Antimicrobial resistance – a global challenge

This was a great session looking at the emerging and now obvious problem of antibiotic resistance.  Melvyn Mer opened with an overview of the problem:

Health professionals are afraid NOT to prescribe antibiotics and this is a major (but not the only) factor driving resistance across the world.  Despite international and national initiatives (such as the Anti Microbial Resistance review from the UK prime minister ) the problem is growing…

The organisms that are involved have changed over the last few years, with the pattern moving from gram positives to gram negatives – that being said MRSA and VRE are still a problem.  However the emergence of extended-spectrum Beta-lactamases (ESBLs) in Klebsiella, E Coli and Proteus along with beta-lactamase resistance among Enterobacters and Citrobacters, AND multi drug resistance in Pseudomonas aeruginosa, Acinetobacter spp., and Stenotrophomonas maltophilia becoming more common sets a scene where we ALL have a responsibility to think about antibiotics.  ICU of course tends to gather a lot of these together – the EPIC studies tell us that half the pts on ICU are infected at any one time.

This (open access) paper from the Annals of Intensive Care is worth a read to get a good overview.

Another takeaway from Melvyn Mers talk (apart from his inspirational quotes and singing!) was the spread of resistant fungals around the world.  An azole resistant candida, previously confined to the southern hemisphere, has now been isolated in the UK and an ICU somewhere in England has been fighting an outbreak of it over the last year (This alert from Public Health England from July this year is worth a read as are their guidelines on treating it).

How can we do anything about this? Well there a number of things.  Mer thought we (as a speciality) need to have clear guidelines to support health professionals NOT giving antibiotics, that there needs to be a push to address the agricultural sector (60% of worldwide antibiotics are used in animals) and, perhaps most relevant, was his plea to “get your own house in order”.  Start small…

There followed a talk from Matteo Bassetti showing the link between MDR infection with mortality – and unsurprisingly perhaps, there is a link.

Also the DALI study was mentioned – a really important ESICM study from Jason Roberts et al which not only said that ICU patients more often than not have inappropriate dosing regimens and antibiotic levels, but linked that with a poor outcome.  Worth a look: open access PDF of DALI trial

One of the solutions may well be tailoring / personalising antibiotics to the individual, including combination therapy, e.g.:

Otherwise, Dr Bassettis summary was this:

Finally in this session we heard about an initially French but now global initiative to help combat antibiotic resistance the – the world alliance against antimicrobial resistance (you can read about it here).  Overall it is one important part of the fightback that aims to bring in professionals from across the animal and human medicine spectrum and take action on antibiotic resistance.