MS. DIANE REHMThanks for joining us. I'm Diane Rehm. More than 70 percent of all the cells in the human body are not human at all. They're microorganisms or bacteria and other types of microbes. But researchers say the overuse of antibiotics is killing off some of the good bacteria and may be linked to the rise of some diseases.

MS. DIANE REHMHere with me to talk about these new studies, Dr. Anthony Fauci of the National Institutes of Health. Joining us from a studio at NPR in New York, Dr. Martin Blaser at the Microbiome Program at New York University. You're welcome to be part of the program. Join us by calling 800-433-8850. Send us an email to drshow@wamu.org. Follow us on Facebook or send us a tweet. Dr. Fauci, Dr. Blaser, welcome.

DR. ANTHONY FAUCIThank you. Good to be here.

DR. MARTIN BLASERThank you. Good to be back.

REHMGood to have you both with us. Before we start on our discussion about antibiotics and the concern with overuse, Dr. Fauci, let me ask you about the discovery of decades-old smallpox vials found in a storage room at the NIH campus in Bethesda. What in the world were they doing there?

FAUCIWell, this is a multi-decade old specimens that were sealed very, very carefully. They were very likely used -- again, it's still unclear. It's being investigated. Very likely used since it was in an FDA facility that happened to be on the NIH campus, and that, since the FDA has been involved in regulation and standards for things, that it is likely that that material was used to test against reference (word?), what have you. That's just the guess, Diane. We don't know. But it's certainly back decades ago.

FAUCISmallpox was kept by laboratories. And then at a certain period of time, everyone gave in their specimens to be destroyed with only two locations, one at the CDC and one in Russia, and at a period of time everyone was asked to look into their freezers for it. So it's very interesting that, just as recently as two years ago, in 2012, the NIH looked at every one of the freezers and had every single principal investigator look at the freezers.

FAUCIThe odd thing about this is that this was literally in a box in a cold room, freeze-dried, that people probably hadn't touched in years and years and years. And the good news about it is -- I mean, obviously, it shouldn't have been there. But the good news is that it was perfectly intact. It was removed, properly taken down to the CDC where it'll be examined and ultimately destroyed.

REHMSo there was no risk to anyone?

FAUCINo. No, no. There was not.

REHMAnd yet this morning, in The Washington Post, some NIH employees are saying they should have been told earlier about the vials.

FAUCIRight. Well, it was an interesting evolution of the situation, Diane. When it was known that this was there, the most important thing to do was to get it secured and get it out of there as quickly as possible to the CDC who could handle it and do the examination and the destruction. And the -- I believe the reason they were not let known because we wanted to make sure that the secure taking it and putting it where it could be completely safe was done without a lot of fanfare and a lot of publicity. And by the time that was done, it hit the press. And then the press knew about it, and everybody knew about it.

REHMOK. And one more thing. Since this was actually the second incident in 30 days involving the mishandling, if you will, of a highly dangerous pathogen by a federal agency, the accidental release of live anthrax bacteria.

FAUCIRight. It -- are you referring to the CDC?

REHMYeah, I am indeed.

FAUCIYeah. I -- again, I wouldn't necessarily say accidental release. There was -- what it was it was handled in a facility that hadn't had the total type of security -- you know, we have the bio level -- the biosafety level, X, Y, Z, one, two, three, four -- and that it was taken out of a facility and put into a lesser secure facility before it was completely inactivated and that they absolutely picked it up. They approached it in the appropriate way, had the individuals that might have been exposed, and those who might have been exposed, had the opportunity to get on antibiotics and/or vaccination.

REHMI see. So they, as you say, were flown to the CDC for further testing.

FAUCIRight. 1

REHMNow, what happens next?

FAUCIIt get destroyed.

REHMTotally?

FAUCITotally.

REHMOK. All right. Dr. Blaser, maybe you have a comment on that or not.

BLASERI do. And it's -- actually, it's a very nice segue into our discussion because the public has mostly focused on bad germs, like smallpox, like anthrax, which are quite real, which are quite bad. But I've become -- after studying bad germs for many years, I've become interested in the good germs, the good bacteria and the question of what's happening to our good bacteria, which in part are a protection against the bad germs. And that's the focus of my book, "Missing Microbes." And I hope we're going to have a great discussion.

