One reason why there’s an Antibiotic Awareness Week every November is to alert people to the unfortunate outcome of antibiotic overuse: the evolution of strains of bacteria that are resistant to the drugs. I.e., when millions of people each year coerce their physicians to prescribe antibiotics for viral and fungal infections, bacteria that are present in their bodies (but that are not causing disease) can evolve to survive the drug. Then when others get sick from these mutant strains, they die. It is estimated that 35,000 people in the United States die every year from infections of drug-resistant bacteria. I believe the worldwide estimate is close to 700,000. Antibiotic misuse is a huge problem.
Most people think antibiotics can kill viruses and other germs
One goal of Antibiotic Awareness Week to inform people that antibiotics kill bacteria but not anything else. This is a major goal because, currently, people are very, very confused.
For example, a 2012 Pew study that found that 36% of Americans think antibiotics can treat viral infections:
That was seven years ago — have all the Antibiotic Awareness Weeks since then succeeded in educating Americans about antibiotics? No. A 2019 Kaiser Family Foundation poll found 55% of participants thought viral infections can be cured with antibiotics:
As an aside, there’s a large gender difference, too, with 64% of men (vs 46% of women) believing that antibiotics can treat viral infections (graph below). And, not surprisingly, an education difference: 75% of adults who lack a high school education think antibiotics can treat viral infections (graph below).
Ignorance is not just for Americans, too. A 2010 publication reports that 53% of Europeans believe that viral illnesses can be treated with antibiotics (and 11% weren’t sure). In Malaysia, 67% believe that antibiotics treat viral infections (Oh et al. 2011). These numbers probably underestimate the problem, too, because some people (e.g., over 87% in Cameroon) also think that antibiotics work against all microbes, not just viruses.
Ignorance about what antibiotics kill can come in different flavors, and I therefore believe it’s important to understand why people are ignorant. Some people, for example, think that viruses are bacteria (perhaps 10%, per Carter et al. 2016). Other people might think that although antibiotics are designed to kill bacteria, they might have some smaller, beneficial effect in treating infections caused by viruses (this can actually be true). Both of these misconceptions can probably be addressed by yearly doses of Antibiotic Awareness Week pushed out by health organizations.
But there’s an unnamed contributor to the ignorance problem. The word “antibiotic” itself suggests it is active against more than bacteria. I.e., unlike “antifungal” (acts against fungi) and antiviral (active against viruses), “antibiotic” is vague — if anything, people assume the “biotic” part refers to a broad category of organisms. People make this assumption because “biology” is the study of all life, not the study of bacteria.
A decade of Antibiotic Awareness Weeks in multiple countries seems to have failed in changing the public’s understanding of whether antibiotics kill viruses (Mason et al. 2018). They are, arguably, a complete waste of money. I believe the failure is, in part, because Antibiotic Awareness Weeks do not confront the confusion caused by the word, “antibiotic.” I think it’s at least worth a try to explore how one might do this.
Antibiotic used to mean “substance that kills microorganisms”
Coined in 1860, antibiotic combines “anti” (kills) with “biotic” (something that’s alive) and, accordingly, was completely broad (“all life”). Over the decades, however, the word’s meaning eventually evolved to refer to just substances that killed microorganisms (still a rather general term). This meaning comes as a shock to most people so here’s a Webster’s Dictionary from 1913 that says an antibiotic “kills microorganisms.”
It was only in 1943 that the word began to refer to substances that killed only bacteria, a usage that has now become firmly established among biologists, doctors, and health organizations. But, unfortunately, the old meaning still survives outside of academia and hospitals, in part because it still (and always will) sounds like a drug that might kill more than just bacteria.
Dictionaries say that antibiotics kill more than bacteria
It’s not just that it used to have a broader meaning. It still does, at least on the internet. Here are just several examples (there are thousands) of current dictionaries and websites defining as “antibiotics” as killing more than just bacteria:
- “a medicine (such as penicillin or its derivatives) that inhibits the growth of or destroys microorganisms.” — Oxford English Dictionary
- “a substance able to inhibit or kill microorganisms” — Merriam-Webster Dictionary
- “any of a large group of chemical substances, as penicillin or streptomycin, produced by various microorganisms and fungi, having the capacity in dilute solutions to inhibit the growth of or to destroy bacteria and other microorganisms, used chiefly in the treatment of infectious diseases.” — Dictionary.com
- “An antibiotic is defined as any chemical substance that is able to kill bacteria, fungi and parasites, and can thus be used against prokaryote and eukaryote organisms.” — DifferenceBetween.net
So it’s not at all surprising that most people think antibiotics are active against a wide range of microorganisms.
Even public health organizations misuse the word antibiotic
What shocks me is that the very organizations behind Antibiotic Resistance Awareness initiatives are often spreading confusion themselves. Below are several instances out of thousands.
