When Thou Liest Howling

There are some things we just don’t want to acknowledge aren’t there? Some things that we would rather not hear, not so much because we don’t think they’re important, but because they embarrass us… Or maybe offend us. Sexually transmitted diseases are prime examples.

For some reason, many of us find them difficult to talk about. Admittedly they require rather special venues, and the very subject casts long shadows on the interlocutors no matter how discreetly it is introduced. Rather than appearing as an intimate trust issue, the very fact of its being raised in the first place tends to arouse suspicion -accusations by proxy.

At first, I wondered if this attitude might be a generational thing. I was raised in an era when the most feared unintended consequence of premarital sex (as we called it then), was assumed to be pregnancy; VD -another time-specific term for sexually-acquired disease- was confined to clearly recognizable and therefore potentially avoidable people. This naïveté, of course, didn’t prepare us for the inevitable consequences of our wide-eyed ignorance and even nowadays, those of us still around could yet be dragged, aged and surprised, into the vortex as I outlined in an essay elsewhere:  https://musingsonretirementblog.com/2016/10/16/too-good-to-be-true/

The initial solace of antibiotic treatment also proved too good to be true. Throughout history, sexually transmitted infections were a scourge –the wages of sin as they were considered then. But with the advent of effective treatments, those debts were forgotten –although clearly not forgiven.

Syphilis, gonorrhea, and the more recently characterized chlamydia exacted a terrible toll on fertility and long term health, but until recently, all were fairly amenable to antibiotic therapy –albeit a necessarily changing one. Gonorrhea, however, seems to be particularly adept at developing resistance to the various antibiotics thrown at it.

There are various mechanisms by which a bacterium can become antibiotic-resistant but a common and easily appreciated reason is inadequate initial treatment. Even if an antibiotic is effective, there will usually be some bacteria that are less sensitive to it for whatever reason, and hence require longer antibiotic exposure for it to affect them. People tend to continue treatment only until they feel well –in other words, until the number of bacteria infecting them has fallen below whatever level was required to cause the symptoms. Unfortunately, the few bacteria that remain, are the less sensitive ones that weren’t so easily killed off at the beginning.

Physical barriers to the acquisition of sexually transmitted infections –condoms, for example- are certainly helpful, but men don’t tend to wear them with oral sex, the World Health Organization (WHO) has warned:  http://www.bbc.com/news/health-40520125  This has led to an increasing problem with throat infections according to the BBC News article. ‘Gonorrhoea can infect the genitals, rectum and throat, but it is the last of these that is most concerning health officials.

‘Dr Wi [from the WHO] said antibiotics could lead to bacteria in the back of the throat, including relatives of gonorrhoea, developing resistance. She said: “When you use antibiotics to treat infections like a normal sore throat, this mixes with the Neisseria species in your throat and this results in resistance.” Thrusting gonorrhoea bacteria into this environment through oral sex can lead to super-gonorrhoea.’

The problem is that a throat infection with gonorrhea may be relatively asymptomatic and hence more likely to be inadvertently transmitted to someone else. And ‘It’s hard to say if more people around the world are having more oral sex than they used to, as there isn’t much reliable global data available. Data from the UK and US show it’s very common, and has been for years, including among teenagers.

‘The UK’s first National Survey of Sexual Attitudes and Lifestyles, carried out in 1990-1991, found 69.7% of men and 65.6% of women had given oral sex to, or received it from, a partner of the opposite sex in the previous year. By the time of the second survey during 1999-2001, this had increased to 77.9% for men and 76.8% for women, but hasn’t changed much since.

‘A national survey in the US, meanwhile, has found about two-thirds of 15-24 year olds have ever had oral sex. Dr Mark Lawton from the British Association for Sexual Health and HIV said people with gonorrhoea in the throat would be unlikely to realise it and thus be more likely to pass it on via oral sex.’

And apparently there are only ‘three drug candidates in the entire drug [development] pipeline and no guarantee any will make it out.

‘Prof Richard Stabler, from the London School of Hygiene & Tropical Medicine, said: “Ever since the introduction of penicillin, hailed as a reliable and quick cure, gonorrhoea has developed resistance to all therapeutic antibiotics. In the past 15 years therapy has had to change three times following increasing rates of resistance worldwide. We are now at a point where we are using the drugs of last resort, but there are worrying signs as treatment failure due to resistant strains has been documented.”’

So, we’ve got a potentially untreatable, possibly asymptomatic, and very definitely prevalent infection out there, and a societal reluctance to talk about it… Perhaps it’s time for another approach. Fortunately there is an active search for a gonorrhea vaccine –and a serendipitous observation may have suggested a possible route –although, in retrospect, it seemed an obvious place to start. http://www.bbc.com/news/health-40555702

‘The vaccine, originally developed to stop an outbreak of meningitis B, was given to about a million adolescents in New Zealand between 2004 and 2006. Researchers at the University of Auckland analysed data from sexual health clinics and found gonorrhoea cases had fallen 31% in those vaccinated.

