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The fight to stay one step ahead of the superbugs

“We see it for so many bugs and antimicrobials; the bugs are always one step ahead. That’s the way it feels.”

That is a warning from Prof Magnus Unemo from the World Health Organisation (WHO) Collaborating Centre for Gonorrhoea and other STIs.

Prof Unemo spoke exclusively to the Medical Independent (MI) during last month’s Pan Celtic Dublin 2016 conference of clinical microbiologists in Dublin. The conference focused on ‘Antimicrobial resistance (AMR): The global threats and challenges in diagnosis, treatment and prevention’ (see panel).

The gathering of clinical microbiologists and other infectious disease experts proved to be a sobering affair, with many speakers pointing to the daunting public health challenge posed by AMR, which is causing growing concern among the global medical community.

In September, the United Nations (UN) General Assembly in New York brought global leaders together to commit to fighting AMR. This was only the fourth time in the history of the UN that a health topic was discussed at the General Assembly (HIV, non-communicable diseases, and Ebola were the others).

But it is not only at a global level that the challenge of AMR is being taken seriously. In the most recent edition of the Irish Government’s National Risk Assessment document published in June, AMR makes the list alongside such worrying threats as terrorist attack, nuclear accident, global warming and major pandemics as issues that the State must be prepared for.

“AMR already represents a significant human health threat and contributes to increase morbidity, mortality and healthcare costs,” warns the document. “If AMR continues to rise, it will become increasingly difficult and expensive to control and treat infections in medical care and more difficult to maintain animal health and welfare.”

The Irish Society of Clinical Microbiologists (ISCM) and the Academy of Clinical Science and Laboratory Medicine (ACSLM) jointly organised the Pan Celtic Dublin conference.

On its opening day, the conference was addressed by HSE Director General Mr Tony O’Brien, who assured delegates that the Executive is aware of the serious nature of the AMR issue.

“While we have had some progress, we do face some considerable challenges,” acknowledged Mr O’Brien.

“Currently, we have a major CRE [carbapenem-resistant Enterobacteriaceae] outbreak in a Dublin hospital and we also have an ongoing outbreak since 2011 in the mid west region as well and we are very much aware of the growing international concern on the emergence of decreased susceptibility to the last line of antibiotics.”

Local outbreaks

Tallaght Hospital, Dublin, has been dealing with an outbreak of CRE since August this year, a hospital spokesperson told MI. However, the spokesperson did not provide exact figures for how many patients or wards have been impacted.

“A wide range of measures have been introduced, in keeping with the National Infection Prevention Control Guidelines. A number of elective admissions have been deferred,” said the spokesperson.

“Restricted visiting has been introduced to reduce the risk of further transmission. Children are not allowed to visit the adult areas of the hospital. The children’s services are unaffected.

“Patients who test positive are either a carrier (CRE is present in the bowel, often referred to as ‘colonisation’) or have an active infection. All patients are treated in accordance with the National Infection Prevention Control Guidelines. Patients are cohorted on to designated wards in single rooms.”

This is a current example of the ‘superbug’ challenge in an Irish hospital setting, but the threat is broader than this, both locally and globally.

Experts agree that the stakes are high and point out that the loss of effective and readily-available treatment options may lead to a future that resembles the ‘pre-antibiotic era’, with increased morbidity and mortality from common infections.

The Pan Celtic Dublin conference heard from various Irish experts who highlighted their concerns over the need for more resources in the area.

Race against time: grappling with gonorrhoea

The emergence of decreased susceptibility and resistance to ‘last-line’ antibiotics for the treatment of gonorrhoea is a major concern, a leading WHO expert told the Medical Independent (MI) in a recent interview.

Prof Magnus Unemo told MI that he believed that a vaccination for gonorrhoea is the only long-term solution to the problem.

Recent figures from the HSE show that the rise in gonorrhoea is not just a global but also a local problem. There was a seven-fold increase in gonorrhoea cases in the decade to 2013, with the majority of cases reported in the east of the country. The overall incidence increased by almost 200 per cent between 2009 and 2013.

In 2013, a total of 1,294 cases of gonorrhoea were reported in Ireland, giving a notification rate of 28.2 per 100,000 population. 

Preliminary data for the first six months of this year, published last month by the Health Protection Surveillance Centre (HPSC), again show significant increases in notifications of HIV, syphilis and gonorrhoea in Ireland, particularly among men who have sex with men (MSM).

Although gonorrhoea numbers in 2015 were similar to 2014, the latest data for 2016 show that gonorrhoea rates in men have risen by 63 per cent. In 2015, 55 per cent of cases of gonorrhoea were in this group.

In addition, it emerged at the Irish College of Ophthalmologists Annual Conference in 2014 that a small but rising number of patients complaining of eye problems that turn out to be caused by syphilis or gonorrhoea were presenting at the Royal Victoria Eye and Ear Hospital, Dublin, and at hospitals and GP surgeries around the country. The underlying STIs need to be treated to resolve the eye issues and, if left untreated, can cause more serious, long-term visual problems.

