MS. DIANE REHMThanks for joining us. I'm Diane Rehm. For years, there have been warnings about the overuse of antibiotics in humans and farm animals. In a new report, the Centers for Disease Control and Prevention quantifies this risk. Twenty-three thousand people die every year from drug-resistant infections, and the number is likely to climb.

MS. DIANE REHMJoining me to talk about why we may be headed to a post-antibiotic era and what we can do about it, Dr. Steven Schwartz, a family medicine physician at Georgetown University School of Medicine, and Dr. Richard Carnevale of the Animal Health Institute. We are going to take your calls, your comments a little later in the program. But, first, joining us from a studio at the Centers for Disease Control and Prevention, Dr. Thomas Frieden. And, Dr. Frieden, welcome to you.

DR. THOMAS FRIEDENThank you very much. It's good to be on the show again, Diane.

REHMThank you. Dr. Frieden, there are a number of bacteria and at least one fungus we used to be able to treat and now we cannot. Give us an overview of the new CDC report.

FRIEDENWhat we have done for the first time is put together everything we know with some new data and some data we had on hand on the problem of drug resistance, antimicrobial resistance in the U.S. And these are really conservative minimal estimates. This is the bare minimum number -- at least 2 million infections per year, at least 23,000 deaths per year, and also, tens of billions of dollars of healthcare costs each year. So it's a serious problem. If we don't act now, our medicine cabinet will be empty, and we won't have the antibiotics we need to save lives.

REHMWhat is so interesting to me is that you say we're getting closer and closer to the cliff. What does that mean?

FRIEDENWe talk about a pre-antibiotic era and an antibiotic era. If we're not careful, we'll be in a post-antibiotic era where we won't have the medicine we need to take care of people who, for example, have an infection after cancer chemotherapy or after a kidney transplant or after treatment for rheumatoid arthritis. So our ability to treat patients may get less and less. And I have to say that I went to medical school residency during the time of the AIDS epidemic in New York City in the '80s and early '90s and was working in tuberculosis control at that time as well.

FRIEDENAnd we had patients with HIV who we couldn't treat because it was before we had these excellent drugs that we have for HIV. And it's a terrible thing to have people dying of infections in this day and age. But that's what's again happening in intensive care units around the country because we have run out of drugs for some patients and for some organisms.

REHMAre you saying that most people get these diseases primarily in hospitals?

FRIEDENThe most severe infections we're seeing today are in hospitals. And we've seen, for example, something that I've called a nightmare bacteria, CRE or Carbapenem-Resistant Enterobacteriaceae. We've seen that spread from one state, just a decade ago, to 44 states today. And for many of those organisms, it affects people in intensive care units who are very ill otherwise. The mortality rate can be quite high. And those organisms can spread quite readily from one organism to another. The resistance can spread. So we really are seeing serious problems, but we do have solutions.

REHMWell, before we get to what you see as those solutions, is it true that half of antibiotic use in humans and much of antibiotic uses in animals is both unnecessary and inappropriate?

FRIEDENWe've studied this in humans. It would be the Agriculture Department and the Food and Drug Administration to look at the animal side of that equation. But we promote responsible antibiotics stewardship everywhere, and it's not happening. It's not happening in humans where at least half of all antibiotics prescribed in this country are either unnecessary or inappropriate.

FRIEDENWe looked at prescribing patterns around the country. And there's a two-fold difference between one state and another in the rate of antibiotic prescriptions. And there's no lower rate of problems or infections in the areas that are using more antibiotics. So I have to conclude that quite a bit of the antibiotic use in this country is, again, either unnecessary or inappropriate.

REHMDr. Frieden, I would think there are going to be lots of parents who are extremely concerned about this, who may want antibiotics for their child's sore throat or ear infection or perhaps an upper-respiratory infection. What are you saying to those people who have these problems?

FRIEDENFor every medication, including antibiotics, there are risks, and there are benefits. More medicines isn't better medicines. The right treatment is the best treatment. For many people with a viral syndrome, it doesn't make any sense to take antibiotics. And you may end up with a complication for it, or you may end up undermining the effectiveness of that antibiotic for your kids when they need it in the future.

