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Will the swine flu epidemic emanating from Mexico be the next great pandemic that everyone fears? It is hard to say. The Mexican government seems to be doing all it can to limit the spread of the infection, and travel advisories attest that other governments are taking this seriously as well. The high number of deaths in Mexico is worrisome, but the low number of hospitalizations elsewhere is encouraging. With significant trade and travel, if this is the start of a new pandemic, it is likely that this virus will spread faster than any previous pandemic. While this will be a significant public health problem, there is an additional issue which may more significantly impact the resulting mortality from this flu (or any future pandemic) and future seasonal flu epidemics: antibiotic resistance.

It has been shown that pneumonia caused by influenza and bacteria is approximately three times more common than pneumonia caused by influenza alone, and these virus-bacterial pneumonias can be more lethal – especially when triggered by Staphyloccus aureus. In the 1957 pandemic for instance, it was found that 47% of individuals co-infected with S. aureus and influenza died, while only 16% of those not co-infected with S. aureus died. This suggests that antibiotics play a significant role in limiting deaths from secondary bacterial infections that occur from the flu. To limit deaths, you need effective antibiotics.

A possible flu pandemic suggests two possible problems: 1) widespread drug resistance, especially MRSA, may be responsible for a higher mortality rate, and 2) increased antibiotic use, both needed and unneeded, from more sick individuals will lead to increased drug pressure and more intense selection for resistance, and this in turn will lead to increased mortality now and in the future. The possibility of this issue becoming a significant problem is made even more significant by the fact that MRSA has spread widely in the community, and has been linked with severe disease in some instances. Significant increases in sick individuals who are possibly colonized by a pathogen that could make them sicker, is a problem. If that pathogen is widely resistant to treatment, we have a catastrophe.

In addition, these problems will be exacerbated in countries with inadequate or overburdened health systems, as the availability of more expensive second-line treatments is low, and antibiotics will be more likely to be abused by individuals without bacterial infections. Additionally, the effects of increased antibiotic usage will not stop when a pandemic is contained, as the resistant bacteria will not disappear with the flu, but will continue to cause serious problems into the future. Modern medicines, especially antibiotics, can often seem magical, as they pull people back from the dead. But the fact is that there are very real consequences that can and have resulted from the overuse of these drugs. It is important that any response to this possible pandemic deal with the possibility that we could see significant numbers of people dying from drug-resistant bacterial infection, and that this could both exacerbate the ongoing epidemic and result in more deaths down the road as drugs become ever more ineffectual.