Spread of drug-resistant bugs fuelled by abuse of antibiotics

If we don’t use our antibiotics appropriately, they are going to be lost to us and there will not be anything left to use in the future.

This warning from South African intensivist, Guy Richards, was delivered during a hard hitting look at the antibiotic pan-resistant era and strategies and solutions aimed at addressing this during the 11th Congress of the World Federation of Societies of Intensive and Critical Care Medicine on Saturday.

The emergence of multidrug-resistant, extensively resistant and pan-resistant pathogens and the widespread inappropriate use of antibiotics has long been seen as a global crisis. However, it was only after extremely drug resistant organisms began to appear in South Africa – in 2011 klebsiella pneumonia was identified in a Johannesburg laboratory for the first time, RPC-2 e. cloacae in Pretoria and OXA-48 in Johannesburg, Cape Town and Port Elizabeth – that researchers took a closer look at antibiotic prescription practices in public and private ICUs in South Africa, he said.

Referring to the Prevalence of Infection in South African Intensive Care Units (PISA) study, Richards said a number of highly disturbing issues were highlighted by this first close look at use of antibiotics and patient outcomes in South Africa.

He said that this study had shown that 43,5% of antibiotics used in public and 60% of antibiotics used in private hospitals were inappropriate. The reason for the better outcome in the public sector was probably due to less access to broad spectrum antibiotics. Inappropriate duration of use of antibiotics – using these for too long – was 55% in public and 79% in private hospitals. Richards said that this was despite the fact that researchers had been liberal with the time period, allowing 10 days to pass before use was deemed inappropriate.

Drug resistant bacteria

De-escalation was practised in just 33.3% of cases in private hospitals and just 19.7% of cases in public patients. However, he said, the most distressing thing of all emerged when the study looked at the number of antibiotics prescribed at any one time. Some patients were receiving up to 10 at one time. This excluded anti TB and anti retrovirals. “I find it difficult thinking of 10 antibiotics that I could use at any one time. It is a case of starting with one and, when a patient didn’t immediately get better, adding another and then another and then another.

Richards said that the spread of drug resistant bacteria either took place through the genetic transfer of resistance from one bug to another or, most importantly, through colonal spread which saw the same bug being transferred from one patient to another primarily as a result of poor infection control.

“The most important thing of all is to decrease the amount of infection. You need to examine hand hygiene which is awful in general,” he stressed, saying that studies had revealed that hand washing transgressions covered a wide spectrum of medical staff. This was not just restricted to nurses or even physiotherapists but also extended to senior medical staff. He said that while surgical staff scrubbed up well in theatre, they washed their hands 83% less often than their peers in wards whilst anesthesiologists were the worst when it came to compliance.

Richards said that in addition to simply curbing abuse of antibiotics, there was a need to understand how antibiotics could be used to actually decrease the development of resistance. This required an understanding of the minimum inhibitory composition (MIC) and the nature of antibiotics so that dosages of time dependent and concentration dependent antibiotics could be adjusted to increase the potential efficacy but control the duration of use.

He said that one of the big problems was that people added in therapies for patients who were failing. He said that when sepsis was present, it was necessary to look at source control rather than simply “throwing another antibiotic at it".

He also advised directing therapy at clinical response and using biomarkers and warned that there was no such thing as finishing a course. When a patient was better, you simply stopped treatment.

11th Congress of the World Federation of Societies of Intensive and Critical Care Medicine press release

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