Issue 9 / 18 March 2013

NOW is the moment for a nationally coordinated system for data collection and surveillance of antibiotic resistance to do the most good in the fight against multiresistant bacteria in Australia, says a leading infectious diseases physician.

Dr Helen Van Gessel, regional medical director for the Great Southern region, WA Country Health Service, said antimicrobial stewardship programs, now mandated as part of the accreditation process for Australian hospitals, were also important, but the challenge was how to put them in place across all health settings.

Dr Van Gessel was commenting on research published in the latest MJA which assessed the effectiveness of an antimicrobial stewardship program at the Alfred Hospital in Melbourne. (1)

The observational study conducted in the tertiary referral hospital compared the rate of use of antimicrobials over a 30-month period before the antimicrobial stewardship program was introduced with an 18-month period after it was established.

Antimicrobial consumption quantities were converted into defined daily doses per 1000 occupied bed-days. The authors wrote that there was an immediate 17% reduction in broad-spectrum antimicrobial use in the intensive care unit (ICU) and a 10% reduction outside the ICU.

“However, the effect of the intervention reduced over time”, they wrote.

The stewardship program provided online approval to use restricted antimicrobials for preapproved indications included in national or local consensus guidelines. Short-term approval could be granted for other non-standard indications specified by a clinician. Pharmacists alerted the antimicrobial stewardship team if unauthorised antimicrobial use exceeded 24 hours.

Dr Van Gessel said that while large, tertiary hospitals could fund full-time infectious diseases pharmacists — one of the requirements for a successful stewardship program in that setting — secondary hospitals, rural centres and smaller clinics have no such funding.

“There is a lot of work being done around what a stewardship program looks like.  The accreditation process supports program customisation but there are some interesting challenges ahead, particularly for those of us working in smaller hospitals”, she said.

“But then, if it was easy, we’d all be doing it already.”

Dr Van Gessel said perhaps the most critical challenge was the establishment of a national surveillance and data collection system which could monitor rates of resistance and share data across states and settings.

“In Australia right now, because we have a relatively low incidence of antibiotic resistance, we have a good opportunity to be looking at very active surveillance and control measures”, she said.

“Prevention and control work best when you do them early.”

Dr Van Gessel said that in WA several years ago there was a small increase in rates of methicillin-resistant Staphylococcus aureus (MRSA) infection and a couple of individuals had decided to do everything they could to stop it.

“Some people thought they were over the top but now WA hospitals report consistently low rates of health care-associated MRSA infections, much lower than the other states and other countries”, she said.

Dr David Speers, an infectious diseases physician and infection control officer at Sir Charles Gairdner Hospital in Perth, said another problem in the battle against antibiotic resistance was falling prices as drugs came off patent, which had negated a large part of the business case for stewardship programs.

“One of the arguments for stewardship programs was that using less antibiotics would reduce costs, but now the bottom has fallen out of that argument”, Dr Speers told MJA InSight.

“The argument now has to be on reducing the ‘selection pressure’ on bacteria, protecting the antibiotics we have.”

An editorial in the same issue of MJA warned that “without a coordinated effort at government level across all human and animal health care sectors, we are likely doomed to failure” in the battle against the spread of gram-negative resistance. (2)

“All of us … have to recognise gram-negative resistance as a looming public health crisis and a social challenge: a new plague”, the authors, led by Dr David Looke, president of the Australian Society for Infectious Diseases, wrote.

“We need to be brave enough to make difficult decisions to re-regulate antibiotics. Without intervention, many of the greatest advances in the practice of medicine — such as transplantation, joint replacement surgery or critical care medicine — will be under significant threat.”

– Cate Swannell

1. MJA 2013; 198: 262-266
2. MJA 2013; 198: 243-244

Posted 18 March 2013

5 thoughts on “Time ripe for antibiotic action

  1. Nancy Nicholas says:

    When I was an RMO at the Royal Women’s hospital in Melbourne in 1966 we were only allowed to order penicillin and sulphurs as antibiotic treatment and had to obtain special permission to order any other antibiotic if a patient had an infection which was not senstitive to either of these. I understood that that rule was to prevent drug resistance developing. We junior doctors all thought we should be able to order any other antibiotic we wanted to- but those were the rules. Perhaps it was a good idea that could be revisited.

  2. Mark Allison says:

    It occurs to me that the veterinary surgeons also need to be included in this. Having recently taken my dog to one I was appalled that they were handing out fairly heavy duty antibiotics for what was a superficial skin infection which only needed local treatment to heal. The underlying problem was hip pain and the lesion was self induced.

    Do vets have any controls?

  3. Matthew Yap says:

    Along the same lines of veterinary antibiotic use, it would be interesting to assess the contribution of agricultural antibiotic use to the rates of resistant strains infecting human populations. A national data collection system may only be measuring a portion of the contributing patterns.

    And given that rises in antibiotic resistance may be blamed upon importing the failures of international antibiotic regulations, it would be nice to follow/lead the international community on antibiotic surveillance.

  4. Ned Iceton says:

    In 1957-58 when I worked in the neonatal unit of the Aberdeen Scotland Maternity Hospital penicillin was the only antiobiotic available. On arrival, I found that most bacteria were penicillin resistant. I found there was a routine practice of putting pregnant women whose membranes were ruptured but who had not yet come into labour on prophylactic penicillin. I argued with the professor that this practice should be stopped and penicillin be given only to that minimal minority who would develop fever, and he agreed. No problems arose. After six months, all bacteria in the hospital were again penicillin sensitive. The selection pressure for resistance had been removed.

  5. Dr. Satish Gupte says:

    One has to look into issues like antibiotics administered to animals and to their use in milk, milk products and meat etc .

    In third world there is a practice of using antibiotics pre operatively which needs to be discouraged…….

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