REHMAbsolutely. And scientists, as you say, have long been concerned about antibiotic resistance, but your concerns are different. Tell us about your research which you do outline in your book "Missing Microbes."

BLASERYes. Thank you. In order to begin, I just have to introduce a couple concepts, the first of which is the Human Microbiome, which you mentioned already, the fact that most of the cells in the human body are microbial. These are the organisms we've lived with since time immemorial. We got them from our moms, and they got them from their moms. And they do good things for us. They help us. They protect us against invaders. They train our immunity. They help us digest food.

BLASERAnd what happens is that, in early life, there's a choreography between the microbes and the host. And that allows babies to develop normally. But we're changing that because of a lot of antibacterial practices, antibiotics, Cesarean sections, food additives. Many kinds of things are changing those initial bacteria in life. And our work and the work of other scientists is beginning to provide evidence that that has cost, that that is changing how babies are developing, and potentially leading to some of today's epidemics: obesity, diabetes, allergies, asthma. I could go on. So that's the big idea.

REHMAll right. And, Dr. Fauci, first of all, explain what is meant by good bacteria and bad bacteria.

FAUCIWell, OK, so I think the simplest way to explain it is the bad bacteria is what we generally refer to as a pathogen or something that could make you ill under certain circumstances. What Dr. Blaser was referring to as good bacteria are bacteria that are really part of the natural environment in various components of a body, the gut being the one that has, you know, the most dense occupation by microbes, particularly bacteria.

FAUCIAnd when we refer to good bacteria, we refer to bacteria that do things that Dr. Blaser has referred to. For example, there are bacteria that are very important in the evolution and the development of your normal immune system, the kinds of stimuli that they give. And, number two, it creates an environment that actually protect pathogens from actually overcoming, in a micro-environment way, the bacteria that are essentially protecting you.

FAUCIThey also are important in metabolic processes. They help you digest your food. They provide certain materials, metabolites that are very, very important. And also, they provide a protection against aberrant responses that you might not want to have in your gut. And sometimes what happens is that when you get imbalance of this type of protective mechanism, you can get diseases, like inflammatory bowel diseases, things like that.

REHMIndeed. All right. And, Dr. Blaser, you mentioned obesity. You mentioned asthma. Talk about the new research specifically as it relates to antibiotic use and obesity.

BLASERGreat. Thank you. The first thing I want to mention is that antibiotics are miraculous. When people are really sick with infectious diseases due to bacteria, there's nothing like it. And to not use antibiotics would be a grave error. Antibiotics can be lifesaving and important. Nevertheless, because they are so effective, we doctors have been using them more and more and more. And we're also -- people are getting exposed to antibiotics in their food and water because of practices at the farm so that the CDC did a survey in 2010. There were 258 million courses of antibiotics prescribed in the United States in that year.

BLASERThat's five courses for every six people in the United States, enormous antibiotic pressure on our microbes. And we've been concerned about the critical time in early childhood when babies are developing. So we began studies in mice to give mice antibiotics or not and see what happens. And in studies that we published a couple of years ago, we could show that the mice got fatter, and it changed their development.

BLASERIn a new study that's going to come out next month, we confirm that and extend it and show their effects on early life immunity in the mice as well. And if we put the mice on a high-fat high-calorie diet, they get fat. If we put them on antibiotics, they get fat. And if we put them on both together, they get very fat, a synergistic effect.

REHMMartin Blaser, and his new book is titled "Missing Microbes: How the Overuse of Antibiotics is Fueling Our Modern Plagues." Short break here, and when we come back, we'll talk further, take your calls. Stay with us.

REHMAnd just before the break, we were talking with Dr. Martin Blaser. He's written a new book titled, "Missing Microbes: How The Overuse of Antibiotics is Fueling Our Modern Plagues." And by modern plagues, he's talking about obesity, he's talking about asthma, he's talking about other conditions of the human situation that can be affected by overuse of antibiotics.

