For years, amoxicillin was Dr. Chris Reiner’s first choice for treating children’s ear infections. “It tasted real good, it worked well, and you only had to give it twice a day,” said Reiner, a Tampa pediatrician. “It was effective. That was always the bottom line.” That’s no longer always the case. The germ most commonly responsible for otitis media increasingly has become resistant to amoxicillin -- the popular pink stuff -- forcing Reiner and other pediatricians to try more potent drugs instead. This means childhood ear infections have now joined tuberculosis, gonorrhea and urinary tract infections, as well as several deadly infections typically seen only in hospitals, that have become resistant to the antibiotics designed to treat them.

Amoxicillin’s waning power is giving the public

its first closeup look at antibiotic resistance, an increasing worldwide problem. It also provides a good lesson in why patients should not demand antibiotics when none might be needed, and why doctors should be more stingy in prescribing them. “One day, even our strongest antibiotics will have resistance,” said Dr. Greg Savel, a Clearwater pediatrician. “We’re hoping they develop new antibiotics. But people should not want their children on antibiotics if they don’t need it.” Many childhood and adult illnesses -- including the flu, bronchitis and some ear infections -- are caused by viruses, not bacteria, so antibiotics are powerless against them. But often they’re prescribed regardless, because patients demand them and because doctors can’t always tell if the infection is viral or bacterial. This helps breed resistant strains of bacteria.

Consider this, Since 1992, federal health officials have charted a 300 percent rise in resistance to penicillins, including amoxicillin, by Streptococcus pneumoniae, a bacterium that causes 7-million ear infections each year. Also known as pneumococcus, it is the leading cause of pneumonia and third leading cause of meningitis. In Florida in 2000, the most recent data available, nearly 44 percent of tested cases of S. pneumoniae in children under 4 were resistant to penicillin, according to the state Department of Health. Most were ear infections. About 70 percent of bacteria that cause infections in hospitals are resistant to at least one of the drugs most commonly used to treat them, the U.S.

Food and Drug Administration says.Resistance is a story of survival of the fittest. Each time you take an antibiotic, a few targeted bacteria may survive. More will survive if you quit taking your medicine early because you feel better, or to save a few pills for the next bug.The germs that survive carry genetic traits that allowed them to do so. They pass these protections to their offspring, and even share them with other types of bacteria. Resistant germs also are spread from person to person, and from animal to person. Although Streptococcus pneumoniae is the most closely followed, other common infections are proving increasingly stubborn. They include Haemophilus influenzae type B, or HIB, a bacteria that causes upper respiratory and sinus infections; E. coli, which causes urinary tract and intestinal infections; and some strains of salmonella.

In hospitals, infection control specialists worry about Staphylococcus aureus, a skin infection that is rapidly becoming resistant to all but a couple of antibiotics. Resistant strains of this staph infection also are being found in day care centers and schools. “It’s not simply, ‘Oh, it’s only resistant to this. It’s resistant to two, three, four, sometimes eight or nine drugs,’ “ said Dr. Stuart B. Levy, president of the Alliance for the Prudent Use of Antibiotics at Tufts University in Massachusetts. “While the worst ones are seen in hospitals, there are some pretty nasty ones” in the general population, he said. Experts cite several reasons for the rise in resistance. The American Medical Association and others put some of the blame on the heavy use of antibiotics in animal feed. Low levels of antibiotics can be passed to people through meats we eat, and resistant germs found in cows and chickens can pass their resistance to germs that infect humans. “There may be enough antibiotics in these foods to kill off some susceptible bacteria in our intestines, and (promote) resistant ones,” said Dr. Juan Dumois, chief of infectious diseases at All Children’s Hospital in St. Petersburg.

The agricultural industry generally downplays the impact, but the FDA is looking at new requirements to limit antibiotics in animal feed. Next month, the agency will hold a hearing on a proposal to stop the use of

Baytril, which is commonly used in poultry feed. The drug is among a class of antibiotics called fluoroquinolones, like the human medicine Cipro, and the agency fears its agricultural use is causing resistance of some bacteria in people. The American Society for Microbiology says the increase of bacteria-killing cleaning products -- from bathroom sprays to hand soaps -- also is a major contributor. Germs that survive the antibacterial spray on the counter pass on their survival skills. But one main reason for resistance, experts agree, is the overuse and misuse of antibiotics -- like amoxicillin -- among doctors and their patients. The U.S. Centers for Disease Control and Prevention estimates that 50-million of the 150-million antibiotic prescriptions written annually are unnecessary. In 1978, when Dr. John Sinnott finished medical school, simple penicillin was the drug of choice for middle ear infections. Ninety-five percent of kids got better. Amoxicillin was the next generation, designed to help when penicillin failed.Now doctors say they have to more than double the dose to get the same effect. They’re also prescribing more potent and more expensive combinations, such as azithromycin or amoxicillin with clavulanic acid, sold as Augmentin. These drugs are effective, but they’re usually at least twice as expensive and often have unpleasant side effects, especially diarrhea Sinnott, head of infectious diseases at Tampa General Hospital and the University of South Florida College of Medicine, said medical students are taught the dangers of frivolous antibiotic use, but practicing doctors often face difficult choices. Patients or their parents don’t like being told there’s nothing they can do. And doctors often can’t quickly tell if the infection is viral or bacterial, so they err on the side of caution and prescribe antibiotics. “Sometimes it’s hard to prove if someone is infected without spending more money than the antibiotics cost,” Sinnott said. “And then you still wouldn’t be sure.”

