Dr Ravina Kullar: animals, they end up dying and we end up eating these animals and they have been fed with antibiotics. So if you end up purchasing a meat which has been fed by antibiotics and that animal ended up developing antibiotic resistance, that ends up being conferred to us humans.
Dr Rupy: Welcome to the Doctor's Kitchen podcast. The show about food, lifestyle, medicine and how to improve your health today. I'm Dr Rupy, your host. I'm a medical doctor, I study nutrition and I'm a firm believer in the power of food and lifestyle as medicine. Join me and my expert guests where we discuss the multiple determinants of what allows you to lead your best life.
My guest today is Dr Ravina Kullar. She's an infectious diseases global expert and researcher who has spent almost 15 years researching in the infectious disease space. And I just want to lead with this, again, I know I've mentioned it before, but if we don't take action now, then 30 years from now, over 10 million people will die every single year due to antibiotic resistant infections. And I'll be honest, this was a really uncomfortable and scary podcast to record because there isn't much positivity at the end of it, if I'm being quite frank. I know Dame Sally, who we've had on the podcast talking about this subject, is a lot more positive, but there is a bit of doom and gloom and I think we actually need to harness that negative energy to provide us with the impetus to do something about this impending situation. Dr Ravina is actively leading strategies worldwide to educate the public about various infectious disease topics and she's actually done three TED talks. I've done one and that's scary enough, but she's done three where she describes a really harrowing personal story about how she got into the field herself. And I highly recommend you watch that as a starter to this podcast because that kind of sets the scene as to why she is so passionate about talking about the subject and making sure everyone is aware of this impending issue, which is the fact that antibiotics will not work in just a few decades from now. She's also published 40 research papers and has been invited to speak worldwide, so it was an absolute pleasure to have her spend some time on the pod with me. She's been an advocate during this COVID-19 pandemic, educating the public about various issues to do with COVID-19 and I really do hope you take some tips from this podcast and look into the subject a bit more. I know it is anxiety provoking, but it's definitely something that we all need to be more aware of. So without further ado, this is my conversation with Dr Ravina Kullar.
Dr Rupy: So Dr Ravina Kullar, thank you so much for coming on the pod. It's been a pleasure already. I know we've been chatting before, but watching your three TED talks really gave me an understanding of where you're coming from, your story, and it's wonderful for you to contribute to the series that we're doing on antimicrobial resistance. I wonder if you could take us back and tell us about where you grew up and how you got into clinical medicine.
Dr Ravina Kullar: Yeah, thank you so much for having me on. This is such an honour to be on. I have fallen into this area of infectious diseases. It's quite a story. First of all, I grew up in the UK, lived there till I was 12 years old, and my family and I, we moved to the US then and we moved to Pittsburgh of all places and I just moved around a lot for school. And I ended up doing my residency and my fellowship in Detroit, Michigan and it actually wasn't my number one choice for residency. I was looking to move to California. UCSD San Diego was my number one choice, but things happen for a reason and I ended up in Detroit and that is actually the mecca of antibiotic resistance. That's where the first vancomycin-resistant Staphylococcus aureus strain was identified. So just to tell you about how, what a pivotal time that was, is we saw a lot of these resistant organisms there. And as a young clinician at that time, that's where I saw the true issue of antibiotic resistance where one of my patients ended up passing away, very young, very healthy, and he never ended up making it because he was unfortunately prescribed several antibiotics when he did not need them. And when he actually needed an antibiotic, he was resistant to every single antibiotic. And that's what forged me to do my first TED talk and then led me to giving two additional TED talks. And it was definitely a pivotal moment. He was a young 29-year-old, just got back from his honeymoon and he went skiing and he fell and required surgery. He ended up requiring an infection after that surgery where he developed an infection and he was resistant to everything and it was shocking to me because he was healthy, he was young, but his background, he had been placed on numerous courses of antibiotics for sinusitis, which is a viral infection, did not even need antibiotics. And he never made it to his one-year wedding anniversary and it was very disheartening seeing what effect antibiotics could have. And many people, they see it as candy. Many clinicians do and it has dire circumstances down the line.