REHMHere's an email from Mike and this goes back to our original discussion. He says, "Are babies born with microbiomes already in place or are they started after birth with organisms from the environment?" Dr. Fauci?

FAUCIWell, when you talk about born, you've got to define born.

REHMYeah.

FAUCIA baby in the womb has a sterile gut. There's no bacteria there. There's no bacteria in any part of the body of the baby. And how the baby comes out into the world. If the baby comes out by a vaginal delivery, the baby picks up microbes, bacteria, actually from the mother's birth canal. And it's really extraordinary, really exciting observation that's so simple but so exciting. The microbiome that that baby develops is very different if you deliver the baby by a cesarean section when the first part of the world outside of the mother's womb that the baby is exposed to is actually the skin.

FAUCISo the microbiome of a baby that gets born from cesarean section reflects more skin bacteria than the baby who comes through the birth canal where it's more vaginal and genital bacteria.

REHMWhat happens -- what about these bacteria, Dr. Blaser, on the skin in the mouth?

BLASERI want to come back to Dr. Fauci's point because it's so important because now about a third of the babies born in the United States are born by C-section. It's gone up dramatically in recent years. And so, more than a million babies a year are being born without that normal passage through the birth canal, which we mammals have been doing for the last 100 million years. So in a century we've changed.

BLASERIn some countries, it's up to 50 percent of the babies are born by C-section. So their founding members of the microbiome are quite different. And as you say, they're picking up organisms from the skin, from the operating room, from other people, not from their mom. So there have now been epidemiologic studies that provide evidence that kids born by C-section are more likely to develop markers of overweight and obesity when they're teenagers.

BLASERThere have been studies that we did in England, studies in Brazil, in Canada that show the same -- a study in Boston as well -- that shows the same thing when you control for all other factors.

REHMBut, Dr. Blaser, here we go into the question of the development of obesity because of other environmental factors, the way our diets have changed, the availability of fast food, the shirking of fruits and vegetables, the substitution of starches. How much of a balance do you see there between the food we ingest and the antibiotic concerns that you have?

BLASERDiet is extremely important. I don't negate it in the least. But diet isn't sufficient to explain obesity alone. And that's why we did the experiments of the mice, where we added antibiotics to mice on a high-fat diet or not and we could see an additive effect. So over time, we're going to try to understand, extend the work beyond mice into people and children to have a better understanding of the relative importance of these two.

REHMAnd...

BLASEROf antibiotics and microbes, as well as dietary factors.

REHMAnd what other elements are you talking about that humans may be subject to with the overuse of antibiotics? You mentioned asthma. How would that develop?

BLASERWell, as Dr. Fauci said, the microbes in the body are involved in the training of the immune system. And we can think of good immune responses and bad immune responses. Actually, it's a very complex context. But if you don't develop your immunity in the proper manner, you may be -- it may be difficult for you to turn off an allergic response. You know, anybody who sees a cockroach is going to wheeze.

BLASERBut the question is, how long are they going to wheeze? Can they turn off the response after the cockroach is gone? And there's evidence that people who have asthma and skin allergies, et cetera have difficulty regulating their immune responses.

REHMAnd are you saying that that may come from overuse of antibiotics when a child is quite young?

BLASERThere was a study in Canada, in Manitoba, 7,000 children asking what is the relationship between antibiotic use in the first year of life and the risk of asthma where they were seven. And they showed the more antibiotics that were used, the higher the risk of asthma at the age of seven. A study in Denmark looked at inflammatory bowel disease, which Dr. Fauci mentioned. Again, early use of antibiotics was associated with a very increased risk of developing Crohn's disease.

REHMBut, Dr. Fauci, as both you and Dr. Blaser have said, antibiotic use is not only important, it can be critical. So what's the dividing line. What is the amount that's useful but not harmful? How do you know when you cross the line?

FAUCIWell, sometimes it's a judgment call. But sometimes, you overreact and give antibiotics in the circumstances when it is on a pure statistical basis, unlikely that you need antibiotics. So as Dr. Blaser said, it's really very important. Antibiotics are life-saving. So you don't want to get the impression from either of us that, you know, don't give antibiotics, they're bad. They're going to get rid of the good bacteria.

