Antibiotic stewardship ‘everyone’s’ responsibility

Matt Woodley

16/09/2019 2:56:42 PM

A prominent GP has said all healthcare workers need to be wary of superbugs, following the first recorded case of extensively drug-resistant typhoid in Australia.

Infant with drug-resistant typhoid
A group of related typhoid organisms has emerged in Pakistan that is resistant to all first-line antibiotic agents. (Image: AAP)

Dr Rashmi Sharma, co-author of the RACGP’s Response to antimicrobial resistance in primary care, told newsGP the case is a warning to practitioners at all levels of the health system.
‘We should be very worried not only as a nation, but I think also as a species,’ she said.
‘We know it’s probably one of the greatest threats we have looming in the foreseeable future. We’re getting more and more resistant bacteria and bugs, and we need to be very judicious in our use of antibiotics and antivirals.’
According to the Medical Journal of Australia (MJA), a 20-month-old Australian-born girl presented to Sydney’s Westmead Hospital in February with features of enteric fever, 14 days after returning from a three-month trip to Pakistan.
Since 2016, an extensively drug-resistant (XDR) group of related typhoid organisms (known as a clade) has emerged in Pakistan that has been reported as resistant to all first-line antibiotic agents.
While there have been seven cases of travellers returning from Pakistan to other countries with XDR-typhoid, Dr Philip Britton, senior lecturer in Child and Adolescent Health at the University of Sydney, believes the Westmead case is the first time it has been found in Australia.
‘Diarrhoea began in Pakistan six weeks before her return and continued despite the use of oral antibiotics prescribed locally in Pakistan. Ten days of high fevers, irritability, vomiting and reduced oral intake prompted admission,’ Dr Britton and his colleagues wrote in MJA.
‘Blood and stool cultures grew extended spectrum β-lactamase-producing Salmonella enterica serovar Typhi [S. Typhi]. The isolate showed microbiological features typical for the XDR clade, with resistance to chloramphenicol, ampicillin, trimethoprim–sulfamethoxazole, fluoroquinolones and third-generation cephalosporins.
‘The child responded to intravenous meropenem and oral azithromycin and was discharged after an uncomplicated eight-day admission to complete a further week of azithromycin.’
The authors also warned that Australia is not immune to the ‘emerging threat’ of XDR typhoid.
‘Typhoid must be considered as a diagnosis for febrile returned travellers from endemic regions, including South and South-East Asia,’ they wrote.
‘Typhoid vaccination is recommended from two years of age if travel is planned to these regions. The important role of GPs in providing travel-related vaccine advice and care to returning travellers must not be underestimated.’

‘We should be very worried not only as a nation, but I think also as a species,’ Dr Rashmi Sharma said of antimicrobial resistance.

Dr Sharma said there are a number of resources GPs can access related to antimicrobial resistance and travel medicine, including the RACGP’s Therapeutic Guidelines, as well as other material embedded into medical software.
‘The other point I would make is, if in doubt, ask. There are many public health facilities … that are able to guide GPs to the latest advice and the latest recommendations,’ she said.
‘Often I’ll leave that sort of thing up to my practice nurses to find out for me … [it’s important because] sometimes you get people, and not only are they going to a country where they have to be careful, but they have their own specific nuances, such as they may be on a biological DMARD [disease-modifying anti-rheumatic drug], or have some autoimmune disorder.
‘Vaccinations are really quite complex now, because of all these comorbidities and drugs that we’re using. So that’s when practice nurses … should follow up and do that legwork to assist in making sure you have the right recommendations.’
Potential early warning system
The emerging threat posed by antibiotic-resistant organisms such as XDR-typhoid has led Australian researchers to try and establish an early warning system using Whole Genome Sequencing (WGS).
The joint project among the Australian National University, the University of Melbourne and Monash University utilised routine data collected by Public Health England (PHE) to gain insights into the genomics of S. Typhi, as well as the number of infections globally.
‘Routine genomic surveillance of pathogens from travellers who have acquired their infection abroad allows us to gain insight into what strains are circulating in different parts of the world,’ PHE’s Dr Tim Dallman said.
‘This provides an early warning system against emerging threats, including those posed by antimicrobial-resistant organisms. Our technology can also play an important role for source tracking future outbreaks in foreign countries, helping to guide public health advice for travellers.’
Overall, nearly one quarter of the 533 isolates collected during the study were multidrug resistant S. Typhi, associated with travel to 10 countries in South Asia, East Africa and West Africa.
The researchers were also able to identify a number of trends showing which genotypes and drug-resistance patterns were present in certain countries around the world, including the first case of drug-resistant S. Typhi in England.
Monash University’s Professor Kathryn Holt described the research outcomes as exciting.
‘This study shows the data now being generated routinely by PHE and other public health laboratories could serve as sentinel genomic surveillance for typhoid-endemic countries that currently lack formal local surveillance programs,’ she said.
‘[It also] provid[es] valuable information on the strains and antimicrobial resistance that could help local disease management.’