Dr Rupy: Absolutely. I mean, you told that brutal story on your TED talk and I think that what really hits home, particularly as a clinician and especially from my perspective as a general practitioner where we see a lot of these quote unquote simple cases of things like sinusitis and stuff and we've definitely got a lot more educated here in the UK about limited use of antimicrobials. But the cumulative impact of those antimicrobials every year, every year. And even today, I still see patients who have that kind of trajectory. And for that to culminate in a horrific scenario because of that list of and the number of times that particular patient has had antimicrobials throughout their lifetime, it's just absolutely heartbreaking. But the reality is, and you hit home this in your TED talk very, very pretty profoundly is this is going to become the norm unless we do something about it now.
Dr Ravina Kullar: Yeah. Yeah, you're right. Yeah, I mean, we have to take action right now. You know, we should have taken action 20 years ago, 10 years ago, but every single day, you know, my current practice setting is a long-term care setting now. I see nursing home residents and they are put on antibiotics just in case. Every day I'm fighting that fight for that long-term care resident and their family members because, you know, they're placed on antibiotics because they have so many other things going on. I think it almost makes the clinician feel better that they're on an antibiotic. So, yeah, we have to take action now and every single person matters because, you know, antibiotics are so different where not only does it affect the person that is taking that antibiotic, but it affects the entire environment and other people which have not even taken an antibiotic. So that's what makes antibiotics, antibiotic resistance so different than a chemotherapy agent where those side effects only affect, you know, that individual person or or or another drug. And that's where, you know, there's this whole issue about antibiotic resistance affecting the community, affecting the environment because it just has such an interplay there, interconnection with affecting every single person and affecting the entire society.
Dr Rupy: I wonder if you could give us a perspective on just how easy it is for bacteria, these microbes in particular, to mutate and outsmart our limited defences in the form of the medications that we currently have.
Dr Ravina Kullar: Yeah, I mean, if we think about it, I like to talk about microbes as them being so much smarter than us. They've been around for 3.5 billion years. I mean, that's a substantial longer time than any of us humans have existed on this earth. And it only takes them about 30 minutes to multiply. So, you know, you have these microbes, these bacteria, and you have random natural mutations that exist where some bacteria are just naturally resistant to antibiotics. And when they're when then they're hit by antibiotics, the susceptible bacteria, they're going to die, but these resistant bacteria, they're going to survive and these resistant bacteria, they now have room to grow and thrive and multiply and they now are able to transfer their DNA onto other bacteria. And that's just, that's how this antibiotic resistance spreads. It only takes them 30 minutes to multiply and there you have this surplus of antibiotic resistance. It's very, very easy and these microbes are so smart.
Dr Rupy: Yeah, I remember looking at some diagrams actually of just how easy it is for bacteria, microbes to to change and to actually share information. It's almost like these communities are all have this common goal to just survive. And I think right now in a situation where we're learning about virulent strains of the current pandemic virus, I think it's an easier idea for people to understand. But the reality is this has been happening all along and this is the really scary pandemic. And I don't mean to catastrophize, but this is something we really need to start having a conversation about now to prevent an even worse pandemic than the one that we're seeing.
Dr Ravina Kullar: That's so true. I mean, right now we're in this COVID-19 pandemic. We have been in a huge, there's been an existing, I would say, almost pandemic of antibiotic resistance ongoing. And I think COVID-19 has shed light on this issue of infectious diseases, first of all. Second of all, it has brought up this issue of variants, of mutations and what dire circumstances they could have. We have three, four variants that are existing in this COVID-19 pandemic. They're, that just shows how easy it is for viruses, for bacteria to mutate very quickly and have a very bad effect on society. People are very concerned about these variants that have come about for COVID-19. For bacteria, it takes even a shorter amount of time for them to multiply and mutate. So, you know, to the point where we have actually no antibiotics for some of these resistant bacteria because the pipeline is completely dry of any antibiotics coming about that have a unique mechanism of action. That, to my mind, is very scary.
Dr Rupy: Yeah, I had no idea about Detroit in particular being the epicentre of Vankomycin resistant bacteria. I mean, that's that's super scary when you think about just how broad spectrum an antibiotic those are. But I wonder if you could shed some light on your experience during COVID-19 and your role. I know you mentioned your clinical duties, but I guess everyone is sort of clambering for your opinion on things right now and how we're handling this current pandemic with the perspective that you know all well about, about antimicrobial resistance, which is something that's in perhaps, yes, 10, 20 years in the future, but it's something that we have to deal with now.