FRIEDENEven, for example, for kids who do have things like ear infections, we know that there are various alternatives to treatment and that the treatment that's given gets more complicated, more difficult, and more expensive as you run through the first and second line types of antibiotics. So, again, important for parents to understand that there are risks and benefits for antibiotics. They can be essentially life-saving, but it's not something that you should be pushing for when you go to see the doctor. You should be trying to get the best possible care for your child. That doesn't mean the most possible care.

REHMSo what's in the pipeline for new drugs?

FRIEDENWell, I think to address the problem of antimicrobial resistance, we need a balanced portfolio. We need to do four core things, all of which are essential: first, prevent the development and spread of infections by doing things like stopping outbreaks and vaccinating more effectively, second, tracking resistance, including with new tools, so we can diagnose it faster, figure out where it's spreading, third, improve use, antimicrobial stewardship -- again, getting to that better use of antibiotics, particularly in hospitals -- and, fourth, develop new drugs and diagnostics.

FRIEDENBecause we will need new drugs, but, unless we improve our stewardship of the drugs we've got, we'll lose those just as quickly as we've lost these. And there are no new drugs right around the corner. They're years away from being in clinical practice, and uncertain how good they will be, so we have to make optimal use of the drugs we have today.

REHMI'm not sure I understand why that is. Why is it that new drugs are so far in the future? Is it a matter of money? Is it a matter of drug companies not being interested in developing these new drugs? What's the problem? What's the delay?

FRIEDENWell, it's a series of things. First, the low-hanging fruit has been picked already. So we've perhaps already found many of the most effective antibiotic classes. So it's getting harder and harder to find things that work really well. Second, it can take a decade to bring a new medication to market. And it cost a lot of money. The Food and Drug Administration, the industry, Congress, have all acted to figure out ways to incentivize companies to make the process a bit easier, but it's still hard and uncertain.

FRIEDENSo we do need to continue to try to make new drugs, but experts tell us that it could be a decade before we've got them. So we need to do much better with stewardship of the drugs we've got today. This was kind of like a gift given to us by a former generation of doctors, scientists who worked really hard to come up with them. We need to preserve these antibiotics so that our kids and our grandkids can benefit from them.

REHMBut, you know, I've been doing this program, as you well know, for more than 30 years, Dr. Frieden. I've been hearing this same story about new drugs being more than a decade away for each of the decades I've been doing the show. So my question to you is, what is the hold up?

FRIEDENIt's not easy to come up with a new drug. Many of the good drugs have been found already. And once you identify a new antibiotic, you have to make sure that it's not harmful. You have to see if it's effective. You have to see what it's effective in. And the number of new drugs approved has been decreasing year after year. So we used to have a few a year. Then we had one a year. Now we have less than one a year.

FRIEDENSo it's getting less and less. That pipeline is getting drier and drier of new drugs. And that's why stewardship is ever more important. In fact, the CDC, we now recommend that every single hospital in America have an antibiotic stewardship program to make sure that the antibiotics that are in use are appropriate and used only when necessary to protect patients and to protect the antibiotics.

REHMBut you're not just calling on hospitals. You're talking about community involvement. You're talking about public health professionals. You're talking about an all-out effort to stop the overuse and to be far more careful in choosing to use antibiotics.

FRIEDENAbsolutely. This is an all-hands-on-deck call. And one of the reasons we've issued this report with such urgency is that not only is the problem serious, but we know what to do about it, and it's not too late. It's not too late if we act, but we need to act now to take better control of our antibiotics, to prevent infections better, to track resistance more effectively, and to continue to rev up that pipeline for new antibiotics.

REHMDr. Thomas Frieden, he is director of the U.S. Centers for Disease Control and Prevention. Thank you as always for joining us.

FRIEDENThank you very much for calling attention to this important issue. I appreciate it.

REHMIndeed. And after a short break, we'll turn to our other guests and your calls.

REHMAnd welcome back. After our talk with the Centers for Disease Control and Prevention's Dr. Thomas Frieden, we turn to Dr. Steven Schwartz of the Georgetown University School of Medicine and Dr. Richard Carnevale. He's vice-president for regulatory, scientific and the international affairs at the Animal Health Institute. First to you, Dr. Schwartz, what are some of the most common problems that people think antibiotics can cure or at least help with?