FAUCIThey also get rid of bad bacteria when bad bacteria get out of control. But what we need to do is take a look at the what we call inappropriate use of antibiotics. And if you look at statistics, for example, if people come into a doctor's office with a sore throat, 60 percent or so might wind up getting an antibiotics when only 10 percent need them. If people have bronchitis, about 70 percent of them will wind up getting antibiotics and very small percentage of them really need it.

FAUCISo what we really need to do is to be prudent and good judgment calls and not be pressured into giving antibiotics because a mother's worried that, you know, my child has a sore throat and has a cold, give him an antibiotic. On the other hand, you got to use good judgment because people, babies or children with strep throats need antibiotics.

REHMOf course.

FAUCISo you've got to be careful.

REHMDr. Blaser, what do you see as the cutoff in age when this kind of determinant factor occurs? Is it age five, is it age seven, when the danger of this seizes?

BLASERI don't know the answer to that. I think it's going to be relatively early in life. But it's a continuum. And I just want to further what Dr. Fauci says. Antibiotics are important. We need to be more judicious in their use. And parents have to understand that antibiotics may have biological costs. They're not free. And the idea that they may not help, but they'll do no harm, I think we have to move away from that.

BLASERAnd all the professional bodies already are telling us that we're overusing it. But one of the reasons I wrote the book is to change that dialogue in the doctor's office so the parents don't feel deprived if the doctor says I've examined your child carefully, they don't need an antibiotic. That parent should feel good rather than their child isn't getting what's needed.

REHMAll right. Now, tell us about the antibiotic use within animals that we are then ingesting. Now, a one-year-old is not going to eat steak, but at the same time as a child progresses, the use of meat, the use of chicken, the use of other products which may contain those antibiotics are there.

BLASERWell, let me back up a step, because in the 1940s, shortly after antibiotics were discovered, farmers found that if they fed low doses of antibiotics to their farm animals, they would gain weight, growth promotion, and it's widely done. That's why most of the antibiotics used in the United States today are used on the farm for growth promotion. One of the consequences, of course, is that this increases antibiotic resistance.

BLASERBut another consequence is that some of those antibiotics are getting into our food. They're getting into meat, as you mentioned. Surveys in supermarket sometimes show it. Sometimes they're in milk. So babies do drink milk. And in some communities, there are trace levels of antibiotics in drinking water because the intake for those water supplies are downstream from the ethylene form industrial farms.

BLASERSo we don't know the consequences of all this trace amount of antibiotics, but it's fair to say that millions of people are being exposed to that. And that's something we actually have to know. So even babies could be exposed from the use on the farm.

REHMDr. Blaser, you've talked about the results as far as either obesity or asthma. What is the mechanism by which the antibiotic creates either asthma or obesity?

BLASERWe don't know the answer to that yet, and that's what we're working on very actively on the lab, we and many other scientists. And it comes back to the human microbiome, all those bacteria that normally live in the human body. And we think that the antibiotics in cesarean section and antibacterial soaps, et cetera, are changing the composition, the populations of microbes in our body, especially in our guts. And these are changing the choreography, how metabolism is developing, how immunity is developing. And that's our major idea.

REHMHow concerned are you, Dr. Fauci, about this new periods of research?

FAUCIWell, I think the idea about antibiotic misuse, inappropriate use of antibiotics and how it perturbs not only the induction of resistance in microbes, which is really one of the critical issues that we're concerned about but also the perturbations of the normal balances that you have among bacteria in the gut that Dr. Blaser is talking about. The idea of any microbial resistance being a problem is a real and present danger.

FAUCIWe're seeing it here in the United States. We're seeing it worldwide. And that has directly to do with what we're talking about as sometimes inappropriately using antibiotics when we don't need to. And it goes well beyond the early issues of whether or not you have an immune system that's being developed properly or not. That's important. But also what's important is that you might be inducing the prevalence and predominance of resistant microbes.

REHMAnd you're listening to "The Diane Rehm Show." Dr. Blaser, I want to move on to another question, the Helicobacter bacteria, which I gather is beneficial for the esophagus, something I'm particularly interested in. Tell us about that.