Dr Ravina Kullar: Yeah, I mean, I think, you know, just taking a step back, this COVID-19 pandemic, we've seen, first of all, how much in need of proper diagnostic tests there needs to be. I mean, the Achilles heel of this pandemic has been proper diagnostic testing where it is able to actually pick out the virus even when you may have a low viral count. You know, this whole issue of asymptomatic COVID-19 cannot be detected by a diagnostic test because it's not sensitive enough. That's concerning. I mean, why are we here in 2021 and there hasn't been a diagnostic test that's been created to pick up, you know, that's that's sensitive enough. So then translating this into antibiotic resistance, diagnostic testing, rapid diagnostic testing is crucial to preventing antibiotics from even being initiated and they're being antibiotics which are stopped early on because it's able to be identified early on that this is not a bacteria, this is a virus or this is not even an infection. So I think diagnostic testing is really important to tackle this issue of antibiotic resistance and tackle this pandemic as well.
Dr Rupy: Yeah, absolutely. I mean, I spoke with Dame Sally Davies about the the the current state of clinical medicine where you're almost practicing with your hands tied behind your back. You essentially have to practice poor microbial practices by dishing out antimicrobials and then waiting on investigations to come back sometimes two, three, four days later as well, depending on which lab you're using. And this is the state of play and it has been throughout my medical career over the last decade. But you know, is there any anything on the horizon that could change that? Because really, it's all about investigations.
Dr Ravina Kullar: Yeah, yeah. Yeah, I mean, I think what, you know, there are rapid tests that are available and I think that institutions, they need to embrace them more. There's rapid tests which we have and I think, you know, many institutions, they see it as an initial cost barrier from the get-go, but the cost, the benefit that comes out, the cost is diminished long-term in terms of the healthcare costs, the burden for antibiotic resistance. So I think it at least for antibiotic resistance, it's embracing those rapid tests that are able to really pick out that organism early on and and embracing that. We have them available and why not embrace it? And I think also in terms of what the government needs to do is really find ways to to create more or or to to help with development, to help, you know, organizations, to help diagnostic companies in developing more diagnostic tests. The government can step in and help and ensure that that's a priority as well.
Dr Rupy: Yeah, I'm aware that the UK government have committed a relatively small amount of money. This is a few years ago actually during a different government, toward research and development for new antimicrobials, but investigation obviously has to go hand in hand with that. I wonder if you have a perspective on the current practices of patients who are admitted with COVID-19. My experience is that we are having to use antimicrobials at the moment because we are very much reacting to the issue of secondary bacterial infections after having a primary cytokine storm that leads to the issues that we're seeing patients suffering with. Is this, is there some best practices that you think we could be doing better when it comes to the huge issue of AMR?
Dr Ravina Kullar: Yeah, I mean, I think, you know, as a clinician, we feel comfortable just giving the patient something even though we know it's wrong. And that's an antibiotic. So, yeah, so a patient comes in, they're febrile, they have this cytokine storm picture, we know it's a virus, but we reach for an antibiotic. So I think we have to retrain ourselves to sit and wait and be patient. So, you know, like if they're placed on appropriate antibiotic, appropriate treatment from the get-go, we know steroids work, we know we have an antiviral that we have Remdesivir that's available, you know, in those mild moderate cases. We have agents which are not antibiotics, which have been shown to be effective in helping a patient from deteriorating from COVID-19. It's going to take time for them to get better. Antibiotics are not going to help with that picture. So I think it's about reminding ourselves that these patients, they are hospitalized, they have COVID-19, it's going to take time for them to get better. Using an antibiotic is not going to help with that. It's going to actually lead to other effects such as C. diff, spore-forming organism that is highly transmissible where they have persistent diarrhoea. So I think it's this whole issue about just us clinicians being patient. It's hard for us to be.
Dr Rupy: Yeah, I know. You almost have this itch to do something when someone presents with something. I mean, pandemic aside, I think a common issue and it's been documented quite a bit actually in general practice journals about the need to reach for your prescription pad. And sometimes it really takes a bit of humility, a bit of patience and demonstrating to the patient, you don't always come here for a pill. Sometimes it's advice, sometimes it's listening, and particularly from a general practitioner's point of view, less so, let's say, acute medicine, that is the best option.