DR. STEVEN SCHWARTZSo the most common problems that people come in with are what you had mentioned earlier, upper respiratory infections from colds to ear infections, sore throats, strep throat, pharyngitis, skin infections. And the reality is some of these, for instance, strep throat, are bacterial and do require narrow spectrum antibiotics to treat them. But many or most of them do not require antibiotics to treat.

REHMSo how does a doctor who gets a call from a patient adult or a parent about a child who says, my child is screaming, the ear is hurting. What does that doctor -- what should that doctor do?

SCHWARTZSo the doctors -- when doctors write antibiotics, they're really doing it out of a desire to help. That's their -- they want to make their patient better. They're trying to meet that patient's needs and, if there's a serious infection, to make the patient get better faster and prevent complications. Some of the infections we have good tools for. There are rules. There are certain physical exam findings. There are certain parts of the story. Strep throat, there's often fever. There's puss on the tonsils. There's swollen lymph nodes. We have rapid strep tests ,so we can get quite accurate diagnoses.

REHMSo you've got to see that patient.

SCHWARTZYou have to see that. An ear infection, you've got to look at the ear. You have to see if the ear drum moves. But some, like sinusitis, which is a very, you know, commonly-made diagnosis, we don't have great tools on the story. There aren't key elements of the story that tell us, or the physical exam is not helpful. You know, sometimes the duration is helpful.

SCHWARTZBut a lot of people -- there's a myth that if the mucus is green, it's bacterial. And that's just -- that is not fact. That is myth. So a patient might call and say, my mucus is green, therefore I need my Z-Pak. I need my antibiotic. And that unfortunately is no better than a toss of a coin.

REHMSo what you're saying again is, the conditions that used to prompt a doctor to say, well, I'll prescribe a Z-Pak for you if your mucus is green, that's a broad-spectrum antibiotic. How does the doctor know whether to prescribe a narrow-focused antibiotic or a broad-spectrum?

SCHWARTZSo the spectrum -- a lot of people think the term broad spectrum or narrow spectrum is a stronger or weaker. But narrow spectrum tends to imply it kills certain specific bacteria, whereas broad spectrum, it kills a wider range of bacteria. One might go for a broad spectrum if you don't know which bacterium it is and what antibiotic will be effective. So when you know the bacteria -- and again I pick strep or perhaps staph -- you can pick a very specific narrow-spectrum antibiotic.

SCHWARTZWhen you don't know or the disease -- the illness is caused by possible multiple antibiotics, you tend to go with broader spectrum. So in the community, I think sometimes doctors prescribe broad spectrum for a variety of reasons. You know, if we think about sinusitis -- even just think about the cold. If I say to you, Diane, this is a cold. My dad always used to say, if you baby the cold, you drink lots of water, it'll go away in seven days. If you do nothing, it'll go away in a week. He was wrong. It could actually take 10 to 14 days. But people want it to go away in four days.

SCHWARTZSo, you know, if I call it -- you have rhinopharyngitis, you worry you have a disease. And if I say, you have a cold, which is the same thing as rhinopharyngitis, you don't worry as much. So we do a disservice by misnaming it. But sinusitis, we know that some sinusitis, some infections of the sinuses are caused by bacteria. And some may be helped by antibiotics. And some, if not treated, can spread to a serious infection.

REHMIsn't there also a problem with over using antibiotics? Can't that create other problems within the human system?

SCHWARTZAbsolutely. So every time we use antibiotics, amoxicillin, augmentin, Z-Pak, zithromax, azithromycin, our bodies are covered inside and outside with different bacteria that like to live on us happily. Some cause infection. But as we use antibiotics, it allows other pathogens, bad germs to grow. And when you use antibiotics to try and prevent that rare complication of a sinus infection, you might cause more problems.

SCHWARTZOne of the drugs listed on the top urgent level of the CDC report, the C. difficile, Clostridium difficile is a very, very serious digestive problem. And when you use a broad-spectrum antibiotic and kill all the healthy bacteria in the intestines, C. difficile has a chance to grow. And we used to never see this in the outpatient setting. It was a hospital-acquired problem. We see it commonly now, and it is a difficult problem to treat.

