I heard an interesting talk by Dr Michael Miller last week on the ethics of screening for MDROs. Whilst we need to think carefully about the ethics of all medical procedures (great and small), I think the benefits to the individual and the population generally outweigh downsides for MDRO screening programmes.
Many guidelines now recommend screening some patients on admission for carriage of CPE. However, very few cost-effectiveness analyses have been performed. A Canadian group have just published a modelling study with a tantalising conclusion: universal admission screening for CPE is likely to be cost-effective, and may even be cost-saving!
The Journal of Infectious Diseases has just published a special issue on norovirus, which is well worth reading. When norovirus strikes, there is an inclination to close the ward to new admissions at the earliest available opportunity in order to protect incoming patients. But when should the ward closure trigger be pulled? Not at all, as recommended by latest UK guidelines (risking continuation of the outbreak, fed by a steady stream of new victims…I mean admissions), when you get a single case of vomiting or diarrhoea (lots of unnecessary ward closure) or only when you have a lab confirmed outbreak on your hands (by which time the horse has already bolted and galloped through your hospital). The special issue included a useful modelling study providing some idea of the impact of various approaches to ward closure in response to noro outbreaks.
Shortly after the PHE Toolkit was published, I blogged some crude sums to size the burden of CRE admission screening a la Toolkit. I’m pleased to report that colleagues at Imperial have done a much better job of this, published in a letter in the Journal of Infection. The study provides some evidence that the recommendation in the PHE CRE Toolkit to perform pre-emptive isolation of suspected carriers whilst obtaining three negative screens is simply not feasible. The team then compare an alternate strategy – of applying the Tookit triggers to admissions to high risk specialties only (intensive care, nephrology, cardiothoracic surgery, neurosurgery and oncology).
As effective therapy using antibiotics becomes increasingly difficult due to resistance, the emphasis must move from cure to prevention of bacterial infection. There is an urgent need to take internationally coordinated action to curb the further development of antibiotic resistance. The steps required are complex and will require engagement on a national and international level. So, it’s encouraging to see antibiotic resistance on the G8 agenda. Here’s eight solutions that have been discussed by G8 summit science ministers:
- Get antibiotic resistance on the agenda. The fact that the issue is being discussed at all demonstrates that the problem is being recognized. The recent rhetoric from Dame Sally Davies (“antibiotic resistance as big a risk as terrorism”) and the US CDC (“deadly, untreatable superbugs”) will help.
- Reduce overuse (abuse) of antibiotics in medical, veterinary and other applications. Antibiotics simply should not be used to fatten up animals and stop barnacles attaching to ship hulls!
- Restrict the availability of antibiotics where they are currently available over the counter. According to Dame Sally Davies, 83% of Russian families use antibiotics inappropriately at home.
- Stimulate the discovery of new antibiotics, and streamline the testing and approvals required to bring a new antibiotic to market. Drugs are expensive to discover and then bring to market. Pharmaceutical companies are not currently focused on developing new antibiotics and need to be incentivized.
- Improve and share surveillance efforts. National and international surveillance systems should be established for emerging resistant strains.
- Highlight the financial burden of antibiotic resistance ($21bn-$34bn a year in the US, £10bn a year in the UK).
- Stop selling antibiotics at the cost of Smarties. Otherwise they will be consumed like Smarties. Generic antibiotics can be very cheap indeed; increasing the price of generic antibiotics will provide a financial barrier to inappropriate over-the-counter use.
- Develop rapid diagnostics to reduce the universal or empiric use of inappropriate / ineffective agents. This does not sit well with the proposed universal use of antibiotics.
There’s no simple solution to the problem of increasing antibiotic resistance. The problem is long-standing, multi-factorial and global. However, international collaboration can make real progress is curbing the increase in antibiotic resistance rates and perhaps even begin to reverse the trend.