The faces of antibiotic resistance

IDSA published 13 Faces of Antimicrobial Resistance to highlight the consequences of AMR for individual patients. The report illustrates the grim future of bacterial infections. In each of the 13 cases I asked myself whether this could happen in an “AMR-virgin country” (the Netherlands), and whether likelihood of that infection had increased in the last 10 years (as in a crisis)? 

Surprisingly (or not), at least 7 (and may be 12) infections were community-acquired. Three were caused by CA-MRSA, most probably USA300; CAP in an adult, otitis needing ambulatory IV-treatment in a 30 month old child and the heartbreaking story of a 15 month old boy rapidly developing fatal septic shock with the killer idenitified at autopsy. CA-MRSA has never really kicked-off in the Netherlands (it did in pigs, but not in humans), as it did in American cities. I have always wondered why. Recent work from Kyle Popovich in Chicago demonstrated that community spread among those “more likely to be African American, to be human immunodeficiency virus-infected, to reside in high detainee release areas, and to be current users of illicit drugs”. Few such areas in our country, I think.

Three cases were C. difficile infection (CDI), although resistance was not obvious in any case. A senior woman developed – after 1 day clindamycin for a root canal procedure – CDI, with rapid progress to  fatal abdominal septic shock. A man had CDI 1 wk after orthopedic surgery and a woman “rapidly” (days, I guess) had it after colorectal surgery for diverticulitis. She had multiple recurrences, only treated succesfully with Fecal Microbiota Transplantation. Again, the Dutch CDI epidemiology never mimicked the North-American situation. As our borders do not protect us from nasty strains, it may be less antibiotics and/or better infection control.

One woman contracted MRSA while hospitalized after a car accident in 1999. Seven years later she had lymphoma and recurrent episodes of ‘encapsulated’ MRSA infections, difficult to treat due to allergies for many antibiotics. Eventually, she was diagnosed with Common Variable Immune Deficiency, that may well explain the MRSA recurrences. Low risk of contracting MRSA in Dutch hospitals, but we do see CVID patients with difficult-to-treat chronic non-AMR infections.

A young guy, contracted MDR-TB. Not 100% impossible, but extremely rare in the Netherlands.

The remaining 5 faces could have been Dutch. Three had P. aeruginosa lung infection; a man got it after 3 weeks in ICU following cardiac arrest just before surgery for aortic aneurysm, that turned into chronic infection treated with oral ciprofloxacin (sounds susceptible to me); the second had HAP after lung surgery for cancer, eventually cured with ceftolozane/tazobactam. The third (very sad) story was an adolescent with Acute Myeloid Leukemia  and multiple infections, including P. aeruginosa for which colistine was “prepared” (not clear if given). Sadly, lung problems persisted after succesfull Bone Marrow Transplant, and she succumbed in septic shock and cardiac arrest during a trachotomy procedure.  Similar sad stories exist in our country, where repeated exposure of P. aeruginosa to antibiotics also leads to cumulative – sometimes pan – resistance.

A young adult had ESBL-producing E. coli appendicular abscess. With 5% carriage of these bacteria in the Dutch population; also possible here. And the last patient had Cystic Fibrosis and chronic Mycobacterium  abscessus infection. Not uncommon, and surprised to see this face included.

Do these faces illustrate the crisis of antibiotic resistance? Only partly, I’m afraid. The true crisis is not CA-MRSA and CDI (I don’t think incidences are still rapidly increasing), is not ESBL-producing E. coli, is not pan-resistant P. aeruginosa, atypical mycobacteria or recurrent MRSA in patients with severe underlying diseases and long treatment histories (those have been around for many years). The faces of AMR will be the same as we see on television now. The poorest parts of the world will pay the price. With ESBL carriage rates as high as 50% among children hospitalized in Zimbabwe (personal note Alexander Aiken, and many similar data from Africa), it will be a matter of years for those strains to produce carbapenamases. The new antibiotics that will (inevitably) come forward from recent and future investments will be expensive and will help us treat the next infectious complication in patients already benefiting from the achievements of modern medicine. Yet, will these antibiotics will be available in lower-income countries? That, and XDR-TB, will depict the faces of AMR. Hope Bill Gates stays around for a while.

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