REHMAll right. I want to turn now to you, Dr. Carnevale, because -- back to the over-use of antibiotics -- the CDC's report states that much of the antibiotic use in animals is at least part of the problem. How do you respond?

DR. RICHARD CARNEVALEWell, Diane, first of all, thank you for inviting me to speak with you today.

REHMYou're most welcome.

CARNEVALEWe appreciate the opportunity. And I also would like to point out that I commend CDC for putting out that report. I think it -- they have put out other information in the past that highlighted important resistance problems but I think this is the first time they've put out such a comprehensive report. And I think it's very good that they are highlighting the key problems in the country.

CARNEVALEAs far as animals go, yes, this has been an issue for some time about the use of antibiotics in animals. And let me say that the antibiotics that are used in animal populations today, particularly food animals, are meant for one purpose. They're meant to keep animals healthy, which leads to healthful and safe food and therefore healthy people. Because the food supply's critical, animals going to the food supply must be healthy in order to produce safe food.

CARNEVALEAntibiotics have been approved by the FDA for many years. They go through a very rigorous process, almost worse and almost harder than they do for human drugs because of the food safety concerns. They're approved for four purposes: treatment -- short-term therapeutic treatment, control -- that would be when certain animals break in a herd and you want to control the other animals from becoming sick -- prevention, which is administering antibiotics before something occurs.

CARNEVALEAnd in many cases, in certain herds or flocks of animals, a producer or a veterinarian will know that they're susceptible to a certain disease at a certain time, and they will introduce antibiotics. The final use that is the most controversial is what's called growth promotion.

CARNEVALEThese are very old claims on a number of older antibiotics, certainly not on any of the new antibiotics. FDA has not approved a claim for a growth promotion in more than 20 years, so these are some older indications that are still on some of the products that are out there -- have been out there for a number of years, like the older tetracyclines and penicillins.

REHMAt the same time, now that the CDC has included antibiotic use in animals as perhaps more than 70 to 80 percent of all antibiotics are used in animals, do you believe that that's going to call for a new look by the FDA at the use of these antibiotics in animals?

CARNEVALELet me comment on the FDA action in a moment, but I would like to address the 70 or 80 percent because, unfortunately, that number has gotten embedded in the media in many people's minds. And even the FDA has taken issue with that number. You cannot compare the databases that that 80 percent -- 70 or 80 percent number has come up with has been comparing data that the FDA itself collected on animal antibiotic sales compared to a commercial database that FDA wasn't involved in.

CARNEVALESo the first problem is you're comparing two separate databases, one for animals and one for humans. The other thing that FDA does point out is that you have different doses given to animals. You have different sizes of animals. Obviously, you can have an 800-pound steer and, you know, a two-pound chicken, so you have various doses there. Plus the biggest factor is there's 35 or 40 times as many animals -- food-producing animals and pets in the United States as there are people.

CARNEVALESo one would suggest that probably the overall antimicrobial use would be higher, but the other thing that FDA points out, that a very large percentage of that 70 or 80 percent that's quoted are compounds that aren't used in human medicine. So when you talk about the antibiotics that are actually used in animals, you have to be very careful to understand that many of those antibiotics and a large percentage of them are simply not used in human medicine. And therefore can't have an impact on antimicrobial resistance.

REHMAt the same time, whether you agree with the FDA or whether you agree with the CDC, the CDC has now come out with this report stating that 70 to 80 percent of antibiotics are indeed used in animals. I ask you once again whether you believe that may cause the FDA to take another look when the CDC says, we're about to go off the cliff with this use of antibiotics. And the question still up in the air is whether this antibiotic use in animals is somehow translating to digestion in human beings. You've got a real question going.

CARNEVALEOK. And let me respond to the FDA issue. Even before CDC came out with this report, FDA has been working, in fact, to control some uses of antimicrobials. About two years ago, they issued a guidance document, it was called, that stated they would like the industry to phase out the use of antibiotics for growth promotion, which are for deficiency and weight gain.

REHMAnd how long did they give for that phase-out?

