Rethinking bugs (part 2)

Thinking Outside the Box bugsLast month, I wrote about my observation that bacteria seem to be ‘trending’ at the moment, and explained my hope that their current popularity might have a part to play in improving care for women and babies. In that article, I questioned how bacteria are portrayed, both in everyday life and in theories of health and disease, and asked whether there may be potential benefit in understanding that our relationship with bacteria is not simple or easily summed up. In this article, I am going to look at some specific examples of how, if we were open to rethinking and embracing our complex relationship with bacteria, we might be able to move our knowledge forward.

Why do we need to re-think?

I am certainly not suggesting that we throw the proverbial baby out with the bathwater (not least because bathing our babies is another area that we need to reconsider), and I want to acknowledge the importance of appropriately detecting and responding to sepsis, as highlighted in the latest MBRRACE-UK report (Knight et al 2014). Pasteur’s achievements were incredible, and we should be grateful to him every time we sip a glass of wine, let alone when we use an antibiotic that is truly warranted. But we don’t have to throw out or devalue his work in order to reconsider elements of it or think about the issues in a more nuanced way. We will soon need a different approach to the current trend of giving incredible volumes of antibiotics to large numbers of people, which is unsustainable in the long term because of antibiotic resistance.

There are many reasons for re-thinking, including that it may help us to get back on track as far as giving effective care is concerned. In Reed and Johnson-Cash’s (2014) overview of emerging knowledge about the human microbiome and the way in which this relates to pregnancy, birth and early mothering, they point to the theory that stress can affect our gut microbiota and ask whether antenatal care should focus on reassurance and relaxation rather than clinical testing and discussion of risk. How many other areas of care could we improve if we could go back to the drawing board?

 

The GBS example

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The prevention of group B strep (GBS) disease is one example of an area in which I believe that a re-think might help us drastically improve the care we offer. Here, we have a situation where a particular kind of bacteria is known to live within about a fifth of people (although testing is not especially accurate, so this figure may not be either) and it causes no harm in the vast majority of situations. It gets passed to about half of the babies born to women who carry it, and most of them experience no ill consequences, but now and again it causes huge and potentially fatal problems for a baby (Wickham 2014). Often, these babies are already compromised, for instance because they have been born preterm, but this is not always the case, so there is no straightforward linear explanation here.

As current methods of screening and treatment require lots of healthy women and babies to be exposed to antibiotics, there is ongoing discussion about whether we could come up with a better response to this problem, with one proposed solution being a vaccine (Schrag and Verani 2013). Yet vaccination also has limitations and side effects, including that it may negatively impact on a woman and baby’s microbiome. To my mind, one of the main reasons that we should also be considering other options is that a vaccine would have to be offered to every woman, too. In an age where we can do almost everything bar make a cup of tea from the comfort of our smartphones (and I expect an app for that will be available soon), can we really not find a way to determine which individual women and babies are at risk – and why – rather than only being able to offer sledgehammer-level treatments to the entire population?

 

The clues in the question

There are a couple of really tantalising clues which may serve as starting points. One is that, although the currently available research studies are not of premium quality (Wickham 2014), there is a bit of a trend in the studies looking at the various possible treatments for GBS, which include chlorhexidine douching and water birth as well as antibiotics. They show that it is relatively easy to reduce colonisation with GBS bacteria but that this doesn’t necessarily lead to a reduction in GBS disease. This might not be the case if we did better research studies, but even the possibility that the presence of GBS is only one of the factors needed for GBS disease to occur may be worth exploring. It might come to nothing, but we’ll never know if we don’t try.

Another avenue for exploration is that we know from the experiences of women whose babies have had GBS disease that some of these women have low levels of antibodies to a certain type of GBS bacteria. Why not look at that, and ask deeper questions about the terrain, or the way in which our bodies relate to the bacteria that live within us? As I recently wrote, “as long as there is a possibility that GBS disease has multiple causes, or is caused by something else in the presence of GBS bacteria then the best thing that we can do for our current and future babies is to keep our minds open to other possibilities” (Wickham 2014).

I don’t know what these other possibilities are. I accept that the roads I’ve described may not be the exact ones that we need and that we may have to go down lots of cul de sacs before we find a better pathway than we currently have, but I think we owe it to women and babies to keep exploring. And it’s precisely because I think that we should keep exploring that I am so delighted about the focus on bacteria. Because, in my book, anything that helps us re-evaluate and re-think what we think we know is a jolly good thing indeed.

 

References

Knight M, Kenyon S, Brocklehurst P et al (2014). Saving lives, improving mothers’ care. Lessons learned to inform future maternity care from the UK and Ireland confidential enquiries into maternal deaths and morbidity 2009-2012, Oxford: NPEU.

Reed R and Johnson-Cash J (2014). The human microbiome: considerations for pregnancy, birth and early mothering. Available at: http://tinyurl.com/oo6usbh.

Schrag SJ and Verani JR (2013). ‘Intrapartum antibiotic prophylaxis for the prevention of perinatal group B streptococcal disease: experience in the United States and implications for a potential group B streptococcal vaccine’. Vaccine, 31(Suppl 4): D20-26.

Wickham S (2014). Group B Strep explained, London: AIMS.

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