Middlemore cases spur call for national plan to combat resistance
By Adrienne Kohler
Microbiologists are urging the Ministry of Health to action a plan to combat the threat of antibacterial-resistant organisms, not just in hospitals but in the entire health system.
The calls come as three patients at Middlemore Hospital add to the growing numbers of cases where patients have infections resistant to carbapenem antibiotics, the powerful group of penicillin-like antibiotics often used as a last resort when other antibiotics have failed.
Canterbury DHB clinical microbiologist Joshua Freeman says the rise of carbapenem-resistant organisms in New Zealand has been a concern for some time because they pose such a major threat to the delivery of healthcare to vulnerable patients.
According to ESR surveillance data, carbapenem-resistant organisms were first reported in New Zealand in 2009. By the end of 2017, the number of reports stood at 54; the latest notifications are the seventh for 2018.
Prior to 2015, New Zealand cases were associated with overseas travel, particularly to India, but in 2017, six of the 53 cases had had no history of travel.
'Clear and present danger'
According to ESR surveillance data, carbapenem-resistant organisms were first reported in New Zealand in 2009. By the end of 2017, the number of reports stood at 54
In April last year, Dr Freeman co-authored a paper in the New Zealand Medical Journal calling for a national response plan to the “clear and present danger” of carbapenem-resistant organisms.
“These are common causes of infections – bugs we see every day in hospitals, but they are resistant to just about everything we know of,” he says.
In the paper, the authors raised concerns that the increasing incidence of carbapenem-resistant organism follows a similar trajectory to the extended-spectrum beta-lactamase-producing Enterobacteriaceae epidemic of the early 2000s, but the consequences for carbapenem resistance are more serious because of far fewer or no treatment options.
Dr Freeman says last year the Ministry of Health published the New Zealand Antimicrobial Resistance Action Plan with a planned implementation timeline of five years.
But he and his co-authors – Matthew Blakiston a microbiology registrar at Auckland DHB; Helen Heffernan, a scientist at the Antibiotic Reference and Nosocomial Infections Laboratories, (ESR); and Sally Roberts a clinical microbiologist at Auckland DHB – are advocating for an overarching plan that covers the entire health system, not just public hospitals.
The ministry did not respond to specific questions from New Zealand Doctor, but the ministry's director of public health Caroline McElnay sent an emailed response saying the ministry is currently working with the health sector to manage carbapenem-resistant organisms and will continue to prioritise existing resources as much as possible.
The clock is ticking
Dr Freeman says New Zealand has a short window of opportunity to prevent the spread of carbapenem-resistant organisms, which would buy time for new interventions and treatments to become available.
“Think of it as a biosecurity threat like agriculture, once it gets in and is endemic, it is really hard to eradicate it. That is why you need systems up front to identify it early,” he says.
“We need to get cracking and the plan needs to be serious and well-resourced. It is a bit like planning for pandemic influenza, it is slower, but it is still the global spread of resistant genes that can cause real harm in our healthcare system.”
The first patient at Middlemore acquired the infection overseas and it was detected during admission screening. Despite infection control measures, a second patient in the burns/ICU care complex was found to be infected with carbapenem-resistant organisms in January, and a third in February, the hospital advised.
The three patients have been placed in isolation and admissions to the unit have been restricted. Options being considered were transferring very serious burns cases, which would normally be treated at Middlemore, to locations in Australia, says Vanessa Thornton, acting chief medical officer.
GPs’ prescribing practices matter
NZMA chair and Warkworth GP Kate Baddock says GPs’ prescribing practises still have a large role to play in preventing increasing antibiotic resistance.
“We are not yet in the situation where every bacterium is resistant to every antibiotic, but that is our future unless we are extremely careful. Not only do doctors have to be extremely thoughtful about what antibiotic we choose and how we use it, but we need people to understand the risk of using antibiotics unnecessarily.”
The growing number of resistant bacteria will affect the ways GPs practise in the future, although, as yet, there are no contingency plans for GPs should carbapenem-resistant organisms become established in New Zealand, Dr Baddock says.