CARNEVALEWell, they would give three years, three years, as soon as they published their final guidance. Unfortunately, the government acts slowly, and we have not seen the final guidance yet. The other aspect...

REHMSo the phase-out has not yet begun.

CARNEVALEHas not started, but the companies that market these products are working with the FDA even before the final guidance has gone in place. So once the final guidance goes in place, the companies will be ready to respond to that.

REHMAnd you're listening to "The Diane Rehm Show." I wonder, Dr. Schwartz, from your perspective, what we know about the human health risk posed by antibiotics used in animals.

SCHWARTZI think that -- you know, I can't say directly. We know that antibiotic use when it is around, in humans and in animals, will essentially create these super bugs, germs that are resistant to antibiotics and germs that are resistant to specific antibiotics or classes of antibiotics. When those bacteria are around and colonized, one is more likely to get infected by them. So, in fact, to be infected with a resistant staph, you didn't have to take an antibiotic to create that resistance in you. That germ could've lived on your neighbor.

REHMAnd we're joined now from Flagstaff, Ariz. by Dr. Lance Price. He's a microbiologist at George Washington University. Hello, Dr. Price. Thanks for joining us.

DR. LANCE PRICEGood morning, Diane.

REHMTell us about the genetic sequencing you're using to test whether antibiotic-resistant germs in farm animals get to people.

PRICESo the research that we're doing at George Washington University and at TGen, the Translational Genomics Research Institute in Arizona, is combining cutting edge DNA sequencing technologies with some of the more classic epidemiology tools to quantify how often these super bugs are making their way from farm animals to people.

PRICEAnd last year, we showed very clearly that new types of -- a new type of MRSA that originated in food animals then jumped, and now routinely jumps, from animals to people. And, you know, I think it's important to point out that MRSA is one of the super bugs listed in the CDC's report and one of the greatest bacterial killers in circulation today. Now we're also looking at something that we call FUTIs, or foodborne urinary tract infections.

PRICEAnd that is looking at the E. coli that's rampant in our food supply, and it's very frequently drug resistant. And there's good evidence that that drug resistance is because of the antibiotics we're using on the farm. We're seeing very clear links between those E. coli and the E. coli that are causing, you know, urinary tract infections in people in the United States.

REHMHow would you go about proving that the bug actually went from, say, cattle or meat to a woman or a man to create urinary tract infections instead of just being there in both?

PRICERight. So it's a tough challenge. And part of the tough challenge is that there's very little transparency in our food animal industry, so it's hard to get access on the farm and to really go right from the source to people. But what we did last year was we went to every grocery store in our city in Flagstaff, which is this little town separated from other towns -- so everybody shops in the same city -- went to every grocery store twice per month, bought every brand of chicken, turkey and pork, which we think are the dominant sources of these E. coli.

PRICEAnd, simultaneously, we got every E. coli from every urinary tract infection from our local hospital Flagstaff Medical Center. And then now what we're doing is we're cracking open every one of those cells. We have over 3,000 E. coli now from food and from people, and we're sequencing the entire genome, so every base of DNA from those E. coli.

PRICEAnd then we're comparing those, and we're asking, how are these related? And we can find very close matches, and sometimes almost perfect matches. And then by looking at the temporal relationships that is over time, what strains are coming into the city over time, and then how are those related to the infections that we're seeing. We can really close that gap.

REHMI think that your work is fascinating, Dr. Price. Interesting to me you left out beef when you went to chicken, turkey, and pork. Maybe you can stay on the line with us. We'll take just a short break and be right back.

REHMAnd joining us now from her office here in Washington, Congresswoman Louise Slaughter. She represents the 25th Congressional District of New York. Hello to you, Congresswoman Slaughter.

REP. LOUISE SLAUGHTERGood morning.

REHMThanks for joining us.

SLAUGHTEROh, it's a pleasure. I'm so glad you're bringing attention to this issue.

REHMThank you. I gather you've introduced a bill that would end the routine use of antibiotics on healthy animals. So…

SLAUGHTERExactly.

REHM…tell us what kinds of restrictions you're looking for.

