Anibiotic May Not Be the 'Protection' You Envision

By Christopher Wanjek Special to The Washington Post Monday, October 22, 2001; 12:35 PM

Lost amid the public health establishment's call for calm about anthrax is the fact that stocking up on antibiotics isn't just a threat to public health. Even if you care only about yourself and your family, taking these drugs is misguided, dangerous and possibly deadly. By administering powerful antibiotics when they're not medically indicated, you can easily wind up hurting the very people you're trying to protect.

"It's a bad idea, a terrible idea" to self-administer an antibiotic, said Stuart Levy, an antibiotics expert at Tufts University School of Medicine in Boston. "People can and do die as a result of antibiotic misuse."

Antibiotics are "powerful, toxic drugs," said Anthony S. Fauci, director of the National Institute of Allergy and Infectious Diseases. You cannot simply pop these pills like vitamins to bolster your health in a time of increased risk. "Once you start doing that," Fauci said, "you open Pandora's box."

Those taking a crowbar to Pandora's stash include people who have purchased Cipro – the powerful antibiotic most often prescribed to treat people who have contracted an anthrax infection – and then take it because they fear they may have been, or may soon be, exposed to anthrax microbes. Unexposed people who take the drug at the onset of those troublingly ambiguous "flu-like symptoms" – which may seem like one of the more reasonable scenarios for self-medication – also put their health at serious risk.

To understand why, let's look at how Cipro works on people who do have the anthrax infection. Cipro kills most, but not all, of the invading anthrax bacteria (and many benign bacteria as well). It keeps the bacteria's numbers low enough that the body's immune system can defeat the invaders. The anthrax bacteria, which release powerful toxins into body tissues, can multiply constantly if untreated and can even go into month-long dormant states to outwit the immune system. This is why Cipro must be taken for 60 days to treat anthrax (but not necessarily another infection).

Some anthrax bacteria can survive Cipro because of certain genetic traits. These bacteria reproduce and pass along that protective trait to their next generation of bacteria, which is more likely to be resistant to Cipro. But as long as Cipro is killing the bulk of bacteria, the immune system can conquer the stubborn remains.

Should you stop taking Cipro prematurely when you have an anthrax infection, the bacteria continue to reproduce and overwhelm the immune system. You can start Cipro again, but your body is filled with the type of anthrax bacteria that is resistant to Cipro. Now you're really in trouble; there is no drug to help you. (This doesn't mean you'll die, but your chances of recovery are not as good.)

Okay, that's bad enough. But let's take the more common scenario, the one that has public health officials so inflamed: You fear you have been exposed because you live or work near the site of an incident, and you have some of those "flu-like symptoms" that can suggest the early stages of anthrax. But instead of consulting a doctor and following his or her advice, you get your hands on some Cipro and start taking it.

First, the drug does nothing to relieve your symptoms, which are likely the result of cold, flu or allergies – none of which respond to antibiotics. Instead, Levy explained, the Cipro starts killing many different bacteria in your body, including the beneficial bugs that line your skin, mouth, throat and gut.

This is bad for several reasons. The good bacteria are necessary for digestion, elimination and removal of excess oil on your skin. More important, the very presence of good or benign bacteria on surfaces in your body prevents harmful bacteria from gaining a foothold.

With good bacteria gone, bad bacteria can move in, such as the kind that can overtake your bowels and cause bloody diarrhea, according to Edward Bottone, an expert on infectious diseases at Mount Sinai School of Medicine in New York. This, Bottone said, is "painful and expensive . . . [and possibly] deadly."

Also, bacteria that cause bladder infections may already reside in low numbers in a healthy person. Taking Cipro for a few days may be long enough for some of these bacteria to become resistant to antibiotics, said Carol Baker, president of the Infectious Diseases Society of America, based in Alexandria. So, as a direct result of taking Cipro (or another antibiotic) when you didn't need it, you have now cultivated a urinary tract infection that cannot be cured by antibiotics.

Taking Cipro as a preventive medicine would work only if you fairly quickly become infected with anthrax and then follow through with the medication regime for 60 days, according to Terry Krulwich, dean of the Graduate School of Biological Sciences at Mount Sinai. In this gamble, you risk killing some good bacteria and cultivating resistant ones to gain a week's head start in combating anthrax.

Antibiotics, like all drugs, come with quirks and side effects. Cipro's can be nasty. Cipro can cause nausea, diarrhea, allergic reactions, serious skin rashes, tremors and nerve damage from overstimulation of the central nervous system. Also, Cipro may cause organ damage when taken with other prescription drugs, such as warfarin (Coumadin), which is used to prevent blood clots, the asthma drug theophylline and the seizure-prevention drug phenytoin. Antacids containing magnesium or aluminum hydroxide will bind to Cipro and can render it nearly ineffective.

Even if you manage (with your vast knowledge of medicine and pharmacy) to use an antibiotic at the correct time and at the correct dose, there is no guarantee that your Cipro-hoarding neighbor will, said Levy. In China, where antibiotics are readily available without instructions and where their abuse is widespread, the majority of bacteria that cause urinary tract infections and other life-threatening diseases are resistant to fluoroquinolone, the family of antibiotics that includes Cipro.

"The number of resistant strains [of bacteria] will inevitably go up" with this current abuse of Cipro in America, Levy said. "This is an experiment in [microbial] evolution that we do not need. We are placing in the hands of consumers the evolutionary fate of bacteria."

Bottone worries that people will hear a news report of a germ outbreak across town or in another city and, panicking, will start taking their hoarded antibiotic as a preventive medicine – even though the outbreak is in a remote location, an infection is not verified and the antibiotic is not necessarily the right one.

"Take this [scenario] nationwide and you can really do some damage," Bottone said. Anthrax and other bacteria may develop resistance to Cipro naturally over the course of many, many years, he said, but with widespread abuse, this can happen within weeks to months.

And then there is the fact that hoarders are reducing the supply for those who really need the drugs. Already anecdotal reports are surfacing of sick children who cannot get Cipro; the stocks in many pharmacies have been depleted. People with certain chronic illnesses, such as cystic fibrosis, rely on Cipro to, well, breathe, for the drug kills a recurring bacteria in these people's lungs.

According to Bayer AG, the maker of Cipro, this antibiotic is the primary drug treatment for a variety of common yet potentially deadly bacteria, such as pseudomonas aeruginosa, which infects desperately weakened individuals in hospital critical care and burn units. Cipro also cures many staph and strep infections, as well as chlamydia and some forms of tuberculosis – all of which are far more common than anthrax, even today. Cipro is needed right here, right now for these infections – while you have a 60-day supply in your medicine cabinet providing no value aside from a misinformed sense of personal security.

If the fear of personal injury, the guilt of hoarding a medicine others critically need or a sense of civic duty cannot dissuade you from stockpiling and using antibiotics, at least stop to consider the price: A 60-day supply of Cipro costs about $600, or $5 a pill.

If you can afford that and still don't care about all the other stuff, good luck. You'll need it.

-- Anonymous, October 22, 2001