to think in order for Candida to be a problem, you must have either AIDS or Cancer and in the intensive care unit recieving massive doses of antibiotics or steroidal therapy, and then it must present itself in upper respiratory/oral areas to be considered significant. Looking back, however, I do recall cleaning up the same type of stooling I was having (orange frequent soft baby-poop smelling type stools) aroung the time these patients were found to be in need of Nystatin. I do think that is both interesting and significant, however, I have never heard of this specific stool described in patients with Candida infection. If anyone has any input of this, I would be interested in knowing if this description is typical. [This message has been edited by moldie (edited 10-04-2000).]


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## Mike NoLomotil (Jun 6, 2000)

Hey Molded One.You make a good point in the first paragraph that used to drive many of us "paramedcials" nutz inthe 70's and 80's...that prescriptioning madly of antibiotics without a C&S (some things its OK becasue it is obvious a broad spectrum antibiotic was appropriate...). It ws like passing out the scrips for broad-spectrums like they were aspirins! But what the hell did we know? We were therapists and nurses, not doctors. I think now this has passedand the general awareness of the problem is much better and most docs have become much more discriminatory out of necessity. WHOA the dermatologist...which skin care line did you get sento home with from germany ro Switzerland? (LOL I was in the medical cosmetics end for awhile with a friend who was an immunologist in Switzerland who was brilliant...and invented this...oh never mind...back on track...)In answer to your questions about normal flora and compettitive inhibition, they taught this to me in my first semester of college...so i never did understand why people with WAY more trainign than me seemd to dismiss the importance of NOT risking knocking-off the normal flora with braod spectrum antibiotics. But Irememeber back in those days nosocomial infectionw as rare, and when it was discovered it was always pseudomonas, and easy to kill...and usually only in trachs and other non-closed wounds. So the environment about such things was more "take it for granted all will remain as it is".The coments you make about patients with automimmune disorders developing new or acquired hypersensitivities is not out of line with a group of concepts contained within the spectrum of listening to immunologists postulate and pontificate...bu the really cool ones always come back to how little is actually known about immune function...just the tip of the iceberg. They still don't know excalty what basophils do or how they do it. Some books stille say BASIPHILS: FUNCTION UNKNOWN!The whole candida thing to me is so obverblown by people with nothing better to do with their time than to shoot holes in sieve. You are a nurse, so you know that so much of clinical medicine involves diagnosis and treatment absent specific quantitation in so many conditions.Oversimplifed, from what I have sen clinically in the context of IBS, is that people either over-attribute candidiasis as the hidden cause of evertyhting from IBS to ricketts to alzheimers, or they insist it does not exist as a pathogen anywhere a full-thickness biopsy has not been done and extansive hyphae visualized under a microsocope. OY VAY!if i had a dime for every time I heard at the bedside or in a conference "there is no evidence of that" only to have it turn up to be true some time later, as technology of analysis catches up with common sense, I would not be talking to you now. I'f be in Curacao drinking Rumrunners, watching my portfolio turn over.I have had exacerbations of my stable IBS twice in the last 5 years. Both times I had clincial signs of intestinal candidiasis for which an agressive course of NYSTATIN was prescribed. My MRT test (LEAP test) for candida reactivity before had been negative as it should be...my immune system saw it as "self". No granulocyte response.When my symptoms exacerbated both times candida came back reactive. Nystatin therapy made symptoms go away and the MRT said non-reactive again.So is this a transient hypersensitivity to candida which responds to su[pression of the flora, or candida somehow becoming pathogenic and responding to treatment? Which comes firt the chicken or the egg? Actually at this time nobodt can say for sure since I did not ket them sciope me and take a full-thicknes biopsy. Took the Nystatin.Is that clinically sound? or is it sound to withold the treatment becasue someone says that this does not happen becasue they read an article somebody wrote that says it does not.Thank god clinical medicine does not work that way.Moldie, have a DFE!MNLSorry for the typos...we are being informal right?


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## moldie (Sep 25, 1999)

Hi Mike, thanks for the response. Never mind the typos, since I make enough of them. I can certainly tell the difference between those, and being just plain illiterate!














If you have any personal insight to the stool description and candida, let me know. It would be nice to be able to differentiate a bacterial from a fungal, but don't know if that is possible.


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## Mike NoLomotil (Jun 6, 2000)

Just my observation that what everybody says on bioth sides of the argument is basically not untrue...assuming clincal infection from the mere presence of candida in the stool is a reach, but requiring that the only diagnosis of intestinal candidiasis that pharmacotherpy should be based upon is a postive full thickness biopsy is not practical. There are definitiely people in between for whom it has elicited an immunologic reaction soncistent with pathogenicity who are lilely symptomatic. And making the dx from apuely symptomatic viewpoint is not possibel with accuracy...look at the symptomologic set proposed by proponents? it is not 100% unique to candidiasis so how can it be diagnostic? what is needed is a definitive method of determining that the patients body is treating candida as a pathogen...thst is, is now seeing it as a pathogen ergo it matters little what the colony count or tissue invasiveness is...it has elicited an inflammatory reaction for wahtever reason thus elimination of thr reaction must be accomplished, either by blocking the reaction or wasting the organism. Now what test ot tests can zero in on that?Film at 11?___________MNL


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