Annette Katelaris: The high cost of resistance

AS a profession, we have to get behind the physicians who organised today’s Antimicrobial Resistance Summit in Sydney and heed their call for “urgent action to address the growing crises of antibiotic resistance”.

What makes this meeting different is that it has been convened by these doctors at their own expense because of the importance of this issue.

This normally sedate group, who often spend hours poring over agar plates and who are wedded to evidence-based medicine, are so disturbed by what they have seen, they have brought together national and international leaders in their field, and from the government and media, to raise the issue.

Just as surprisingly, they have resorted to the use of colourful language to get the message across.

All speakers emphasised the need for a coordinated approach. We need surveillance, we need education of our profession and the public, we need ongoing scientific study and, according to many, we need more formal controls on antibiotic prescribing.

We were reminded at the summit that the ongoing practice of modern medicine is unthinkable in the absence of effective antimicrobials. What happens in our intensive care units, neonatal intensive care units, dialysis and chemotherapy wards, orthopaedic wards full of trauma and joint replacements if our tools of trade don’t work?

There are few issues in medicine that affect just about every part of the profession. This is one of them.

The antimicrobial resistance, even to community-acquired infections, is rising.

With methicillin-resistant Staphylococcus aureus (MRSA), vancomycin resistant enterococci (VRE) and hypervirulent Clostridium difficile all flourishing, there is no time to waste and the consequences of antimicrobial resistance is devastating (15% mortality with this strain of C. difficile).

Yet, it seems Health Minister Nicola Roxon was too preoccupied with Parliament sitting to attend the summit or to send a representative. Instead, Chief Medical Officer Jim Bishop opened the proceedings.

Associate Professor Tom Gottlieb, current president of the Australian Society for Infectious Diseases and president-elect of the Australian Society for Antimicrobials (who convened the conference), crystallised what we know ― that as a society we have come to believe in the infallibility of antibiotics.

He said that “no other drugs have been used with such joie de vivre” and if we continue down this path “unabated antibiotic use will have a sting in its tail”.

Before he addressed the summit, I had the chance to talk to the lead speaker Professor Otto Cars, who co-founded the International Society of Anti-Infective Pharmacology and the global network ReAct, Action on Antibiotic Resistance.

It was daunting to realise just how far behind this country is in its surveillance and regulation of antimicrobial use.

The Swedish Government has been behind this initiative since 1999 and in that country less than 1% of staphylococcal blood cultures are MRSA.

In Australia, up to 30% are MRSA.

Professor Cars was emphatic that although there are knowledge gaps in Australia, we must act now. “We can’t wait for the data; we know that antibiotics are misused and overused. We know that infection control could be improved without new information.”

He attributed the causes of antimicrobial resistance to three things:
• indiscriminate use of antibiotics
• indiscriminate effects of antibiotics, ie, broad activity
• global spread of resistance facilitated by the rapid dynamics of gene transfer between bacteria as a result of travel, trade and poor sanitation and hygiene.

In Sweden, even the doctors have to wear plain theatre gear in the wards, no ties and no jewellery. As Professor Cars said, “the doctors don’t like it but it works”.

He admonished the World Health Organization for devoting only sparse resources to the problem and called for a global government alliance, emphasising that the burden of antibiotic resistance falls disproportionately on poorer countries.

At times we all employ some “magical thinking” and assume that we have an endless supply of new antimicrobials.

Professor Cars burst our bubble and made it clear that there was “an alarming decline in antibiotic development … and that there were no new drugs in the pipeline”.

He feels that we have a “scary 5 years ahead”.

Dr David Looke, infectious diseases physician and clinical microbiologist at Princess Alexandra Hospital, Brisbane, warned that “in the foreseeable future, we won’t be able to treat a lot of community-acquired infections”. He told me that we are already using our drugs of last resort.

He expressed frustration with the government that is willing to spend millions on influenza surveillance, education, vaccination and treatment, yet seems unwilling to put anything into this creeping epidemic of antimicrobial resistance, which is a much bigger threat to Australians.

Professor David Paterson, infectious diseases physician at the Royal Brisbane Hospital, told the Summit that there are no new antibiotics available in the next 10 years against gram negatives.

He said that “carbapenems are our end-of-the-road antibiotic” and that patients with gram negative infections resistant to this class were on the “road to death”.

Professor Peter Collignon, director of infectious diseases and microbiology at the Canberra Hospital, told the summit that despite there being almost no evidence to support the use of antimicrobials for prophylaxis or growth promotion in animals, these practices persist in agriculture, although banned in countries like Denmark, with no detrimental effects.

It put me off eating imported prawns, which sometimes have chloramphenicol residues, or imported apples with gentamicin, which even survives the oven when bound for apple pies.

Australia has a proud history in the development of penicillin and boasted  Howard Florey, on our $50 note.

It is time the Australian Government acted responsibly, supported this group and worked with it to develop effective surveillance and control of antimicrobials.

All is not lost as it seems that resistance levels fall with the sensible use of antimicrobials.

Dr Annette Katelaris is the editor of the MJA.

Posted 7 February 2011