Prof Unemo told MI that the “WHO has also a large global programme developing vaccines for several of the STIs.

“But for gonorrhoea, it is still in the very early phases, clearly in the pre-clinical phases and still on research level. But if the forces of joint funding were available, I would say it could be possible in 10 years.”

However, Prof Unemo added that even if a vaccination was created, the implementation of a mass vaccination programme would not be without its own obstacles.

“There are other difficulties. You need to probably give it to ideally rather young adolescents and parents never think their children have any sex and so there are issues like this,” Prof Unemo told MI.

“I think it would be difficult to implement it. But it is also a different situation than the HPV vaccine, because here it doesn’t matter if you have one or a couple of episodes of gonorrhoea, not like HPV — if you have it once you have it for life, basically. So here, you might not need to go so low in the ages for those who are vaccinated.”

The Swedish expert said gonorrhoea is not the only STI that may need a vaccination solution in the end, but the area of vaccination development has been slow in recent times.

“Hopefully there will be more focus on vaccine development, which has stagnated a lot and it has not happened a lot for most infections,” said Prof Unemo. 

“We clearly see for many infections that antimicrobials are not the best or a sustainable solution. We see it for so many bugs and antimicrobials; the bugs are always one step ahead. That’s the way it feels.”

Resources

“There is no simple solution to the complex AMR problem,” Ms Lisa Rose, Senior Medical Scientist in Microbiology, St James’s Hospital, Dublin, told the conference. 

“The growth of AMR poses a particular challenge for those of us working in diagnostic microbiology laboratories, as I find as I work as a medical scientist in St James’s Hospital.

“We collectively have the medical and scientific expertise to address some of the issues of AMR, but we currently do not have sufficient resources to address all of these effectively on a national basis.

 “It is essential that we have access to rapid diagnostic tests, improved surveillance of drug-resistant organisms, improved antibiotic stewardship and education around AMR.”

Ms Rose’s colleague Dr Breida Boyle, Consultant Microbiologist, St James’s Hospital, who spoke on the opening morning of the conference, also highlighted the need for increased investment.

“We have the expertise [but] we need the capacity,” she said.

Dr Boyle said that research she had undertaken at St James’s has shown that money is saved in the medium to long term with the reduction of infection rates. She added that work undertaken by the World Bank had also pointed to the serious global financial cost of AMR.

“Although antimicrobial resistance is a global issue, it is our local reality,” she said.

Prof Hilary Humphreys, Professor of Clinical Microbiology at the RCSI and a Consultant Microbiologist at Beaumont Hospital, Dublin, highlighted research from the Netherlands, where the health service carries out a very “aggressive” policy towards MRSA and VRE. Cost analysis of these measures has proven that investment in the short term would yield benefits in the longer period.

“They found that the cost of their measures of ‘search and destroy’, which is aggressive MRSA prevention and control, were significantly less than the cost of the infections and indeed deaths,” he said during his presentation at the conference.

Prof Humphreys said this promise of long-term savings has to be brought to health management across the service in Ireland.

Speaking on behalf of the Executive, Mr O’Brien admitted that infrastructure cutbacks had had an adverse effect on areas such as dealing with AMR.

“[There has been an] economic impact in particular on our capital programme and there [is] work we have to do to bring our estate back up to the standard that it used to be,” he told delegates. 

“There are some major projects underway but we still have significant challenges through-out our service.”

Organisers of the conference noted that “all new builds in acute care have 100 per cent single rooms”.

“While many older facilities certainly require upgrade, the standard of recent new builds is excellent,” said the organisers in a statement.

“A challenge will be to continuously improve our healthcare facilities.”

The new National Children’s Hospital, and most likely the planned new maternity hospitals, will have all single rooms, which should aid infection control. However, Ireland’s current public hospital landscape only has a minority of single rooms and still depends on ward structures.

Screening

Prof Humphreys said that the HSE’s 2013 MRSA guidelines were well received when published.

During his presentation, he said that there had been different conclusions from recent studies regarding rapid testing in hospitals.

“I think the message is if you want to control the prevention and transmission of any drug-resistant organism, there isn’t one solution to it,” said Prof Humphreys.

“Rapid testing is part of it but you have to do other things as well and certainly rapid testing in certain circumstances can help you to do that.”

But looking at a recent example, Prof Humphreys added MRSA continues to cause serious problems in hospitals, despite considerable progress in reducing its incidence in Ireland in the last decade.

“We recently had a problem in Beaumont Hospital with MRSA in a surgical ward that presented tremendous logistical difficulties,” he said.

“Difficulties like inadequate isolation facilities, problems in closing wards when there are huge pressures coming from the emergency departments and for urgent, particularly vascular, surgery.

