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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
The 2 day Summit on Antimicrobial Resistance was very interesting, needs direction from a national strategy with focus on research and education and communication via TV advertisements, current affairs, newspapers, and national education of medical, nursing and community, aged care and disability services.
There is clearly a need for all medical and nursing personel to have training, suggest compulsory, so that everyone is on the same page with protocols at service areas, eg, hospitals, aged care facilities and medical and community centres.
Overall there were many educated people with real concerns for the future of antibiotics need when people are requiring treatment for bacterial infections that are life threathening and in approx 10 years no antibiotics to fight these infections. we need to act now to help future generations. There needs to be funding for this to be successful.
Appropriate prescribing and infection control practices must be taken seriously if this problem is to addressed before it is too late. One area that needs urgent attention is the aged care sector. There is little control over what antibiotics are prescribed and how they are prescribed. With the ageing population and recent shifts in the focus and delivery of health care and aged care services have come new challenges. This increased interaction between acute care and aged care facilites the transfer of pathogens between these facilities. In aged care, there is currently no systematic approach to surveillance and very limited resources attached to infection control. As Professor Carr stated – there are huge gaps in our knowledge of the true state of antimicrobial resistance in Australia and this is especially true in aged care. We must lobby Government to put more funds into monitoring and controlling the spread of antimicrobial resistant organsisms in this major reservior. We need action now at a National level before it is too late.
A well-written article on an important initiative. I have recently started working at an international clinic in China. There is a real problem in these privately run facilities where Azithromycin is dispensed with the throat lozenges and every child with a runny nose leaves the practice with Augmentin and a lollipop. Physicians’ bonuses are tied to the dispensing fees from an in-house pharmacy stocked with most classes of antimicrobials. Individual responsibilty is a good first step but it is a global problem.
What is the collective madness that leads to the unnecessary use of antibiotics in all segments of society. Is it the “just-in-case” phenomenon, driven by the fact that we cannot provide instant confirmation of the pathogen causing an infection, leading both doctor and patient to hope for a benefit because neither can be sure up front there won’t be some? Are antibiotics their own worst enemy because they are “safe” and designed to do no harm to the host, making them easy to prescribe “just in case”? (This is the only class of drugs for which this is true). Why is it that all medical practitioners feel that they have a “right” to prescribe antibiotics with appropriate training? Would we tolerate medical practitioners without appropriate training taking out our inflamed appendix, inserting coronary stents or treating our cancer? Did we make a mistake allowing them to be readily accessible at the beginning?
A lot of questions I know, but when we have the answers to them we may strengthen our collective resolve to cure the madness.
This is an incredibly important area for the MJA to be encouraging concern and debate. The facts about the risks of increasing resistance are indisputable yet government allows itself to be held captive by spurious economic arguments and has constructed ineffective methods for oversight. This applies in two areas – ‘licensing’ for the use of antibiotics by farmers – currently tanker loads of antibiotics are poured into Tasmanian salmon farms.
Second, the regulation of the use of antibiotics in human healthcare is negligible. Here again the claims of the pharmaceutical ‘industry’ have considerable sway and PBS approval the norm.
Governement then expects, or rather hopes for, local (eg, hospital level) restrictions, yet as previous commentators have remarked, there is substantial ignorance among most clinicians about appropriate antibiotic usage. There are also minimum ID and pharmacy personal available to run local restrictive systems and perform the necessary feedback to the clinicians.
We have no national surveillance system and a fraction of the vast amounts of money spent on pandemic preparedness (with its political appeal) could have funded a permanent microbiological surveillance system with links to antibiotic prescribing (including severe and mandatory PBS controls).
Yet if the government continues to ignore the resistance problem, deaths will occur and expensive ineffective post-hoc solutions will be implemented – all avoidable by the preventive work we need now.
So can anyone tell me their ideas for improving the way doctors prescribe antibiotics? The whole summit basically agreed that this was what we needed to do – but no-one had any grand ideas. Everyone was waiting for some top-level down legislation which will probably never happen. We need grassroots changes at not just the doctor level but at the public level. Until consumers stop demanding antibiotics and start demanding safe prescribing nothing is going to happen. This is as important as climate change.
The summit was highly successful in bringing together professionals from diverse vocations and engaging in meaningful discussion about the enormous problem of antimicrobial resistance. All of these ideas and resolutions need to be translated into action using a multi-faceted approach. Education of health professionals as well as the public is paramount. In the hospital system many doctors have a poor understanding of antibiotics and microbiology, and often junior doctors are “doing what they’re told” without thinking about what is the correct treatment for the diagnosis, nor are they empowered to change a treatment decision from a superior. Too often ID registrars and physicians are accused of being scare-mongerers because we see the community/societal problem of increasing antimicrobial resistance, but we only need to see the amount of international traffic of humans and animals to realise that the problem is massive – drug resistant bacteria don’t respect international boundaries.
