Use it and lose it?

I recently heard that a friend of mine with two extremely premature twin babies took her children to the doctor because they had fevers and ear infections. Their ears ruptured and drained and it was clear from the odor of what drained that this resulted from a bacterial infection. The doctor refused to give them any antibiotics. The twins didn't improve, and frantic for her children's health, she finally found a doctor willing to prescribe some antibiotics and the children are okay now.

WHAT WAS THAT DOCTOR THINKING? Despite his seeming lack of medical skill, he was probably trying to be responsible.

Overuse and misuse of antibiotics are almost always cited as the reasons for resistance. Doctors are being taught this and encouraged to withhold antibiotics from patients.

The accusation that misuse of antibiotics is the cause of resistance is unduly strong considering there are very few data to support it. This accusation has never been experimentally tested and the observations leading to it have never been statistically tested. It is based in general observations, and far reaching assumptions. For every observation that supports the accusation, there are several to refute it.

In support of the accusation, antimicrobial resistance is less frequently observed in Scandanavian countries and the Netherlands than it is in Italy, France, Greece, Turkey, and Tunisia. Scandanavian countries and the Netherlands use antimicrobials less often than the more southern European countries. That would seem to support the accusation.

On the other hand, when hospitals stop using an antimicrobial, resistance to it usually doesn't decrease. Sometimes resistance actually increases in frequency after the antibiotic is no longer in use.

Also, resistance is found in bacteria located at the most pristine parts of the earth where humans have never used antibiotics.

Also, for brand-new antibiotics that have barely been used, resistance emerges rapidly, and is often present in bacteria before the antibiotics are even released.

These observations all seem to refute the idea that by reducing antibiotic use, we can stop resistance.

A well tested pillar of evolutionary theory is that in a really large population, genes that confer even a small increase in fitness will tend to spread through the population.
Bacteria have unfathomably large populations. The bacteria inside one person outnumber all the humans alive on the earth. When all of the bacteria on earth are considered, it is usually pretty accurate to think of them as an infinitely large population. This means that even if an antibiotic is very rarely used, resistance to it might spread because there could be some fitness advantage associated with the resistance gene. In other words, if we use antibiotics at all, resistance will follow. We can't stop it unless we give up antibiotics completely, which simply isn't an option.

Does this mean that we should use antibiotics with reckless abandon? No, certainly not. Many antibiotics are mildly toxic to humans and from that perspective alone, they should be used judiciously.

Also, even though any use of an antibiotic might cause resistance to spread, using an antimicrobial a lot will cause resistance to spread more rapidly.

However, we certainly need to explore options for controlling resistance that extend beyond indoctrinating doctors to use fewer antibiotics. That just isn't an effective way of preventing resistance, and it sometimes compromises the health of patients.