Tackling healthcare infection challenges

Our ability to deliver good patient outcomes for modern healthcare interventions and treatments rely on the availability of effective antimicrobials. Scarcity of new agents from the antimicrobial pipeline compounds the acuteness of the situation. A choice of antimicrobials still remain for Gram positive organisms but the options available for Gram negative pathogens in some instances is becoming very limited. In Enterobacteriaceae, the earlier emergence of TEM enzymes, followed by the expansion of extended spectrum beta-lactamases removed whole classes of antimicrobial from the therapeutic armoury. During this period some Enterobacteriaceae also possessed determinants conferring resistance for quinolones and aminoglycosides rendering the pathogens multi-resistant. Now, the recent emergence of carbapenemases removes these agents from the therapeutic options available for the infected patient. Judging by past performance, sporadic geographically localised emergence or clonal global spread is inevitable. In the past, this has been seen in the widespread occurrence of pathogens possessing Extended Spectrum Beta- Lactamases (ESBLs). There is no reason why carbapenemase resistance should be different. There are already signs of this from the proliferation of Klebsiella pneumoniae carbapenemase in the US and Israel, Greece and Italy. However, the problem is much larger, with the development of multiple mechanisms conferring carbapenem resistance and across enterobacteriaceae and non-enterobacteriaceae (such as Pseudomonas sp. and Acinetobacter sp.) Some carbapenem resistance is chromosomally mediated but more worryingly resistance carried by mobile genetic elements has the potential to spread across species. Colistin resistance is already being seen in some organisms. The difference between some diseases (diabetes/hypertension/cancers) affecting the individual and infections is that the latter have the potential to spread to others. This spread may result in outbreaks affecting many people. Spread may occur in the acute as well as the community healthcare facilities. If we reflect upon the opportunities and failures from the past, single interventions will not be sufficient to limit spread nor control proliferation. Multiple approaches and strategies will be an essential prerequisite. If we are to learn lessons from the past then an early, coordinated, national approach to reduce the pace of spread is critical. Although not exhaustive, a number of the following are a useful start:

• Sustained compliance with best infection control practice.
• Surveillance to monitor the extent of the problem.
• Communication between healthcare facilities and sharing information.
• Adequate cleaning to destroy the reservoirs.
• Good personal hygiene to prevent acquisition.
• A strategy of enhanced antimicrobial stewardship combined with prudent antibiotic prescribing.
• Public and professional awareness and cooperation.
• Partnership working with industry/development of new antibiotics/global fund/incentives.
• Enhanced infection control in healthcare facilities and care facilities.
• A community strategy.
• Treatment in healthcare facilities abroad may lead to acquisition.
• Each acute health facility should have an action plan or policy on how to manage potential cases to prevent spread.

There is an ideal opportunity at present to put control measures in place to prevent these organisms becoming endemic in our care facilities. Everyone (clinicians, nurses, GPs, patients/public and Government) must play their part; it is everyone’s responsibility to reduce the spread of resistant pathogens. Symposia like those organised by Govtoday will help raise awareness of the problem.