And although it may not be popular, maybe it’s time to really reduce the widespread practice of issuing repeat antibiotic prescriptions in the community that enable patients to self treat themselves (or family members) at some point within the next 12 months whenever they feel like it…
I’m a trainee and have seen a huge increase in resistant organisms even in my professional lifetime but no corresponding increase in new antibiotics to combat this threat. I think my generation would embrace guidance to use the right antibiotics at the right time, incorporating computerised decision-making systems supported by antimicrobial stewardship teams. To make any progress though, this means resources are needed to put systems in place, to educate doctors, nurses, pharmacists and the community, and to properly enforce any well-intentioned recommendations. We can’t achieve this without support from the highest levels of government.
How refreshing to have an opportunity to listen to like minded people who are also members of the human health fraternity speak so candidly about the challenges they see in addressing such issues as incompetent antibiotic prescribing practices and the reckless disregard for hand hygiene amongst their colleagues. It is a rare but healthy thing to have the cards laid so bare on the table. Perhaps the veterinary fraternity needs to share some information also. It might include such things as almost all antimicrobials are held in stock at the particular practice until they are sold to the client. Even with a typical mark-up of 100% there is a financial burden to carrying an in-house pharmacy which is an obvious driver for turning over the stock and limiting the range used. Hardly a recipe for judicious use. Perhaps a step toward reform would be the issuing of prescription pads to veterinarians many of whom would be grateful to have the drug costs blamed on the local pharmacy. Equally important that empirical (with a little bit of help from MIMS) use is the order of the day and culture and sensitivities are rarely if ever carried out at all. This practice norm is likely due a large part to the extreme reticence of the general public to pay for the true cost of veterinary care including the cost of pathology services.
It was a privilege to attend the Summit the last two days and witness the enthusiasm, commitment and positive discussion surrounding the pressing issue of antimicrobial resistance. Numerous health care professionals, veterinarians and agricultural sector professionals are committed to take further action on this issue. However, as Tom Gottlieb stated at the Summit, we are “preaching to the converted”. The notable absence at this meeting were those to which the messages have the greatest importance; health care policy makers, politicians and representatives of the specialist Colleges. Sadly, it would seem from the experience of our overseas colleagues that wielding the stick is more effective than the carrot.
We need bird flu or swine flu to remind our health care colleagues and the public that infectious diseases do not affect just one person. Antimicrobial resistance has been a silent epidemic with significant casualties, but it’s not just the patients who have died (or lost limbs) from untreatable infections who lie buried. Time for everyone to excavate their heads and take responsibility. It’s a complex, multifaceted problem, but a good place to start is with doctors. If you prescribe an antibiotic without thinking about indication or appropriateness, you are contributing to the problem. One day it might be you yourself who picks up an untreatable infection. In the meantime, how many patients have you adversely affected?
Last year I was an HMO at one of Melbourne’s biggest tertiary hospitals, and can testify to antibiotic misuse being rampant. In the haematology ward we frequently were putting people on meropenem and vancomycin for poor indications, and even when cultures came back there was reluctance from senior doctors to narrow the spectrum as they didn’t want to take any chances with the young sick patients. The ID team got annoyed because we would ask for them to consult on the sick/complex infections, and then totally ignore their recommendations. This was all somehow regarded as ‘caring’ for our patients.
Are nurse practitioners permitted by the Health Minister, Nicola Roxon, to prescribe antibiotics?
As an RMO, I have had first hand experience with poor antibiotic prescription due to significant pressure from consultants insisting on innapropriate treatment protocols. For example, a particular orthopaedic ward is notorious for prescribing several weeks worth of ampicillin and 240mg second daily gent for all geriatic patients post op with a mildly elevated crp! It’s no wonder there is a crisis looming….
Just finished a locum at St Swithins-in-the-Sticks.
i) RMOs writing up merepenem for all technically compound fractures (ie, graze on the same limb) or wounds-for-exploration because one of the orthopaedic registrars asked for it so they assumed that was “what they wanted.” I would cheerfully agree to filling in pages of requisition-to-pharmacy forms on the odd occasion I need this drug to avoid that happening.
ii) No information from the lab – in spite of asking – about resistance patterns. The wards send home LOLs with hospital acquired UTIs on trimethoprim and they bounce, fit young women with their first honeymoon cystitis get extended courses of 2nd line antibiotics.
iii) Quite a lot of community acquired, or non-multiresistent MRSA. So will co-trimoxazole or doxycycline work? Should we combine the latter with fluclox for empiracal treatment of ?staph or strep cellulitis? No idea, the lab just plates it against beta-lactams and vancomycin.
iv) Practically every wound seems to get a 5-day course of “prophylactic” flucloxacillin. I don’t mind the prophylaxis so much – although I stick to the view that anything clean enough to be sutured primarily doesn’t need antibiotics. But the 5 days bothers me, and so does the timing. Better to give a gram orally now rather than a script to be started tomorrow.
The emergency department was distinguished by common sense and had a firm “follow the little pink book” (therapeutic guidelines) policy. But it’s easier for many to do what they see the VMO and surgical registrars doing…