‘The bacterium that causes meningitis, Neisseria meningitidis, is a very close relative of the species that causes gonorrhoea – Neisseria gonorrhoeae. It appears the Men B jab was giving “cross-protection” against gonorrhea.’ This is very early in the work, however, and it seemed only to be effective in a third of those vaccinated. But it is certainly encouraging.

Be that as it may, however, I can’t help but worry that if there is development of an effective vaccine against gonorrhea, it will once again fool us into forgetting about the other diseases potentially transmissible by oral sex, including viruses such as hepatitis, herpes, and HPV (for which, thank god, there is also an effective vaccine), not to mention the bacterially-caused ones like syphilis, chlamydia, and many others that don’t make for salacious headlines.

But I’m not advocating for the formation of a Temperance League to combat a practice that is likely as old as humanity, nor do I have any religious or ideological objections to its persistence in our society, but I do believe that the Past informs the Future. I think that it would be prudent to ensure that all participants –newcomers to the field, as well as those who have already passed through and are merely nibbling at memories- have a working knowledge of those risks that should not be placed, as Shakespeare put it, on the windy side of care

I just wonder if those who are entrusted with sexual education nowadays would put it so beautifully.

 

 

 

 

 

 

 

 

 

 

 

 

http://www.bbc.com/news/health-40555702

 

 

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Biding the Pelting of this Pitiless Storm

Hubris –the extreme arrogance that was so offensive to the old Greek gods that they reacted with punishment and an exile from grace- is that what this is? I’m not sure anymore… It’s not, perhaps, so obvious as the vaulting ambitions of a Macbeth or the arrogance of a Caesar, nor even the overweening pride of an Oedipus in the Sophoclean plays, and yet… And yet, viewed from a distance, it’s hard not to notice the similarities that inhere in the attitude that End justifies Means, that intentions trump consequences, that methodology is the servant of results –however narrowly beneficent we define them. And it’s important that we not be so blinded by those touted benefits that we ignore other, perhaps less harmful routes, to achieve them.

And what, you may reasonably ask, prompted this jeremiad? It was a study reported in the New England Journal of Medicine (NEJM) on the addition of a second and possibly more powerful prophylactic antibiotic during non-elective Caesarian Sections to reduce post-operative infection rates: http://www.nejm.org/doi/full/10.1056/NEJMe1610010?query=gynecology-obstetrics -certainly a worthy aim, to be sure. Who could possibly take issue with that? Well, in this era of increasing antibiotic resistance, and the unfortunate dearth of replacement antibiotics in the wings, I think not only the study, but also the idea demands more than a cursory analysis. This is not to criticize the intent, so much as to explore alternative roads to the same destination.

Few would argue that antibiotics, when they are deemed necessary, should be used according to the infecting bacterial sensitivities if they are available –or considered expectations as to sensitivities if they are not. It’s why we can no longer use penicillin for everything –not all infections would respond. Surgical prophylaxis (where there is not yet an infection) is one of the few exceptions, and even there, the antibiotics are chosen in anticipation of the type of bacteria that might reasonably be expected in the surgical field (although there are some who believe that their effect is merely that of decreasing the total bacterial load in the area whether or not the expected ones have been targeted). But, nevertheless, we toy with resistance at our peril.

I’ve chosen to link the editorial rather than the study itself because of the insights it offers. The full-length study to which it refers can be accessed via a link in that editorial, however.

As I mentioned, the study by Tita and colleagues, in a randomized trial, attempted to reduce post-operative infections by adding another broad-spectrum antibiotic (Azithromycin) to the usual antibiotic (cefazolin) in non-elective Caesarian sections (i.e. there was some condition in mother or baby that required urgent delivery) where the current infection rate was 12% -and it worked! Compared to the usual group that just received the cefazolin alone, they dropped the infection rate to 6.1% -not zero, but at least an improvement. And, ‘Neonatal outcomes, which were tracked up to 3 months, were similar in the two trial groups.’

But on closer analysis, 73% of the population in the study was obese -and that, plus the fact that the Caesarians were unplanned, certainly added to their risk of infections. So far, so good.

But, as the editorialist wonders, could the fact that these women were obese have meant that the usual dose of cefazolin was inadequate: ‘[…] should the potential pharmacologic benefit of higher doses of cefazolin alone be evaluated further before the addition of a second agent?’

Another consideration leading to the study of adding azithromycin to the regimen, was that it may be useful for eliminating a potentially  infective organism in the vagina –ureaplasma– that cefazolin doesn’t touch. Unfortunately, there are no prospectively adequate data for the contention that the organism was even present in the studied women.

And finally, the azithromycin was more beneficial in those women whose incisions were closed with staples, and there seems to be evidence that staples, themselves, may increase the post-operative infection rate.