Dr Ravina Kullar: I was just going to say, you know, it's crazy in medical school, it's amazing how much time we spend on memorizing information only to forget it days later. And in all that time spent on memorization, a reflex is created like pairing bacteria with antibiotics. But in that in that education that we've learned, I think what's lost is the appropriateness of treatment. You know, we and we should be teaching not just what an antibiotic, what antibiotic to use, but also when to use it. And I think that that's something that we that just needs to be taught from the beginning. This reflex that is created as medical providers, you know, is appropriate for that.
Dr Rupy: Absolutely. I want to talk about antimicrobials beyond medicine because I think we have a general steer about what we can do in medicine, reduce the unnecessary use of them, try and re-educate patients about demanding antimicrobials and the detrimental impacts that can have, as well as better investigations. I think those are sort of the trifecta of things that we can do with their medicine. But this conversation around microbial resistance extends far beyond medicine, doesn't it? I wonder if you could touch on other ways in which this sort of issue is evolving.
Dr Ravina Kullar: You're completely right. I mean, if you think about it, antibiotics, about 70% of antibiotics are actually given to animals. They aren't given to humans. And that's where a lot of the misuse has come about. And this translates into humans developing antibiotic resistance. But so say, you know, in the farm, in the farming community, unfortunately, there's bad practices that are followed where there's several animals which are all huddled together and they just inevitably develop infections. And so what these farmers do is that they give these animals antibiotics prophylactically to prevent them from getting infections and that leads to antibiotic resistance. These animals, they end up dying and we end up eating these animals and they have been fed with antibiotics. So if you end up purchasing a meat which has been fed by antibiotics and that animal ended up developing antibiotic resistance, that ends up being conferred to us humans. We end up having antibiotic resistance conferred onto us. So I think it all goes back to not only does there need to be proper practices followed in human behaviour in antibiotic use, but animals and agriculture as well. You look at India and India, samples of water have been have been isolated out where there's antibiotic resistance in that water. And that's concerning where the water, where even plants have antibiotic resistance. So it's an entire environmental issue that we need to tackle here.
Dr Rupy: Yeah, I was pretty shocked to hear about the use of antimicrobials actually on plants as well. I can't think of why that practice is necessary. Is that something you've come across?
Dr Ravina Kullar: Yeah, I mean, it happens in, for instance, in India where, you know, these, these, these fruits, these plants, they have, they're being sprayed with antibiotics to help them potentially thrive better, to be sold at a higher rate, which does not, that's not a good practice. So, yeah, I mean, that's what's being done in certain parts and that's not, it's not helping us with this whole antibiotic resistance crisis.
Dr Rupy: Yeah. It sounds with the way things are and how despite the pandemic, we're still very disconnected when it comes to a universal solution to things like agricultural practices. I mean, the dreaded Brexit is also defining that for us as well. I mean, we've been pretty well protected from antibiotic-fed cattle, but everything's up for up for grabs now. It sounds as if this is inevitable. Am I right in saying that or do you believe that we can actually stop this happening?
Dr Ravina Kullar: I unfortunately think that this is inevitable and I think this COVID pandemic has not helped out at all because, you know, just as we were speaking about, antibiotics have been used to fight a viral infection. So, you know, if anything, things have gotten worse during this pandemic and it's concerning because there are no novel antibiotics in the pipeline. So I think it's inevitable. I think that the government, the World Health Organization has taken a stance to say that this is a priority, but unfortunately, I think that's shifted now that we're in a pandemic where this has been left to the wayside and we'll tackle this afterwards, but this needs to be tackled every day. And and some action items is us as clinicians, we need to keep in mind of every time we reach for that antibiotic, think twice. I think we need to think about infection prevention. You know, that's something that has been brought, that has been definitely put on the forefront here during this COVID pandemic that infection prevention is key, hand washing, making sure that, you know, we follow good infection prevention procedures, vaccines. Vaccines prevent any of these, you know, bacteria or viruses from even happening. So, you know, those are just some low-hanging fruit measures that we can do to prevent antibiotics from even being used.
Dr Rupy: Yeah, you know, everything that we're talking about today kind of reminds me of an era before antimicrobials existed and the number of people that died from infectious disease. And also with your comments about vaccines as well, the eradication of smallpox and the amount of human suffering that we've had to endure. And I think we've got quite comfortable in a scenario where we don't have to deal with these conditions and we've conveniently forgotten about just how privileged and luxurious our lives are without the interference of microbes. And I think that's another thing that has spearheaded sort of people's lack of awareness about the science and just how much that's afforded us in terms of our relatively protected lifestyles. Is that something that you you've thought about or you agree with?