SLAUGHTERIt's almost impossible now for a farmer to buy feed without antibiotics in it. And I want to hasten to say that the 80 percent figure, that you were aware of, was absolutely accurate. We got it from the FDA, and they have never questioned it. So we know that antibiotics are fed to healthy animals on a daily basis. We certainly have no objection to treating sick animals. And I would not want anybody to think that. But what we're saying is this overuse and really devastating overuse of antibiotics is making it harder and will become almost impossible for us to treat human infections.

REHMSo I gather that you see Dr. Price's research as kind of the smoking gun. He's on the line with us.

SLAUGHTERHe's wonderful. Dr. Price has done magnificent work.

REHMWell, Dr. Price, I'd like to bring you back in because you didn't have a moment to answer my question about why you didn't include beef in your research. You mentioned chicken, turkey, and pork.

PRICEWell, it turns out most urinary tract infections are caused by E. coli, you know, probably 80 percent in the United States. And E. coli's interesting because, even though it all has the same name, it has multiple personalities. And so -- but from a clinical standpoint, there's the kind that we all carry around, that just helps us digest our food. And then there's the kind that causes diarrhea.

PRICEAnd that's, you know, like, remember the Jack In The Box incident? Now, that kind of E. coli can come from beef. But the kind that causes urinary tract infections appears to be most closely associated with poultry products, then followed by pork, and then much lower down by beef. And so that's why we focus on those three meat types.

REHMAll right. So, Congresswoman Slaughter, what would your bill -- what would your proposal do, as far as the meat industry, the chicken farming group, pork-raising and turkey? What would it do?

SLAUGHTERWe're saying that eight classes of antibiotics would be kept for human use. Again, if their animal's sick, we want it to be used. But let me tell you that I disagree even with the CDC report. The number we have of persons who die from incurable infections is $70,000 -- or excuse me, 70,000. A member of Congress always thinks in money...

REHMRather than the 23,000?

SLAUGHTERSeventy-thousand persons dies of uncontrollable infections. And there have been some statements made by people that we support and approve of that strep throat could really become a fatal disease. Now, I want you to know this bill has over 450 outside groups supporting it, including the Union of Concerned Scientists, the Pew Trust, the AMA. All of these people cannot be wrong and Dr. Carnevale be right.

REHMSo we're…

SLAUGHTERAnd it is absolutely -- it is no -- there's no question about it, that their lobbying up here has kept this bill from getting to the floor. And I want to tell you that I know the United States lurches from one crisis to another, but this is one that affects our health.

REHMSo how much support do you actually have on the Hill?

SLAUGHTERForty co-sponsors. We've been at this since 1999. And we have 40 co-sponsors. I think there are five in the Senate. And it is simply because we can't get a hearing. And, frankly, I've not had a lot of help out of the FDA. The last conversation I had with them was a couple months ago. They're going to give the farmers three more years to cut out this overuse of antibiotics.

REHMYeah, so you say you can't even get a hearing.

SLAUGHTERRight.

REHMSo your fellow members of Congress don't want to deal with this?

SLAUGHTERAnd numbers of people in the administration don't want to either. I don't think -- I would be totally unfair if I didn't say that.

REHMAnd you're arguing that it's because of the lobbying from the agribusiness.

SLAUGHTERPharmaceutical companies who make money and from the Cattleman's Association and the people who sell livestock. Let me tell you one story here -- this is very important to get people an idea of what they're eating. There was a chicken inspector working for the FDA in upstate New York, 39-year-old young man. The chemicals that he inhaled off that assembly line caused his lungs to bleed out, and he died.

SLAUGHTERNow, all this stuff, it's more than just an antibiotic. At the end of the chicken line, they soak the chicken in cool water and Clorox. And then it is wrapped up in plastic wrap and sent to your grocery store. We think we can do better than that, but, indeed, we're going in the wrong direction because the Agriculture Department has said they are going now to cut back on food inspection.

SLAUGHTERThey are raising the number of chickens inspected a minute from 100 a minute to 140, at the request of the industry. And the worse fact -- they're going to let other countries inspect their own food before they send it in here. I want America to wake up to what's going on here and what we're feeding our children and what we're eating ourselves.