So why, you may ask, have I chosen to comment on this rather obscure study –especially since it seems to have demonstrated the benefits it expected? First of all, I think we have to be careful that we don’t lose sight of the forest as we wend our way through the undergrowth. There do seem to be other options that could be explored before the addition of yet another antibiotic –and indeed should be anyway, given the non-zero infection rate even with the addition of azithromycin. Such things as more ‘stringent adherence to infection-control protocols’, avoiding the use of staples in this high-risk population, or even re-calculating the dose of the standard prophylaxis (cefazolin) to account for differing patient weights before deciding to add the new antibiotic.

I don’t mean to be the new Cassandra, issuing thundering prophesies of doom that will not be heeded anyway, or aspersing well-intentioned attempts to improve our lot… And yet we must not forget that consequences follow actions, not precede them. To be fair, we do try our best to anticipate and thereby avoid, or at least minimize them, but history is riddled with examples of unintended outcomes. The road to disaster is paved with should’ves –only seen with clarity, after arrival.

It seems to me that, wherever possible, we should be exploring options that reduce the likelihood of incurring bacterial resistance. And the answer may not lie in the reliance on new antibiotics -new guns for our on-going war with the microscopic world. It’s a battle in which we cannot hope for more than a temporary truce while we search for peace. Without that, as the map makers of old were said to write on unexplored regions, Here be dragons.

 

The Colour of my Baby

What a great idea: a bandage that tells you when what it is hiding, is itself hiding something –an infection.  http://www.bbc.com/news/health-34808273

I suppose it was an idea looking for a platform. When bacteria are growing, they often invent ways to keep doing just that. Sometimes they overwhelm by sheer numbers to defeat the body’s defences, at other times it’s toxins that break down tissues and help them invade. The body, for it’s part, has its own bag of tricks. In the end, infections are often simply a kind of parry and thrust contest –a fencing match, if you will.

Most bodies are not unduly challenged by wounds, however –keep them clean and cover them with some sort of dressing, and they heal. Antibiotics are seldom required. The problem, of course, is that sometimes the foes are not evenly matched. People on immune suppressants (transplant patients), or those with already compromised immune systems –whether from disease or immaturity (babies, for example)- may not be able to mount a suitable response to bacteria in a wound and are at risk of severe infections. These are the ones in whom a timely and appropriate antibiotic would be prudent.

Sometimes, though, antibiotics are used like soap: if it looks dirty, or if it might turn out to be dirty, why not use an antibiotic? Just in case. Well, the simple answer is that the body is usually pretty good at dealing with bacteria. After all, we are all exposed to bacteria from day zero. It starts with the journey down the obviously non-sterile birth canal, and progresses to crawling along things, tasting things… none of which could be said to be free of bacteria of some sort or other. Bacteria are what we do, where we live… Bacteria live in our mouths, in our bowels, on our skin. There are more bacteria in our intestines than cells in our bodies; we simply cannot get rid of them all.

Nor should we. I’ve written before about the benefit of these usually commensal creatures and the benefits they provide both for continuing health and development: https://musingsonwomenshealth.wordpress.com/2014/05/15/the-human-microbiome/

But let’s not be naïve about bacteria –they don’t give a fig about us -they are amoral. A bacterium prefers to live with others –family. They grow and prosper with no regard for boundaries or house rules. Without suitable checks and balances they would take over. Like pouring water in a cup -too much and it merely overflows the constraints and moves on. That’s an infection. That’s when the body may need some help.

The trick is obviously intervening when it is necessary, but monitoring when it is not. Why? Well, treating every wound, say, with an antibiotic might get rid of the truly sensitive bacteria, but leave behind those that don’t respond quite as easily or quickly. The result of the treatment may therefore be to select for those bacteria that don’t mind the antibiotic –the resistant organisms. That’s how it happens.

So in those people who may not be able to deal with bacteria efficiently, it would be helpful to know when –or if– to intervene. That’s where the bandage that changes colour when bacteria in wounds begin to proliferate and infect would be helpful. There are other ways, of course: the old Latin aphorism I was taught in medical school, for example: Tumor, Dolor, Rubor, Calor – Swelling, Pain, Redness (inflammation), Warmth (infection). But sometimes it’s nice to have another tool in the kit that may detect a problem earlier -before these signs are present. Or, in the case of a body incapable of even producing the signs- when an infection would be catastrophic.

Clearly a lot of work needs to be done to detect the mischief of different types of bacteria –they don’t all produce toxins, and even if they did, there would likely be differences in their structures that would have to be accounted for in the detection mechanism. But this may be the bandage of the future –a Facebook band aid that is constantly posting. Almost like refrigerators that tell you what you need, or coffee pots that turn on when they hear the toilet flush in the morning. A brave new world.

It is ‘a hit’, as Osric, a courtier, says of Hamlet’s thrust as he is dueling with Laertes, ‘a very palpable hit.’ Let us hope so.