BLASERWell, first, the organism is called Helicobacter pylori. And we just abbreviate it as HP, because it's easier to say.

REHMGood. I'll remember that.

BLASERSo HP was discovered in the early 1980s and it was a magnificent discovery. These are organisms that live in the stomach. And Marshall and Warren who discovered the organisms found that people who have the organisms are more likely to have ulcers, stomach ulcers and duodenal ulcers. And they showed if you cleared the body of those organisms, ulcers would go away. And that was a phenomenal observation.

BLASERIn fact, they won the Nobel Prize for that. And we and others later showed that these organisms also were responsible for stomach cancer. So the dogma for many years is that the only good Helicobacter is a dead one. But as Helicobacter has been disappearing with modernization, with clean water, with antibiotics, ulcer disease is going down, stomach cancer is going down, but new diseases are rising.

REHMSuch as?

BLASEROne of them are -- one of them are diseases of the esophagus like GERD and reflux and then that leads to a form of cancer, too. And we and others have done studies showing that people who have Helicobacter are less likely to get GERD. And that opened up a whole new body of evidence that Helicobacter is bad for us in terms of ulcers and stomach cancer, but it's good for us in terms of esophageal disease -- GERD and the adenocarcinomas of the esophagus and, more recently, asthma as well.

BLASERSo this is a very complicated organism, and it's not surprising because it's been with us humans for at least 100,000 years and probably longer and pretty much disappearing over the course of the 20th century.

REHMSo I'm getting two signals here. The first is that natural vaginal birth is better for the child because the child then inherits the mother's bacteria. And secondly, that the overuse of antibiotics in the first few years of life may set the path for the entire health of that human being going forward. Am I overstating this, Dr. Fauci?

FAUCIGenerally, what you're saying is correct. I think we got to be careful when people may misinterpret. Cesarean section, when you look at the studies that Dr. Blaser was talking about, has a clear impact on the ultimate microbiome in the gut. However, you got to be careful when you say it's bad for them. Sometimes you need a cesarean section to save the life of the mother and the baby.

REHMOf course, of course.

FAUCISo you have to do the balance of what's...

REHMYeah.

FAUCI...what do you mean by bad? I mean, relatively speaking, all other things considered that, as Dr. Blaser said, when you look at the evolution of all mammalian species here, that delivery into the world through the mother's vaginal canal has a very important positive impact on the baby. And when you perturb that, you may have to because you may need a cesarean section, but when that's perturbed, it has consequences. And the consequences are sometimes negative.

REHMBut we do know that more and more cesareans are optional these days.

FAUCIRight, exactly. And that's the kind of thing we need to take another look at, whether or not that's appropriate.

REHMAnd what about the use of antibiotics when a child is very young? How to create that balance between what's needed and what's not.

FAUCIAnd just as we've said, you know, a couple of times is that it's the prudent use, it's the not deprive the child of antibiotics when it's clear that the child has a pathogen that requires antibiotics. But don't willy-nilly give antibiotics to a child who really doesn't need it, who has a sore throat that's unquestionably viral but you just want to make you and the family feel better by giving the baby an antibiotic.

REHMDr. Anthony Fauci, he's director of the National Institute of Allergy and Infectious Diseases at the NIH. Dr. Martin Blaser, his new book is titled, "Missing Microbes: How The Overuse of Antibiotics is Fueling Our Modern Plagues." Short break. When we come back, time to open the phones. Stay with us.

REHMAnd welcome back as we talk about the use and indeed overuse of antibiotics and the problems that that can create. NPR has just published a blog stating the total doses of antibiotics sold in clinics and pharmacies around the world rose 36 percent from 2000 to 2010. Is that surprising, Dr. Blaser?

BLASERWell, in the United States, you need a doctor's prescription to get antibiotics. And that is, I think, very important and very good. In many parts of the world, when people don't feel well, they just get an antibiotic. In China, people are using antibiotics two to four times as much as we are. And there's growth of antibiotics here in the U.S., but it's especially bad all over the world. And interestingly, many of the same epidemics that we're talking about, obesity, asthma, diabetes, are happening there, too. They started later.