REHMWell, clearly, you have woken up at least a few people today.

SLAUGHTERI hope so.

REHMCongresswoman Louise…

SLAUGHTERWe don't have a lot more time here.

REHMI totally understand your position. Thank you for joining us.

SLAUGHTERYou are very welcome. Thank you for asking me.

REHMThank you, Congresswoman Louise Slaughter. She represents the 25th Congressional District of New York. And, Dr. Price, I hope you'll stay on with us. We are going to open the phones now. First to Little Rock, Ark. Monica, you're on the air.

MONICAHi, Diane.

REHMHi there.

MONICAThanks for taking my call. I'm so glad to have you back. I hope you enjoyed your vacation.

REHMThank you so much.

MONICAOK. So I have two questions. First of all, my pediatrician and I are both very careful. The current things that I am going for antibiotics for -- and tell me if there are other things I need to do or not do -- are strep throat, if my children have strep throat, or if a sinus infection goes, like, for two weeks and is just not stopping. And then my second question is, I read a report that mentioned that chiropractic care might be as beneficial or more beneficial for ear infections.

REHMAll right. Dr. Schwartz?

SCHWARTZWell, thank you for the call. I mean, I think what we just heard there is exactly what we're looking for, is a partnership between patients and their doctors to improve stewardship. And I think the examples in respiratory infection you gave are just exactly right -- identifying strep, treating strep. If it's a viral sore throat, it doesn't need antibiotics.

SCHWARTZSinusitis is a little bit more difficult, but most guidelines do say in children, if the symptoms are beyond 14 days and not improving or worsening, certainly if the severity is moderate to severe, those may be appropriate. And for the most part, every other upper respiratory infection probably does not need antibiotics. And even as you carefully pointed out, most ear infections in children don't need to be treated with antibiotics. There's certain guidelines on that. So I think you're right on the mark with that.

REHMAll right. Thanks for your call, Monica. To Stow, Mass. Ally, you're on the air.

ALLYHi, Diane.

REHMHi.

ALLYI love your show.

REHMThanks.

ALLYAnd this show is really important to me. I feel like when we go at these issues with antibiotics, we don't discuss the money in following the profits. You have to understand that the antibiotic use in agricultural animals is the number one consumer to these pharmaceutical companies that make the antibiotics. They're the number one customer. They don't want to lose that. They don't want to lose that.

REHMDr. Carnevale?

CARNEVALEWell, thank you for the call. I will say that the only reason the antibiotics are being used is because there's a need for them. Producers operate on a very tight margin with regard to their production. And they really don't want to use anything that's going to cut into their profit margin if they don't have to. So, obviously, these antibiotics do serve a need.

CARNEVALEPharmaceutical companies go through a lot of work trying to produce these products according to FDA strict standards, prove that they're safe and effective. They're certainly not being used indiscriminately. There are judicious use programs from every commodity group out there -- beef, pork, cattle and chickens -- to make sure these drugs are used properly. And they only use them because they get a significant benefit of keeping their animals healthy.

REHMOur earlier caller also asked about the use of chiropractic for ear infections.

SCHWARTZYeah. I wanted to just make one other comment on that. Since most ear infections don't require antibiotics, you know, it's more symptom relief and time. I see a chiropractor myself. I'm not opposed to it. The reason you tend to get ear infections is fluid accumulates in the ear, and it's plausible that a manipulation might allow for better movement to the fluid back down the Eustachian tube. I don't think there's really strong evidence that it helps. I don't think that it hurts. But, you know, time will do the job.

REHMYou know, what works for one person may not work for another, but I've just come back from a long airplane trip with a sore throat. So as soon as I got home, I began gargling with warm salt water. And salt does do it for me. Whether it will work for anyone else -- I know a number of people who use it at the beginning of any kind of throat infection, and I offer it to all of our listeners as something you might try yourself. Let's go to Tampa, Fla. Hi, Michelle, you're on the air.

MICHELLEHi. I am the mother of a 2 1/2 year old who has had many infections of the ear. And the first thing that he's prescribed is antibiotics. I try to keep antibiotics out of our house as far as through our food supply. But I'm wondering if there are alternatives to the antibiotics for ear infections for small children. And how do we find out about it if our pediatricians aren't really willing to give us any alternatives? Because I don't want to rely on the Internet for information when it comes to my child's health.

