People vs. germs: The germs will win!

September 2001

All of you are aware, I’m sure, of the Great War on germs. It goes on all day, every day, virtually wherever germs can be found. Well-known battle sites include toilet bowls, toilet seats, sinks, showers, articles of clothing, kitchen cutting boards, kitchen and dining area tables in the home and most assuredly in restaurants, sheets, blankets and mattresses, and – of course – toys!

Weapons of war

The favorite weapons used by people are, of course, household disinfectants and germicides of various types, some containing household bleach as the active agent, but many containing the increasingly popular antibacterial agent, triclosan. Now available are antibacterial cleansers, soaps, toothbrushes, dishwashing detergents and hand lotions.

The battle plan, as articulated by the self-appointed generals in this war, consisting of companies that manufacture and distribute the ammunition to be used, is simply to wipe out germs wherever they might be. Take no prisoners — just kill them all!

Tactical plans are communicated extensively through the media, especially television (though I don’t listen to commercial radio enough to know whether if that medium is used as well). The attractive women (the troops seem invariably to be attractive women!) all smile beneficently as they eradicate the germs in the toilet bowl and in the kitchen!

OK – you have the picture by now. But there is one more picture you need to visualize: the total antibacterial house! Sometime when you are surfing the Web and have nothing better to do, go to www.akconcepthome.com and there you will find “the antibacterial house.” I quote from its 6/14/2001 Internet wire:

“The country’s first antimicrobial house, Camino de Robles, is a concept home being built by AK Steel. The home is being outfitted with a new technology: antimicrobial-coated steel. The antimicrobial compound has been proven to suppress the growth of bacteria, mold and fungus. This revolutionary steel will be used in ‘high touch’ zones around the house: from doorknobs and handrails, to sinks, faucets and food prep areas. Even the heating, ventilation, and air conditioning ductwork will be made from the bacteria-resistant steel.”

There you have it. Sound idyllic?

A little further exploration of that Web site indicates that the active agent is silver ion, which is coated onto the steel surface in some unspecified manner.

Origin of obsession

How did this obsession with germs come about? It appears to be an affliction unique to the developed world.

Undoubtedly we can all think of many reasons, but most of it is an unanticipated consequence of the whole antibacterial drug era, beginning early in the last century, but really becoming a public interest phenomenon only in the last 2 decades. The public has heard so many increasing concerns from physicians about antibiotic resistance, resistant bacteria and superbugs (aka “emerging pathogens”), that it concluded simply that all bugs are bad; therefore, let’s just wipe them out. In a capitalistic society, it didn’t take long at all for manufacturers to see potential profit in the Great War on germs.

Fortunately, a few voices of reason and caution are now emerging, and a modest amount of science as well. Stuart Levy of Tufts University School of Medicine, and long a protagonist for prudent use of antibiotics, has been in the forefront here. He presented his reasons for concern about the profuse deployment of antibacterial agents, especially triclosan, at the International Conference on Emerging Infectious Diseases in Atlanta in July 2000. His presentation was subsequently published in Emerging Infectious Diseases (2001;7 [3 Suppl]:512-515). For those wishing to read his report, it is available online at www.cdc.gov/ncidod/eid/index.htm.

In this report, Levy reviewed the evidence that resistance emerges to triclosan, just as other antibacterial drugs. Moreover, development of triclosan resistance may also confer resistance to other antibacterial agents as well, including some used for treatment of infection in humans. Schweizer and his colleagues at Colorado State University studied the development of triclosan resistance in Pseudomonas aeruginosa, and found that ciprofloxacin (Cipro, Bayer) resistance was also increased (AAC. 2001;45:428-32).

Other consequences like asthma

Levy also pointed out a potential immunologic consequence of the “antibacterial craze,” namely, a possible increase in asthma and other atopic disease. There is evidence that “excessive hygiene” may interfere with normal maturation of the immune system, perhaps in part by eliminating the stimulation of commensal flora. This resulted in an imbalance between the T-helper 1 cells responsible for cellular immunity and the T-helper 2 cells promoting antibody production. Note that this is still somewhat speculative, but the immune system, like the musculoskeletal system and others, may need to be exercised regularly to function properly.

Antibacterial craze

Even all these risks might be acceptable if there was some health benefit to be realized by the antibacterial craze; needless to say, no such benefit has ever been demonstrated, at least in normally immunocompetent families. It is possible, of course, in families with one or more severely immunodeficient persons, that there may be some benefit that can be realized by household disinfection, but even that has yet to be demonstrated.

It’s time for us to educate — to tell the public about the good things bacteria do for us, that bad bacteria are only a small minority of the population, and to speak out against the possible dangers of the antibacterial craze. Who will take up this cause? Infectious Disease Society of America? National Foundation for Infectious Diseases?

Briefly on another topic: the recent demise of icanPREVENT and icanMD was a sad and truly regrettable end to a promising enterprise. The hospital epidemiology community has lost an enormously rich resource. If this was related to the present economic downturn, then perhaps we may look forward to a rebirth when economic growth returns. If not, it will probably be well into the future before we see a comparable achievement.