A Fecal Transplant Chaser to Go With Your Antibiotics?

Infectious disease physicians continously warn of the danger of antibiotic overuse. This is often put in terms of increasing resistance, side effects, C.diff and costs. However, these often seem impersonal to the patient who is sick--usually from a viral infection--and is demanding an antibiotic (or even worse is a parent of a sick child). To them, even the threat of a side effect is outweighed by the potential benefit they believe they will gain from an antibiotic.  

Powerful evidence has begin to amount, however, that the danger of antibiotic misuse is much greater than the (still true) standard answers. This answer revolves around alterations in the microbiome that are induced by exposure to antibiotics.

To back up, shortly after birth humans are literally covered with bacteria in almost every crevice of their body (skin, digestive tract, mucosal surfaces)--the microbiome or microbiota. These organisms perform vital functions for us that include metabolizing certain substances, preventing "bad" bacteria from gaining hold, and interacting with myriad cells from multiple organ systems (including the nervous system). When this retinue of bacteria is disrupted by antibiotics, certain microbes go "missing" and the result is not good. 

All this, as an infectious disease physician, I knew but no where had I seen it presented in a manner that lists the litany of microbiome disruptive diseases and summarizes the leading research in an easy comprehensible manner to provide the full context of the issue. That all changed with the publication of Dr. Martin Blaser's Missing Microbes: How the Overuse of Antibiotics is Fueling Our Modern Plagues which I just finished.

In this book Dr. Blaser, whose work I think will make him a household name in the future, catalogs and expertly explains the importance of the microbiome and theorizes, with ample evidence, that such modern plagues as autism, asthma, reflux, obesity and esophageal cancer may have their origin in the alteration of the microbiome, induced largely by antibiotics (as well as birth via C-section). The point he makes is that anything that prevents an infant from acquiring the microbiome that humans evolved with--whether it be antibiotics or a birth canal-bypassing c-section--will have ramifications. 

I once heard a lecture by Dr. Arturo Casadevall in which he described how infectious diseases physicians of the future will spend their time. His answer: microbiome specialists. I am convinced of his and Dr. Blaser's predictions and can't wait to see how unexplained illnesses melt away when viewed in the context of the microbiome and what novel treatments are devised (probiotics, prebiotics, bacteriophages, etc,)

Maybe in the future the possible need for routine fecal transplants is something we can use to scare people out of unnecessary antibiotics?

Understanding The Power of Plagues: Context and History

During the time of the Ebola media whirlwind, I often reminded people that infectious diseases have been a force in history since the dawn of civilization. While I firmly believe that the basic motive force of history is ideas, infectious diseases have played supporting roles. 

The Plague of Athens during the Peloponnesian War, Justinian's Plague, and the death of Alexander the Great are some of the more ancient examples. Modern examples include the Black Death, the collapse of the Aztec Empire, Napoleon's retreat from Russia, the 1918 flu pandemic, and HIV.

With that context constantly in mind conditioning every bit of knowledge I have of infectious diseases, it was not hard for me to integrate the daily happenings of Ebola--which brought 3 nations to the brink of collapse--with the storied history of infectious diseases of past eras.

The Power of Plagues by Professor Irwin Sherman  does a very good job of cataloging such invaluable facts. When contemplating any current or future infectious disease outbreak, having the ability to activate this vast amount of information gives one a powerful tool with which to make predictions and understand the situation. 

I just finished this 2006 book and found it very relevant 8 years after publication and particularly so with respect to Ebola, even though it is not a formal part of the book. Specially when Sherman discusses how a society responds to a new disease it was almost as if I was reading a contemporary after-action report on the current Ebola outbreak, attesting to the validity of the principles identified. 

Most of the contents of the books were familiar to me but Sherman's explanations of popular nursery rhymes, words, and activities whose origin can be traced to disease were somewhat new. Also, the presentation of malaria, the discovery of viruses, and other topics proceed in a very inductive manner which allows one to follow the key discoveries in a manner that retraces how the intellectual progression developed.

For those who want an easily digestible overview of the topic of infectious disease, this book would serve the purpose well (and would even benefit more expert readers).

Jonas Salk: An Original Scorpion Team Member

Last night on the CBS show Scorpion one of Pittsburgh's most esteemed former residents was mentioned: Dr. Jonas Salk.  For those who don't know, Scorpion is a show about a team of geniuses that assists the Department of Homeland Security with special problem--a premise I find fascinating.

The context of the Jonas Salk mention was regarding the strategies needed to tackle difficult problems. Specifically, when Salk was solving the problem of the polio vaccine he battened down and thought through the problem and didn't just wish that things would go his way. This is the admonition to  never putting anything above the facts of reality, or as Ayn Rand succinctly put it, never put an "I wish" above an "it is"--something that physicians and scientists, especially, must never forget. 