Dr Ravina Kullar: Yeah, I mean, definitely. I mean, I think that, you know, this, I think unfortunately during this pandemic, science has been questioned and I think that we need to put that in the forefront in terms of thinking about, you know, not questioning science. All of the, all of the guidance that's put out by the CDC, by the World Health Organization, by various different governmental boards, it's all backed by science and we need to trust that. And vaccines, they've been around for a while and and and they have advanced, they've expanded life in terms of, you know, us not having to have those infections here anymore. I do want to bring up one other thing as well. You know, we brought up livestock. So that's another thing that consumers can do as well is, you know, a lot of these fast food chains, they unfortunately serve meat that is been, that has antibiotics in it. So there's a scorecard that's been created where you can look and see which fast food chains have actually ranked the highest in terms of not having antibiotic-fed meat there and and I would advocate for that by going to those places that only serve, you know, antibiotic-free meat and and if they don't, you know, writing in to those places saying that that's what's needed. You need to, you know, advocate for that for not serving or purchasing meat that has been fed with antibiotics.
Dr Rupy: Yeah. Do you think this and I'm not a vegetarian or vegan or 100% plant-based, although I am largely plant-based. Do you think there is a role for a completely plant-based diet for the human race if we are serious about slowing antimicrobial resistance?
Dr Ravina Kullar: I mean, I think we don't need to be as drastic as going plant-based. I think that we, you know, we can think about ways to, to better manage these animals which are raised in the farm. You know, why are we cramping up all of these animals in a, honestly, detrimental area? I mean, it's honestly animal abuse is what I see it as. And, you know, I think it can just be handled in that way is not having animal abuse and then giving them antibiotics because they're going to inevitably get infections and really raising up these animals in an appropriate way to prevent infections and prevent antibiotics from even being given to these animals.
Dr Rupy: Yeah. Yeah. In a in a sort of, in a way, the way I see a potential solution, and I'm not trying to suggest that we can figure this out on this podcast here at all, but if we were to slow the rise of antimicrobial resistance such that, you know, we prevent that scary number of around, was it 10 million people dying of infectious diseases every year by, is it 2050? Is that correct?
Dr Ravina Kullar: Yeah, that's right. One, 10 million per year worldwide. That's one person dying every three seconds, which is mind-boggling.
Dr Rupy: Yeah, absolutely mind-boggling. And I think, you know, even in the context of the current pandemic, which has been absolutely drastic, we're not near that number at all. But that aside, if we were to slow the rise of antimicrobial resistance and we were to figure out better ways of producing food, perhaps even cell-based foods or better formed foods that didn't actually require any sort of farming industry that relied on cramping animals together, giving them antimicrobials, not only from the perspective of fattening them up, but also from from actually treating them if they do become ill because of those conditions. Do you think that could be a way in which we could at least give us some more time or an extended period of time where we can figure something out?
Dr Ravina Kullar: I think so. Yeah, I mean, I think you're completely right in terms of if we can find other ways, you know, to other ways, you know, like, you know, to then to give not give, to mitigate giving antibiotics in those scenarios which goes into that plant-based, goes into other mechanisms. I think that might that might help support this or prevent or curb antibiotic resistance. Yeah.
Dr Rupy: Yeah. Well, this has been a fascinating conversation. Thank you so much for for joining me on this. And hopefully, you know, the more I talk about it and you know, I'm hesitant to talk about it so much because I feel like it's a really doom and gloom subject, but it kind of has to be had more often than I'm having currently. So I really appreciate the work that you're doing and and the work that you'll continue to do as well on a patient-to-patient level as well as on a on a much grander scale.
Dr Ravina Kullar: Thank you, Rupy. This has been amazing and I really hope the viewers can take heed and think twice before they take an antibiotic, educate others, and that's the only way that, you know, we're going to spread this message of the dire circumstance that we're in with this antibiotic resistance crisis.
Dr Rupy: Thank you so much for listening today. I know it was a heavy topic to discuss, but it's definitely something I think we all need to have the courage and be brave enough to talk about because we all can do things to slow this issue and hopefully we can not just slow, but actually prevent what is currently inevitable if we don't do anything about it. Please do go check out those TED talks with Dr Ravina Kullar. You can find out more information on the doctorskitchen.com. For now, I will see you next time.
