Long term antibiotic use for Lyme disease doesn't work, according to new study

Fifteen years. That's how long scientists have been trying to prove a negative: that "chronic Lyme disease" does not exist, and that long-term antibiotic usage does not help with symptoms that include joint pain and fatigue. This past week, a study in the New England Journal of Medicine showed that long-term antibiotic usage–the favorite treatment prescribed by doctors who call themselves "Lyme literate"–is a failure. Will it convince any of those doctors to change their practice? I doubt it.

Lyme disease is a serious illness, caused by bacteria that are transmitted through tick bites. Although the disease has been infecting humans for centuries, it got its name relatively recently, in 1975, when two Yale doctors, Stephen Malawista and Allen Steere, investigated a cluster of illnesses near the town of Lyme, Connecticut. The symptoms included joint pain that resembles arthritis, so much so that Malawista initially called it "Lyme arthritis." A few years later, biologist Willy Burgdorfer discovered the true cause, and the bacterium Borrelia burgdorferi was named after him. As deer have spread through the suburbs of modern society, ticks traveling with them have spread Lyme disease far and wide; the NIH reported over 36,000 cases in the U.S. in 2013. (Note that the CDC estimates the true number of cases may be closer to 300,000, ten times the number actually reported to health authorities.) Lyme is also common in Europe.

Luckily for most of us, a brief course of antibiotics usually cures people completely of Lyme disease. For some people, though, symptoms including fatigue and joint pain can linger for up to six months. The cause of these longer-term symptoms remains a mystery, and is an active area of current research. One possible explanation from the CDC is that

"the lingering symptoms are the result of residual damage to tissues and the immune system that occurred during the infection."

Unfortunately, the lack of a scientific explanation has opened the door to wildly speculative treatments, based on little or no evidence, by doctors who think they know the answer. These doctors, some of whom have adopted the label "Lyme literate," insist that their patients suffer from what they call Chronic Lyme Disease. Among other things, they've formed an association called ILADS that claims that:

"Most cases of chronic Lyme disease require an extended course of antibiotic therapy to achieve symptomatic relief" and "many patients with chronic Lyme disease require prolonged treatment until the patient is symptom-free."

Not only do these treatments cost far more than the 2-week course of treatment recommended by the Infectious Disease Society of America, but they also have the potential to cause harm: it's just not good for you to be on antibiotics for months or years. Indeed, one of the first studies (in 2001, by Mark Klempner and colleagues) to look at the efficacy of long-term antibiotic use explained its motivation as follows:

"Case reports and uncontrolled trials describe success with prolonged antibiotic therapy, often with a recurrence of the symptoms after the discontinuation of therapy. In view of the substantial morbidity and even death associated with prolonged parenteral antibiotic treatment of Lyme disease, it is important to determine the efficacy of such therapy."

"Substantial morbitity and even death": clearly, long-term antibiotic treatment is not something to be prescribed lightly. The 2001 study found no benefit from long-term versus short-term antibiotic usage for the treatment of Lyme disease.

Despite the science, some doctors persist in prescribing–against the advice of professional societies–long-term courses of antibiotics. Because the practice continues, a European group conducted a new study of long-term antibiotic use in patients who claim to have persistent symptoms from Lyme disease. Anneleen Berende and colleagues reported the results of this well-designed double-blind, placebo-controlled study in the New England Journal of Medicine just last week. Their findings matched those of the 2001 study: long term antibiotic use has no benefits for patients.

The study had three arms: a placebo group and two different treatment groups, who were given two different antibiotics. Everyone got a two-week treatment with real antibiotics, followed by 12 more weeks of either antibiotics or placebo. The pills were created just for this study to look identical, so that neither the doctors nor the patients knew who was getting the placebo.

In an editorial accompanying the article, my Hopkins colleagues Michael Melia and Paul Auwaerter explain that the take-home message is that

"Patients with subjective, vexing symptoms attributed to Lyme disease should not anticipate that even longer courses of antibiotics will produce relief, a finding that is in concert with results from previous trials."

I doubt that "Lyme literate" doctors will accept the latest results and stop prescribing long-term antibiotic use; their websites indicate that they already know that they are right. I hope, though, that patients will start to question doctors who put them on long-term, possibly harmful antibiotic regimens that don't provide any benefit.

(For more information, see this excellent video by Dr. Auwaerter about Lyme disease and its treatment.)

Raw milk enthusiasts want you to drink a bacterial stew. Yum.

Sometimes it is astonishing how ignorant people can be. Now it's the turn of fans of "raw milk," a new fad that is sweeping the U.S.

I still remember reading milk cartons as a kid, and asking my parents what "pasteurized" meant. While I don't remember exactly what they said, I'm sure they told me that it made the milk safe by killing bacteria. Even as a kid, I understood that bacteria in my milk were probably a bad thing.

Louis Pasteur is one of the most famous scientists in history, and rightly so. In 1862, he invented the process of heating milk to kill the bacteria in it. Pasteurization, as we now call it, has saved millions of lives in the 150 years since. Pasteur also created the first vaccine for rabies. He was a true giant.

Fans of raw milk appear to be stunningly unaware of Pasteur's achievements, and equally ignorant of the dangers of bacterial infections. Many of the health and safety claims for raw milk can be found on sites such as RealMilk.com, a site that is chock full of

• Conspiracy theories: the Government is hiding the truth from you.
• Denialism: raw milk never hurt anyone, and even protects you against bacteria.
• Shifting the blame: infections are caused by other contaminated foods, not raw milk.

