The war against superbugs

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Cover onlineA 73-year old woman is in hospital after surgery to remove a bowel cancer.  She is given broad-spectrum antibiotics to prevent infection at the site of surgery, but she develops pneumonia one week after the surgery.  The bacteria causing this lung infection are resistant to many antibiotics; the organism causing this infection is called MRSA (methicillin-resistant Staphylococcus aureus).  Because the infection is so resistant, treatment is difficult and prolonged, although she does eventually recover.

A 62-year old woman is hospitalized with a serious kidney and bladder infection.  The infection is not responding to the usual standard antibiotic treatment. The urine and blood cultures show that the infection is caused by an E. coli bacterium with NDM-1 form of resistance, a highly resistant organism, which is spreading worldwide. The only effective treatment available is with a toxic antibiotic, and the response to treatment is delayed.

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The cases described above are but two examples of serious infections caused by antibiotic-resistant organisms. ‘Superbugs’ or antibiotic-resistant organisms such as bacteria or viruses, whether acquired in a health care setting or in the community, pose a major global threat to public health. The World Health Organization agrees. Their recent global report paints a grim reality that will only worsen if we are not able implement effective strategies to curtail antimicrobial (antibiotic, antiviral, antifungal medications) resistance. The world, the report declares, is headed for a dangerous ‘post-antibiotic era’ where antibiotic resistance is very high, among bacteria and viruses. Common serious infections caused by bacteria that were once treatable such as blood stream infections, skin infections, diarrhea, pneumonia and urinary tract infections, will become harder to manage, and ultimately fatal.

Antimicrobial resistance in healthcare

In health care settings, antibiotic resistant organisms often cause life-threatening infections in patients with weakened immunity from, for example, having kidney disease treated with dialysis, receiving chemotherapy treatment for cancer, or having undergone a cardiac surgical procedure for heart disease.  Rates of antibiotic resistance may continue to climb if effective infection prevention and control measures are not adequately implemented, and if antibiotic agents continue to be inappropriately used.

The burden of these resistant organisms and their devastating effects on patients is alarming and significant. Approximately 8,000 patients in Canada and 23,000 patients in the United States die annually related to superbugs in health care facilities. Economically, antibiotic resistant organisms add an estimated $50 to $100 million to annual Canadian health care costs.

Now the world faces a disconcerting, new frontier in antimicrobial resistance. Over the last four years, the superbug NDM-1 (New Delhi Metallo-beta-lactamase-1) has emerged. The enzyme known as NDM-1 makes the bacteria resistant to almost all known agents including the most powerful, last line of carbapenem antibiotics. These organisms are highly resistant and the infections they cause are proving to be extremely difficult to eradicate.

What can be done to stem the tide of resistance in health care settings

In Canada, we still have an opportunity unlike other countries, to act now, and more aggressively to control rates of resistance.  Governments and our health care system need to:

  • enhance the existing National Surveillance System to better monitor rates of antibiotic resistant organisms and antibiotic utilization in health care settings, in a more timely and responsive manner.
  • interrupt and/or prevent spread of resistant organisms by means of a stronger emphasis on performing proper hand hygiene in health care settings.
  • conduct screening and monitoring programs for current and newly admitted high-risk patients.
  • continue investing in resources and innovations in dedicated environmental cleaning.
  • collaborate closely with Infection Prevention and Control programs to ensure the best design and construction of health care facilities.
  • continue to implement and formalize Antibiotic Stewardship Programs in hospitals to ensure appropriate selection and use of antibiotics to maximize clinical cure or prevent infection, while minimizing consequences related to over-use. Programs should be implemented within a collaborative and consultative framework between Infectious Diseases, Pharmacy, Microbiology laboratories, and clinical teams.

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Antimicrobial resistance in the community

Drug-resistant organisms in the community are emerging in significant numbers. In 2012, 84,000 cases worldwide of multi-drug resistant tuberculosis reported to the World Health Organization represented only 21 per cent of the estimated resistant cases that emerged that year. Multi-resistant gonorrhea, drug-resistant malaria, anti-viral resistant HIV, and resistant strains of influenza virus are also emerging worldwide.

What you can do to reduce the ‘resistance footprint’

Similar to reducing our carbon footprint to stop climate change, Dr. David Patrick, Director of Communicable Disease Epidemiology at the British Columbia Centre for Disease Control, and Dr. Jim Hutchinson, a microbiologist in Victoria, BC, coined the concept to reduce our (antibiotic) ‘resistance footprint’.

Resistance is fuelled and magnified by the selective pressure of antibiotic use. When an individual takes a heart medication, a blood pressure pill, that pill only affects her or him.

But, when an individual takes an antibiotic, there is the potential for it to affect an entire community. Individuals need to consider the wider implications of taking antibiotics unnecessarily or inappropriately for infections such as the common cold, sinusitis or ear infections.