REHMHmm.

BLASERBut they're happening there as well.

REHMNow, you just mentioned diabetes, and you do include juvenile diabetes in your studies and in your concerns.

BLASERYeah, so juvenile diabetes is one of those autoimmune diseases that Dr. Fauci has talked about. We know that it's an autoimmune disease with immune destruction of the parts of the pancreas involved in producing insulin. And juvenile diabetes has been rising in recent years. It's doubling about every 20 years in the Western world. And it's getting younger. Kids are getting younger and younger.

BLASERAnd those facts together suggested to me that perhaps antibiotics have play a role. So a very talented student in my lab, Alexandra Livanos, just got her PhD on studies of giving antibiotics to mice. And we have evidence from her studies, which we've presented at national meetings and we're preparing for publication, that antibiotics in that model in mice is accelerating the course of diabetes.

REHMHmm. What about the bacteria that babies get from their mothers when they nurse, Dr. Fauci? Formula can't do this. Sam in Durham, N.C. posed this issue: "Please talk about the overlooked fact about nursing versus formula."

FAUCIWell, let me just answer the first question. The milk that comes from the mother doesn't have bacteria in it. What the milk that comes from the mother has is antibodies that are very, very helpful in protection.

REHMRight. Protection, right.

FAUCIVery likely, since the nipple is part of the skin, that there is skin bacteria that the baby gets in their mouth, which is very, very clear that that would happen. Right.

REHMSo it makes good sense, if possible, to nurse?

FAUCIOh, there's no doubt. I mean, if you look at, for example, the -- particularly in the developing world where nursing is sometimes becomes problematic in, for example, HIV-infected mothers. Now it's OK because they're -- we're treating them, and you can do that. But, if you look at formula versus the milk that contains protective antibodies, that the health of babies who are breastfed versus babies who have formula is very striking difference.

REHMAll right. And, Dr. Blaser, the second part of this is, "Could you talk about different kinds of yogurt and their effects on microbes in the gut?

BLASERYeah. I want to just come back to formula for a moment.

REHMSure.

BLASERAnd it touches on the yogurt, too, because, in addition to the antibodies, as Dr. Fauci mentions, milk is full of nutrients to help the baby grow. But, interestingly, there are certain nutrients that baby can't digest at all. They're designed for the good bacteria. Milk has compounds in it that select for good bacteria so that, again, it's part of the choreography that the milk is designed, that the baby comes through the mom's vagina and picks up lactobacilli. That lactobacillus is on the skin on the breast. Now it goes back to the baby with foods specifically designed for lactobacilli...

REHMHmm. Hmm.

BLASER...so that the baby's founding populations will be the right ones. So we have to understand, what are those right organisms? And those are the ones we have to put into yogurts and other things, but not necessarily the ones we get off cheese and from cows, et cetera. We want to find and discover human-specific bacteria that we're going to be putting back into baby foods.

REHMDo you eat yogurt, Dr. Fauci?

FAUCII do, Greek yogurt.

REHMAnd do you, Dr. Blaser?

BLASERI do. I love it, and Greek also.

REHMSo do I. So do I. Plain Greek yogurt. And Pat wants to know -- she says, "Please discuss the potential leak between -- link" -- sorry -- "between antibiotic overuse and the alarming epidemic of autism in recent years." Dr. Blaser?

BLASERWell, I mention autism in "Missing Microbes." We don't have any proof that there's any relationship between antibiotic use and autism. But it is biologically plausible. In the book, I talk about the idea that we have all these epidemics that have been rising more or less in parallel -- obesity, diabetes, asthma, autism -- that we think have a origin early in life that have to do with our changed microbiome.

BLASERAnd autism would fit that perfectly well also. And we are just beginning studies in our lab to look at that question. And I know that there are a lot of other investigators who are interested in the question of the effects of the early life microbiome, how it develops, and whether that affects how the brain develops. We know it affects how metabolism develops, how immunity develops. Possibly it's involved in brain development as well.