The lack of a quick and accurate test has hampered doctors’ ability to distinguish a virus from a bacterial infection. But Sinnot and Dr. Pam Patranella, a St. Petersburg pediatrician, said physicians can look at other indicators for help in making an accurate diagnosis: What are the symptoms? How sick is the patient? What

DRUGS LOSING THEIR PUNCH AGAINST KIDS’ INFECTION – Antibiotics are running up against resistant forms of infections in both children and adults. Experts blame overuse and misuse of the drugs.

By WES ALLISON

ANTIBIOTICS FIGHTING INFECTIONS

SINCE 1970

STOP THE MISUSE AND OVERUSE OF ANTIBIOTICS!

RESISTANCE IS SPREADING.

YOU CAN HELP!

10-15 YEARS LATER

BACTERIA RESISTING INFECTIONS SINCE 1992

Resisting Bacteria Inc.

Resistant

Bacteria Inc.

bugs are making the rounds in local day care centers and schools? And in healthy adults or adolescents, some say it’s worth waiting a couple of days for test results before prescribing antibiotics.

The Florida Health Department is seeking

$120,000 from the CDC to launch an educational program for patients and doctors this fall. Linda Baldy, the state’s antibiotic resistance epidemiologist, said it would include brochures explaining the problem of antibiotic resistance and tips for telling the difference between a bacterial infection and a virus. The agency also plans to give physicians a form for patients diagnosed with a virus. The form, which is available from the CDC at www.cdc.gov, explains that an antibiotic won’t help, and offers tips on relieving symptoms. “That way the patient can walk away with something, but they don’t walk away with a prescription for an antibiotic,” Baldy said. The key is talking to patients about their illness and what will or will not work, experts said. “There’s always a group that just wants you to do something,” said Reiner of Pediatric Health Care Alliance in Tampa. “You can decide for yourself if you’re going to buckle under that pressure, or stand up and educate the patient.”

BIG BAD BUGS

Many bacteria increasingly are becoming resistant to the antibiotics that once easily killed them. Here is a sample:

Streptococcus pneumoniae: A common bacteria responsible for an estimated 7-million ear infections each year, as well as thousands of cases of meningitis and pneumonia. Surveys by the state Department of Health show that roughly 40 percent of cases in children are resistant to the penicillins long used to treat them, including amoxicillin.

Tuberculosis: Resistance to antibiotics is contributing to a resurgance of TB worldwide after it was nearly wiped out in the 1970s. It has become resistant largely through improper use of antibiotics. In Florida, TB patients must take their medication in the presence of a state health worker, to ensure they complete the full course of antibiotics.

Salmonella: A strain of this bacteria, a common cause of food poisoning, called Salmonella typhimurium has become resistant to a wide variety of antibiotics, including ampicillin, sulfa, streptomycin and tetracycline. It has caused illnesses in the United States, Canada and Europe.

Gonorrhea: Surveys of clinics that treat sexually transmitted diseases have found that more than 30 percent of the cases are resistant to penicillin, tetracycline, or both. More powerful antibiotics now are needed.

Enterococci: This bacteria primarily infects wounds or urinary tracts and serious cases primarily are treated with vancomycin, a powerful antibiotic used for a variety of hospital infections.

In 1989, the United States had no reports of vancomycin-resistant enterococci; by 1993, resistance was found in more than 10 percent of cases. Infection control specialists say this is a serious increasing problem.

Staphylococcus aureus: Resistant srains of this common staph infection, known as MRSA, are becoming are becoming endemic in hospitals and may be increasing in the general population. Several cases of strains that are resistant to vancomycin, the drug of last resort, have been reported in the hospitals in the United States and Japan. Because of fears of resistance to vancomycin, this drug typically can be used only with special permission at most hospitals.

-- Sources: National Institute of Allergy and

Infectious Diseases; Florida Department

of Health; Alliance for the Prudent Use of

Antibiotics. Published March 17, 2002

Published March 17, 2002