- “Antibiotic resistance happens when germs like bacteria and fungi develop the ability to defeat the drugs designed to kill them. That means the germs are not killed and continue to grow.” — About antimicrobial resistance (CDC)
- “Millions of people in the United States receive care that can be complicated by bacterial and fungal infections. Without antibiotics, we are not able to safely offer some life-saving medical advances.” — Antibiotic-resistant infections threaten modern medicine (CDC)
- “Antibiotic-resistant germs can spread in the environment. Aspergillus fumigatus, a common mold, can make people with weak immune systems sick. In 2018, resistant A. fumigatus was reported in three patients.” — The interconnected threat of antibiotic resistance (CDC)
- “Antibiotic resistance is the ability of a micro-organism (such as bacteria) to stop an antibiotic from working effectively.” — What is antibiotic resistance? (NSQHS)
As an aside, for an issue that has such a clear relevance to people needlessly dying, failure to convey a crisp, error-free message about what antibiotics can and cannot do is a problem. I would strongly urge governments to recruit some actual biologists to proofread all materials on Antibiotic Awareness Week websites.
How to provide better antibiotic awareness outreach
I have five suggestions for improving current antibiotic-resistance awareness programs.
1. Clearly state that antibiotics are substances that kill just bacteria
If you are in charge of running an antibiotic awareness initiative, fully embrace the fact that the majority of the population doesn’t accept that antibiotics treat only bacteria. So give a definition of antibiotic rather than assume people understand. And embrace the unfortunate fact that the word itself confuses people and that many dictionaries support that confusion. I’m astonished that not a single awareness campaign addresses why the public might be confused.
2. Use the word “antibacterial”
An easy way to clarify what antibiotic means is to just put “antibacterial” in parentheses. You only need to do this once. E.g., “Antibiotics (antibacterials) are useful in treating some infections.”
3. Change name to “Antibacterial Awareness Week”
Perhaps the best way to avoid the confusion about antibiotics is to not bring up the word in the first place. Just call it, Antibacterial Awareness Week. An example of this approach is demonstrated by the Antibacterial Resistance Leadership Group — by choosing “antibacterial” the group instantly avoids all confusion about the focus of their group. I.e., if they had used Antibiotic Resistance Leadership Group, instead, people would likely assume the group was interested in all types of antimicrobial resistance.
For the same reason, physicians should opt for the word, “antibacterial” when discussing medications with patients. E.g., I suggest saying “You have a cold (a virus) so I don’t think you should take antibacterials“ instead of “You have a cold (a virus) so I don’t think you should take antibiotics.” The latter sentence leaves open the hope (in the mind of a typical patient) that antibiotics might also treat some viral infections. Using “antibacterial” is one more syllable than “antibiotic” but it could save doctors a lot of grief.
I’m not, of course, suggesting that academics and doctors need to ban the word entirely. “Antibiotic” can still be used in journals and in hallways. My suggestion above is how to communicate with the public. That said, some scientists do in fact already use “antibacterial resistance” in journals and lectures in order to avoid ambiguity, so the change would not be a shock to anyone.
4. Hold a “Antimicrobial Awareness Week” instead
I think one major reason why antibiotic-awareness programs often have errors is that organizers are, ultimately, trying to alert the public to the dangers of evolution of resistance in all types of microorganisms, not just bacteria. So I think it is better to just have an Antimicrobial Awareness Week, a time when all different types of resistance could be highlighted.
On this note, I have found two organizations that have used “antimicrobial” in their awareness-week names: Misr International University, International Federation of Medical Students Associations. I will add others as I find them. The point is that for current organizers of Antibiotic Awareness Resistance Week, there are precedents for changing the name. And using search/replace can probably do the bulk of the change in just an afternoon.
5. Avoid the use of “germ”
For some reason, designers of antibiotic-awareness initiatives love to use the “germ” and “microbe” as a synonym for “bacteria.” That seems unwise given that both terms are broader categories.
Plea to pollsters
I would be grateful if somebody could explore whether participants’ responses change when “antibiotic” is replaced with “antibacterial” in a survey question.
For example, ask, “How effective are antibacterials for treating viral infections?” I hypothesize that a person is more likely to a give a correct answer when “antibacterial” is used. This might seem obvious (because the word gives away the answer), but there are many biologists and physicians who I’ve spoken to over the years who truly don’t see how the word “antibiotic” is flawed.
Given how many hundreds of thousands of people are killed yearly by antibiotic-resistant strains of bacteria, poll data like this might be sufficiently sobering to get people to reevaluate their love of the word, “antibiotic.” I.e., I think switching to “antibacterial” in outreach programs and in doctors’ offices would result in far less misuse of antibacterials and therefore a slowing of the evolution of resistance to such drugs. A simple search-and-replace action (antibiotic → antibacterial) would take mere seconds and potentially save lives. Given that current campaigns are ineffective, I think it’s worth a try.