REHMWhat about that, Dr. Fauci? Is the NIH doing testing there?

FAUCIWell, I think I -- we need to emphasize also that this, as Dr. Blaser said, there's no real evidence that that's the case.

REHMRight.

FAUCII mean, you could make an argument as the feasibility, but we've really got to emphasize that 'cause I don't want people now to all of a sudden think that there's a clear link between antibiotics and autism 'cause there's no evidence to say that that's the case. Studying that obviously is very, very important, and there are studies of long-term following of children, you know, who are, you know, we have the children's study at the NIH was going to be looking at a variety of aspects. I'm not sure it's going to be looking at that aspect with regard to antibiotics. But following over cohorts of people, as Dr. Blaser had mentioned, over long periods of time will give us that information.

REHMIs the NIH developing new medications that might avoid the problems that antibiotics seem to be creating?

FAUCIRight. Yes. We clearly are very much involved in collaboration with industry and biotech in trying to get a better pipeline of new antimicrobials that are much more specific to certain types of bacteria. You know, if they said in plain language you want to try to get as specific as possible to get the bad guys at the vulnerable point that bad guys have that some of the good guys don't. The only trouble is there's such commonalities among bacteria that it's very difficult to do that, but not impossible. But the direct answer to your question, Diane, is that we certainly are working on trying to get more specific antibiotics.

REHMAll right. Let's open the phones. We'll go to Louise in Baltimore, Md. Hi. you're on the air. Louise, are you there? I guess we've lost her. How about to Barbara in Panama City?

BARBARAHi.

REHMHi.

BARBARAThanks for taking my call. I'm a big fan of the show.

REHMThank you.

BARBARAI just wanted to talk a little bit about that I was diagnosed with Crohn's disease at 20 years old -- I'm 50 now -- and ended up needing to have a permanent ileostomy. I've had long-time relationships with antibiotics and steroid combinations. I guess my question to either of the doctors is about parasitic worms. I was introduced to them about 10 years ago and took them for about three years. And actually it's -- by taking them, I needed less Remicade treatment. However, the GI doctor said that, if I had gotten the worms earlier, that they probably wouldn't have had such a difficult job, so...

REHMDr. Blaser, what do you know about parasitic worms?

BLASERWell, this is an area of investigation. It's based on the concept kind of that some of these worms would be in the category of good germs and that they are training our immune system in the right way. And there are clinical trials that are ongoing now in the United States and elsewhere to really answer that question. Do -- will -- in a controlled clinical trial, will they affect the outcome of inflammatory bowel disease? And I don't know the answer to that. Perhaps Dr. Fauci has more current information.

FAUCINo.

REHMNope.

FAUCINo, I don't.

REHMOK. All right. Let's go to Orlando, Fla. Hi, Alex.

ALEXHello. Thank you very much for taking the call.

REHMSure.

ALEXQuick question for both the doctors today. I believe what you said so far is right on target. And the whole answer is to not overuse, but antibiotics are critical in addressing certain key diseases. And in that vein, my daughter has been diagnosed with Lyme disease. She's 16. She's had it for half her life. And I wanted to ask specifically Dr. Fauci, with your background in AIDS research and the like, infectious diseases in general, do you believe the NIH and the CDC are doing enough to develop a reliable test that will allow us to isolate folks that need antibiotics for the treatment of Lyme borreliosis and Bartonella and Bobesia? Thank you.

FAUCIWell, there certainly is research going on in that area. That is a problem of diagnosis, particularly when people go on with chronic symptoms and signs to try and determine just exactly what that's due to. Is it a persistent of organism? Or is it just a response that lingers beyond that? So work on better diagnostics is clearly an important part of the research agenda.

REHMDr. Blaser, have you looked at Lyme disease at all?

BLASERWell, as Dr. Fauci says, the diagnosis of Lyme disease is difficult. And I'm concerned that there's a lot of overdiagnosis of Lyme disease and overtreatment, again, based on the idea that two months, six months of antibiotic has no biologic cost. But I'm concerned that it does have cost and that we need to balance the cost of that. And I don't mean just medical costs. I mean, biological cost effect on the microbiome with the potential benefit it has. I think we are overdiagnosing and overtreating that as well.