“And many of these patients are chronic patients; they have skin wounds, underlining vascular disease. We tried other alternatives to decolonisation without success, so it is a really difficult problem. It lasted a number of months.”

The need for antimicrobial stewardship

Last July, HIQA released a report on antimicrobial stewardship that called for “better co-ordination” to “counter [the] growing superbug threat” in HSE hospitals.

The report found that “while many hospitals have made significant progress to reduce these risks, more needs to be done in hospitals and the community to better protect patients”.

‘‘This review examined how well public acute hospitals implement antimicrobial stewardship best practice,” said Mr Sean Egan, HIQA’s Acting Head of Healthcare Regulation, at the time of the launch of the report.

“We identified that a number of hospitals need urgent support from the national HSE in this area, as they do not have an antimicrobial stewardship programme in place and lack specialised resources.

“This is a significant patient safety concern and should be reviewed as a matter of urgency by the HSE.”

The HIQA report noted that “a small number of hospitals had no antimicrobial stewardship programme in place. This is a significant patient safety concern and is not in compliance with National Standards”. The exact number of hospitals was not given in the report.

Last December, MI reported that four HSE hospitals still did not have antimicrobial stewardship teams in place. Last week, the HSE said it was not in a position to provide updated figures for the number of teams in HSE hospitals and pointed MI towards the various Hospital Groups for more specific information.

The HSE responded to the HIQA report in the summer by saying it “remains fully committed to ensuring that the 2009 HIQA National Standards for Prevention and Control of healthcare-associated infection (HCAI), which includes minimising AMR, are implemented and that all acute public hospitals are in compliance… The HIQA report has acknowledged some of the good work that is already well established to address the ongoing threat of AMR and promote antimicrobial stewardship”.

Government reaction

On the Government’s side, Minister for Health Simon Harris recently highlighted the most up-to-date HPSC figures, which he insists show some progress on AMR. 

“There has been a marked decrease in the rates of MRSA reported for Irish acute hospitals since 2007, both in the number of cases and as a percentage of overall bloodstream infections reported, which have also decreased,” Minister Harris told the Dáil in late September.

In 2007, the HPSC reported 536 cases of MRSA infection from a total of 1,393 overall isolates, representing 38.5 per cent of cases.

In contrast, the Minister said that in 2015, the HPSC reported 199 cases of MRSA infection from a total of 1,082 overall isolates, representing 18.4 per cent of cases.

The Minister also cited provisional HPSC data for the first quarter of this year. The data shows “the downward trend in cases of MRSA infection continuing, with a small increase in overall bloodstream infection rates”, said Minister Harris.

“However, the HPSC cautions that provisional data is subject to change and it cannot be assumed that quarterly data yet to be reported will mirror data as reported in previous quarters.”

Concern about the over-prescription of antibiotics by GPs has been recognised by the HSE and Department of Health in recent years. Again, in this area the Minister has been recently highlighting what he sees as good progress.

“A recent review of antibiotic prescribing via the Primary Care Reimbursement System (PCRS) has shown a reduction in the rate of antibiotic prescribing, particularly among children and young adults who have been the principal target groups of public information campaigns in this area and of the www.undertheweather.ie website,” Minister Harris said in reply to a question from Sinn Féin’s Spokesperson on Health Deputy Louise O’Reilly in September.

“In addition, this review has shown that the pattern of antibiotic prescribing has improved, in line with national primary care antibiotic prescribing guidelines.”

Concern about the over-prescription of antibiotics by GPs has been recognised by the HSE and Department of Health in recent years. Again, in this area the Minister has been recently highlighting what he sees as good progress 

Committee

A new national AMR action plan is currently in development, according to the Department of Health. This plan will cover the use of antimicrobial medicines in animal health and agriculture, as well as for human health.

The plan is being developed by the Interdepartmental AMR Consultative Committee, which is co-chaired by the Chief Medical Officer and the Chief Veterinary Officer of the Department of Agriculture, Food and the Marine.

The Committee was launched on European Antibiotic Awareness Day in November 2014 and consists of representatives of both Departments and of the relevant HSE and veterinary specialist agencies, including other relevant bodies with a remit across the two sectors; membership is representative of major stakeholders.

The Committee meets bi-annually and its most recent meeting took place on 13 April 2016.

There is also an ongoing review and update of the National Clinical Effectiveness Committee (NCEC) National Guidelines on MRSA (2013) and Clostridium difficile (2014) for healthcare professionals, says the Department of Health.

Last year, the HSE established a National Taskforce on AMR following concerns about outbreaks of multi-drug resistant organisms (MDROs) in recent years. The Taskforce’s remit is to direct and co-ordinate an effective system-wide response to the issue of HCAI/AMR.

The group is tasked with addressing the above issue and is drafting an action plan to address issues relating to antimicrobial resistance.

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