REHMDr. Schwartz?

SCHWARTZSo that's a difficult challenge. Again, there are some cases where, you know, it's not just one infection or another infection. First of all, you want to make sure that they are clearly confident that they are making the diagnosis of an ear infection. Sometimes it's hard to see, and the doctor will just say, well, maybe, yes. Or sometimes they are legitimately seeing ear infection after ear infection. Once you start getting multiple ear infections, say -- you said a 2 1/2 year old -- you're at four, five, six ear infections in a year, that's usually when you want to refer off to a specialist.

SCHWARTZThey'll look at the ear drum. Sometimes -- we don't do it as much as we used to. Sometimes ear tubes are needed, decongestants -- although we don't like to use decongestants in young children because the cold medicines in young children don't seem to help their anatomies. It can be difficult. You may look at allergies as an option, as well.

REHMAll right. Thanks for your call. And, Dr. Price, you mentioned MRSA, and we do have a caller who has interest in MRSA infections. Nancy, in Peoria, Ill., you're on the air.

NANCYHi, my question is, what is the connection between MRSA and gross promotion of antibiotics in animals? My daughter was an athlete, and she's had frequent MRSA infections. And our doctor has said that it's connected to her being an athlete and maybe, you know, in the locker room. But I also know that she's been treated with antibiotics for MRSA with little success and now has allergies to antibiotics.

REHMAll right. And before you respond, Dr. Price, let me remind you you're listening to "The Diane Rehm Show." Go ahead, Dr. Price.

PRICEWell, you know, MRSA gets around when people get crowded together and under unsanitary conditions, which often happens in locker rooms for kids, right. So their things are stuffed in a locker, and they don't wash them that frequently or maybe uses a wetsuit on vacation that somebody else has used. And you can pick up bugs that way. And the CDC talks about how crowding and unsanitary conditions and such can lead to the spread of MRSA.

PRICEBut I would say that there's no place on Earth where there's more of this crowding, unsanitary condition then a concentrated animal feeding operation. And so you crowd the animals together, they can spread the bacteria between one another, and then we add that magic ingredient of antibiotics. And it's more than just an invitation for MRSA. It's almost a guarantee for MRSA.

REHMAll right. And, Nancy, I want to ask you, since your daughter is an athlete, is she eating a lot of proteins? Is she eating a lot of beef, chicken, pork and the like?

NANCYYes. Yes, she does. And that brings up the other question that -- I'm able to afford antibiotic-free meat for her, but then we come to the question of these infections are becoming poor people's diseases because they cannot afford meat that comes from someplace other than Walmart.

REHMDr. Price?

PRICEThat does underscore, you know, the social justice issue. You know, why should the wealthiest or the more wealthy in our society just be able to afford the products that are perhaps cleaner and safer? And that's why we really need a national regulation to create a safer food supply. So let's decrease the antibiotic use across the board. Let's get the antibiotic use down. Let's stop that driving force that's helping create these new strains of super bugs.

REHMAll right.

PRICEAnd let's make a safer food supply for everybody.

REHMI want to give you the last word, Dr. Carnevale.

CARNEVALEWell, I'm not sure I know what Dr. Price is talking about because we do have a national regulation. And poor people are not suffering any more than rich people. Food is inspected by the USDA equally. The FDA sets tolerance for residues in food. There are no antibiotic residues in food, contrary to what people believe. And food is inspected for bacterial pathogens the same way. So there is national regulation. It's called the Food Safety and Inspection Service. So this business about poor people being affected more than rich people, I totally reject.

REHMAll right. And that was Dr. Richard Carnevale of the Animal Health Institute. We've also heard from Dr. Steven Schwartz of Georgetown University School of Medicine, Dr. Lance Price, microbiologist at George Washington University, and Congresswoman Louise Slaughter, who has tried to introduce legislation which would ban the use of antibiotics in animals. And we should mention that Congresswoman Slaughter has a degree in microbiology. Thank you all for joining us. And thanks for listening. I'm Diane Rehm.

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