REHMHere's a question from Bev. "Could the increase of genetically modified organisms in the food supply be doing the same thing to bacteria in our gut?" Dr. Blaser.

BLASERThat's a very interesting question. I don't know the answer to that. Something that should be studied.

REHMDr. Fauci.

FAUCINo. I don't -- not...

REHMIt's going to take a while to find out about that. And you're listening to "The Diane Rehm Show." Let's go to, let's see, Rebecca in Durham, N.C. You're on the air.

REBECCAHi, Diane. Thanks so much for taking my call.

REHMSure.

REBECCAMy question is whether your guests could comment on the use of antibiotics in labor. As you know, I'm sure, Group B Strep is -- you know, all pregnant women are tested, and about 20 to 25 percent are positive for it and are treated with antibiotics, which is penicillin, in labor. I believe the number needed to treat -- to prevent one case of Group B Strep infection and it's about one to 200.

REBECCAThey need to treat 200 women to prevent one case. Given all that you're saying about long-term effects of the antibiotics, what do you all think about this? You know, is the standard of care that we're doing right now -- is this what we should be doing? Or should we be more cautious about treating women broadly in labor? Thank you.

REHMDr. Blaser.

BLASERI am so glad you brought this up. This is a really important point. As you point out, more than a million moms and babies in the United States each year are getting penicillin right at the point of birth. And there is benefit to that because it can prevent very serious infection from Group B Strep. But, as you say, we're way overtreating -- 200 women to prevent one case because of our standard of care. Now I want to contrast the U.S. with Sweden because, at every age, the Swedes are only using 40 percent of the antibiotics that we're using.

BLASERWhen our kids have gotten 10 courses of antibiotics by the time they're 10, in Sweden, it's only four courses. And in Sweden, they have very different guidelines for Group B Strep prevention. It's not given to every woman who's positive, but they have definite criteria. And the rates of Group B Strep infection in infants in Sweden are no higher than here. They are just using the antibiotics more judiciously. And that's what we have to do.

REHMDr. Fauci.

FAUCIWell, agree, but also, we need to do better diagnostics that are more specific, and also, we're working on is a Group B Strep vaccine that I think would be important.

REHMSo from your point of view, Dr. Blaser, and yours, Dr. Fauci, does all of this research point to a lot more research into new forms of antibiotics?

FAUCIOh, for sure. I mean, I think there's a lot of things that the research feels needs to go, and one of them is to really better understand what we were talking about about this interaction between the normal flora of our gut and a variety of other things.

FAUCIWe've been speaking about many of them -- bowel disease, autoimmune disease, obesity, et cetera, et cetera -- but also to understand the importance of not perturbing that in a way that actually has negative consequences, so that we want to get antibiotics that have a specificity for pathogens that do not perturb at all the normal bacteria that are there that are doing good things that are helping to engage the immune system in a positive way and protecting us in many ways. So the research clearly needs to be directed at more specificity when we try to knock out the bad bacteria.

REHMAnd, Dr. Blaser.

BLASERI want to corroborate what Dr. Fauci said and go back to two points he made. One is that we need better diagnostics. When a child comes to the doctor's office, we need a diagnostic that's going to say with some accuracy, this is a viral infection, doesn't need antibiotics. This is a bacterial infection. And if it's a bacterial infection, is it strep, is it staph, is it haemophilus?

BLASERAnd then we need that product that Dr. Fauci talked about, that narrow spectrum antibiotic just designed for that bacteria which the diagnostic tells us is present, that won't do collateral damage to the good guys. And so we need to do the research. And we're going to have to develop new products and a whole new economic of how to give this.

REHMWell, certainly a fascinating discussion. Thank you both so much. Dr. Martin Blaser, his new book is titled "Missing Microbes: How the Overuse of Antibiotics is Fueling Our Modern Plagues," and Dr. Anthony Fauci of the National Institutes of Health, thank you both so much.

BLASERThank you, Diane.

FAUCIThank you. Pleasure.

REHMAnd thanks for listening, all. I'm Diane Rehm.