antibiotics antimicrobial resistance drug resistant typhoid

newsGP weekly poll Would you be willing to provide a firearms health assessment for your patient?


Login to comment

Thinus van Rensburg   17/09/2019 6:46:23 AM

The focus is on primary care but our hospitals are just as much to blame. Our local hospitals are fond of sending out patients with chest infections on Augmentin, Doxycycline, Prednisolone and Tamiflu. Despite all cultures and viral screens being negative.
A child presenting with otitis media to an emergency department never leaves without antibiotics.
And what about theatre. Orthopods just about drown their patients in IV Cephalosporins and some even pour antibiotic powders into the wounds before closing.

And this is in Canberra

Confused   17/09/2019 10:51:09 AM

Isn't azithromycin the first line therapy anyway? TG says "Typhoid and paratyphoid fevers are almost always acquired outside Australia." So our local alleged "drowning patients in antibiotics" hasn't caused this problem, has it?! And this info is present on TG since ages "Resistance to amoxicillin, chloramphenicol and trimethoprim+sulfamethoxazole has limited the options for treatment. Reduced susceptibility to quinolones is common in infections acquired on the Indian subcontinent and in Southeast Asia. While awaiting susceptibility results, azithromycin or ceftriaxone should be used for initial therapy for infections acquired in these regions."
Just confused whats new and why sensationalise now?!!
Thought newsGP would be different than mainstream media!

HANNAH GEORGIA-PRICE   17/09/2019 5:36:26 PM

We need to apply this message to every doctor's day to day practice but this is not what I am seeing on the ground. We need to get this message filtered down into actual practice. The only way I can see this happening is making a mandatory RACGP module as part of the CPD triennium requirements.

Nima Patel   18/09/2019 2:57:30 PM

You can make as many modules mandatory as you like and increase the timestrapped GP's workload with more paperwork which will make him write more scripts of antibiotics and send the patient home with his 5 minute medical care .The responsibity lies with all doctors and now pharmacists that prescribe antibiotics .Some GPs and pharmacists are either giving in to pressure from patients or dont have the time to explain the reasons for not prescribing or are just practicing defensive medicines or in case of pharmacist ,making money as saline wash is too cheap . I tell patients,I could have seen 3 more patients by now but this is important for you to understand why I am not prescribing antibiotics . Today I saw a patient who went to a medical centre and got "Keflex "for viral sounding laryngitis and chlorsig for a viral conjuctivitis dished out otc by the chemist !!!. It just annoys me to see this happening in Australia -We are not third world doctors !!

A.Prof John William Kramer   19/09/2019 6:26:58 PM

I'm still waiting for someone to acknowledge the massive use of antibiotics in veterinary and agricultural practice. Take a walk through most dairies and see what's there to tyreat mastitis in cows.

Graeme Banks   22/09/2019 7:34:08 AM

Prof Kramer is dead right. You could also add fish farms, feed lots and chicken farms to the mega antibiotic users. Stop sinking the boot into the doctors. Where is the AMA and the RACGP when you need them to stand up? Missing in action again.782002