Medical Grand Rounds

Our missing microbes: Short-term antibiotic courses have long-term consequences

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Recent years have seen dramatic increases in the prevalences of chronic diseases such as type 1 diabetes,1 gastroesophageal reflux disease,2 asthma,3 inflammatory bowel disease,4 and, notably, obesity.5 I propose the hypothesis that much of this increase may be due to loss of diversity in the bacteria that make our guts their home.6 While multiple causes contribute, much of the blame may be attributed to the use—and overuse—of antibiotics.


Today, nearly 40% of US adults are obese, and nearly three-fourths are either obese or overweight.7 More alarming, the prevalence of obesity is also high and getting higher in children and adolescents,8 having increased from 10.0% in 1988–1994 to 17.8% in 2013–2016.

And not just in the United States. Trends in weight have been going up around the world, with a lag of about 30 years between developing countries and industrialized countries.5


I believe that the bacteria we carry are not random, but rather have coevolved along with us, passed down from generation to generation in a state of dynamic equilibrium between microbes and host. Evidence supporting this comes from a study by Ochman et al,9 who analyzed the DNA from fecal samples from different hominid species (including Homo sapiens) and found that the phylogenic relationships among the bacteria mirrored those among the apes.

Interacting with each other and with us in complex ways, our bacteria are a diverse community to which we can apply the term microbiome. They are acquired in a standard, choreographed process,10 and their composition comes to resemble that of adults by the age of 3.11

Before modern times, microbes were transferred from mother to child during vaginal birth, from the mother’s breast during nursing, through skin-to-skin contact, and from the mother’s mouth by kissing. Now, widespread cesarean delivery, bottle-feeding, extensive bathing (especially with antibacterial soaps), and especially the use of antibiotics have changed the human ecology and altered transmission and maintenance of ancestral microbes, which affects the composition of the microbiota. The microbes, both good and bad, that are usually acquired early in life are especially important, since they affect a developmentally critical stage.12

Loss of microbial diversity in the mother appears to be cumulative over succeeding generations.13 For example, in a study in Japanese families, Urita et al14 found a decline in the prevalence of Helicobacter pylori colonization from 68.7% in the first generation to 43.4% in the second generation and 12.5% in the third. Clemente et al15 studied the intestinal microbiota in a previously uncontacted group of Yanomami people in the Amazon jungle and found they had the highest diversity of bacteria ever reported in a human group. By comparison, the research team calculated that we in the United States have already lost 50% of our microbial diversity, and 2 other groups, the Guahibo (another Amerindian group) and rural Malawians, were in between. More recent studies are confirming these observations.16,17

Next Article:

A new reason to reconsider that antibiotic prescription: The microbiome

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