One of the more chilling facts about RealMilk.com is their emphasis on feeding raw milk to infants, who are at the greatest risk of dying from infections.  Their "Campaign for Real Milk" advocates

"universal access to clean raw whole milk from pasture-fed cows, especially access for pregnant and nursing mothers and for babies and growing children."

We have plenty of good science about raw milk. CDC review of infectious disease outbreaks across the U.S. from 1993-2006 found that

Langer et al., Emerging Infectious Diseases 18:3 (2012).

Among other findings, a

"The rate of outbreaks caused by unpasteurized milk (often called raw milk) and products made from it was 150 times greater than outbreaks linked to pasteurized milk."

Dr. Robert Tauxe, an infectious disease specialist at the CDC, debunks some of the myths about raw milk in an article freely available on Medscape. John Snyder and Mark Crislip have both written compellingly about the dangers of raw milk at sciencebasedmedicine.org.

If I were being cynical, I might say that the wild-eyed proponents of raw milk deserve whatever infections they get. But their children don't. 3-year-old Kylee Young, who the Washington Post wrote about this past Sunday, didn't deserve to suffer kidney failure and a stroke after her mother fed her raw milk that was infected with E. coli O157:H7. Kylee can no longer walk or talk and needs constant care. Her mother now says

"If I had known what I know now, I would never have fed [raw milk] to my daughter." 

Louis Pasteur and his wife had five children, three of whom died of childhood infections. These tragedies were Pasteur's motivation for studying infectious disease. Thanks to his work 150 years ago, no one today needs to die from drinking unpasteurized milk. The raw milk movement insists, despite the evidence, that they know better.

So go ahead, drink your raw milk and eat a paleo diet too, while you're at it. But don't ask our modern medical system to pay for your treatment when you get sick. And most of all, don't subject innocent children to the unnecessary risks of raw milk.

GMOs versus antibiotic overuse: which is the greater evil?

People who worry about eating healthy food (and who doesn't?) have recently been very worried about genetically modified organisms, or GMOs.  Meanwhile, industrial livestock producers feed enormous quantities of antibiotics to cows, chickens, and bigs, as a way to make them grow faster.  Which of these practices poses the greater risk?

This one isn't even close. The threat of GMOs pales in comparison to the overuse of antibiotics, which are creating dangerous superbugs that already kill tens of thousands of people each year.

The anti-GMO forces have been making a big push recently to add "GMO" labels to foods. This particularly campaign is based on the hard-to-disagree-with notion that more information is always good. People have a right to know what they're eating, right?

Well, sure. But how many people out there understand what genetic engineering means? How many understand that virtually all the food we eat is genetically modified - including the most wholesome organic foods? Unless you live out in the wilderness eating wild nuts and berries, you're eating plants and animals that have been genetically modified over the centuries by humans, by selecting which ones to plant and breed.  The term GMO is meant to refer to something else:  precise genetic engineering, designed to alter just one or two genes. This creates genetic changes that are far less dramatic than the ones that turned ancient maize into today's modern corn, for example.  Thus the problem with "GMO" label is that it won't inform people unless they have a solid grounding in molecular genetics.

Teosinte is un-modified corn. Not so yummy, is it?

GMO opponents claim that GMOs are bad for you.  So far at least, there's no scientific evidence for this claim.  If GMOs were so bad, people would be dropping like flies every night after dinner.

But in the world of infectious disease, a different, far more deadly scenario is unfolding. Drug-resistant bacteria are spreading fast. Scientists have been warning for years that we are blindly marching towards an era when people start to die of previously treatable bacterial infections. Antibiotics, one of the greatest technological advances in the history of civilization, are losing their effectiveness.

Last week, the Washington Post reported that "nightmare bacteria" are real and on the rise.  In the U.S. alone, over 23,000 people died last year as a result of drug-resistant bacterial infections, according to the CDC. The CDC report implicated the use of antibiotics in animals as one of the primary causes.

Also last week, the Center for a Livable Future at the Johns Hopkins School of Public Health issued a report looking at how we've responded to report 5 years ago that recommended ways "to curb the threats to human health posed by modern industrial agriculture practices." How have we done? According to Dr. Robert Lawrence, director of the Center:

"There has been an appalling lack of progress.  The failure to act by the USDA and FDA, the lack of action or concern by Congress, and continued intransigence of the animal agriculture industry have made all of our problems worse."

Can the FDA regulate antibiotics in livestock? Not really, thanks to intensive lobbying by industry. One of the authors of the Hopkins report commented that the FDA is “almost pleading with industry to make voluntary changes.”

But industry isn't going to do this on their own, and so far the government has been utterly ineffective.  The study points out that:

"Congress has killed every effort to restrict the feeding of farm animals the same antibiotics used in human medicine ...  even as antibiotics have grown less effective in treating infection."

So listen up, GMO alarmists: you're protesting the wrong thing. If you really want people to eat healthier food, start raising Cain over the use of antibiotics in livestock.  If you want labels on our food, insist on labels showing whether our food animals were raised antibiotic-free.  Stop worrying about a hypothetical fear of a few genetic changes in soybeans, and worry instead about the very real rise of superbugs.  You're right to worry about how we raise our food - you're just looking in the wrong place.