Being from Pittsburgh, Jonas Salk has a special resonance with me. I have heard countless stories from people who knew or met him and I'm a bit jealous of their opportunity. Walking around Pittsburgh, being an odd person, I sometimes think about what it would be like to see him walking down the road, getting a slice of pizza, or other things that I do in Pittsburgh every day. In the book Splendid Solution: Jonas Salk and the Conquest of Polio--which I highly recommend--it details his almost ritual lunch at a now long gone Chinese restaurant where The Pittsburgh Press (also long gone) science reporter John Troan would try to get an indication of what was transpiring with the polio vaccine work that ultimately changed the face of this dread disease. 

One scene in particular really grips me. After the resounding success of the clinical trial of the vaccine was announced in Michigan, Dr. Salk returned to Pittsburgh and was greeted by throngs of people expressing their thanks for he and his team's achievement. His motorcade had a police escort. Imagining Dr. Salk receiving the fanfare almost exclusively reserved for the Pittsburgh Penguins, Pittsburgh Steelers, and the Pittsburgh Pirates is kind of exhilarating and I can almost experience the sense of justice and Pittsburgh pride that must have electrified the air on that day.

I am glad that Scorpion, a show whose theme I believe revolves around the crucial survival value of intelligence saw fit to pay homage to one of the real life examples that concretizes the veracity of its theme. 

Athlete's Foot Shares the Wealth with Mumps in Locker Rooms

Everything comes to Pittsburgh after it comes to New York: cool hamburger bars, hipsters, boutique hotels, and mumps. Headlines in Pittsburgh today are detailing Penguin captain and superstar Sidney Crosby's bout with this relatively benign disease that causes characteristic salivary gland enlargement.

As a good proportion of the population has grown up during the post-mumps vaccine era--which began in 1949--there is concern about its reappearance and the risk it confers. What bears emphasis is that mumps is not one of the horseman of the apocalypse, even if it is capable of sidelining several hockey players. As I have written before, severe complications of mumps, such as meningitis, are rare, more common in adults, and recovered from uneventfully (even those who experience meningitis).

Mumps resurgences are due to waning immunity coupled with the exposure pressure inherent in closed populations such as college dormitories or hockey locker rooms. While even I probably have waning immunity to mumps, I don't have much exposure pressure and certainly am not party to "saliva spray". As such, mumps doesn't represent a significant public health threat at this time.

The diagnosis of mumps, a nationally notifiable disease, is usually based upon seeing the classic facial appearance. Confirmation is made either by looking for antibodies to the virus, growing the virus, or detecting the genetic material of the virus. Antibody tests may be hard to interpret in a previously vaccinated person who has a breakthrough infection and may be falsely negative (as seems to be the case with Crosby); other tests may prove more useful in that setting.

Another concern is the contagiousness of mumps. While it is a minor illness, it is important to try and delimit spread. Mumps is spread through direct contact with respiratory secretions and people are contagious 2 days prior and 5 days after salivary gland swelling. I can imagine a hockey player locker room being strewn with snot, spit, and other secretions--a perfect playground for mumps.

The case in Pittsburgh has caused some added concern because another Penguin being investigated for mumps visited a hospital. Since mumps is not airborne, it is not clear that a major risk of transmission existed and even if significant exposures occurred, the consequences, if any, will be minimal as vaccination uptake is high amongst the population.

Though I enjoy it when there's general interest in any infectious disease, a recalibration of threat perception is needed: we are likely in for a rough flu season and that is of much greater concern than hockey player's faces morphing into those of chipmunks.

Heroes Sabotage Nazis with Fake Typhus Vaccine: It Really Happened

I imagine it's hard enough to be a scientist in the best of conditions because it amounts to exacting work demanding complete focus. I think it is almost unfathomable to perform such work in less than ideal situations, let alone war torn nations or dictatorships. The latter is the setting of The Fantastic Laboratory of Dr. Weigl: How Two Brave Scientists Battled Typhus and Sabotaged the Nazis by Arthur Allen. 

This book tells two stories: one about typhus and the other about the scientists plight under Nazi rule. 

There are a few facts about typhus that I think everyone should know:

• It is a disease known since antiquity
• It is spread through body lice
• It can wreak destruction in populations that don't wash their clothes regularly -- just ask Napoleon
• Countermeasures against typhus were a priority for the military in the pre-antibiotic era

Given this context, you can see how typhus vaccine---invented by Rudolf Weigl--would attract the attention of the Germany military during WWII. 

The enormous benefit and ingenuity needed to make the vaccine isn't the most remarkable part of the book however. What I found most remarkable was that during the Nazi occupation of Poland, when the laboratories were under strict Nazi control,  heroic scientists thought to sabotage the Nazis by giving inert control vaccine to the Nazis while giving real vaccine to those in the Jewish ghettos. 

Such acts really give concrete form to the definition of hero, formulated by philosopher Andrew Bernstein, as "the man who lets no obstacle prevent him from pursuing the values he has chosen."