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Wastewater confirms high level of antimicrobial resistance in aged care


Alisha Dorrigan


5/10/2023 4:57:49 PM

More than 90 resistant E. coli isolates were identified from just three facilities, suggesting concerning rates among one of Australia’s most vulnerable groups.

Close-up of hands holding various pills.
Wastewater analysis reveals antimicrobial resistance in aged care facilities

New research published in the Microbiology Spectrum has revealed concerning rates of antimicrobial resistance in Adelaide’s residential aged care facilities.
 
Antimicrobial resistance is considered one of the top threats to global health by the World Health Organization and is largely driven by the antibiotic overuse that leads to bacteria changing over time and no longer responding to previously effective treatments.
 
Lead researcher of the study Associate Professor Rietie Venter from the University of South Australia told newsGP that resistance patterns in aged care facilities represent an important challenge and monitoring emerging resistance has been limited in this setting.
 
‘Given our ageing population, there is a crucial need to regularly monitor these facilities and mitigate the threat of antimicrobial resistance,’ she said. 
 
‘High and sometimes inappropriate antibiotic use has been documented for residential aged care facilities. As a result, these facilities could represent selective environments favouring the development of antimicrobial resistance.’
 
Associate Professor Venter’s team analysed samples of wastewater from three facilities and found unique patterns of antimicrobial resistance in each location, which may be related to whether or not antimicrobial stewardship programs have been implemented.
 
By analysing the wastewater of around 300 residents over an 18-month period, the researchers were able to isolate strains of E. coli and determine phenotypic and genotypic resistance. Following this process, the ‘antimicrobial resistome’ of each water sample was uncovered.
 
The sensitivity of E.coli was identified for multiple antibiotics, including cefepime, ceftazidime, piperacillin-tazobactam, gentamicin, meropenem, trimethoprim-sulfamethoxazole and ciprofloxacin – a total of 93 resistant E. coli isolates were identified in the study.
 
The aged care facility that did not have an antimicrobial stewardship program was found to have higher levels of antimicrobial resistance and a higher prevalence of mobile resistance genes that can potentially be transmitted to other bacteria.
 
‘The results of this study highlight the need for ongoing surveillance of residential aged care facilities when it comes to medication use,’ Associate Professor Venter said.
 
According to the most recent report from Antimicrobial Use and Resistance in Australia Surveillance System, around 10 million people in Australia are prescribed at least one antibiotic every year under the PBS, representing approximately 40% of the population.
 
The report highlights that antimicrobial resistance is projected to lead to more than 10,000 in Australia between 2015 and 2050, and is calling for ‘an urgent re-focusing by all prescribers to align with national and state and territory guidelines for antimicrobial prescribing’.
 
Chair of RACGP Specific Interests Aged Care Dr Anthony Marinucci told newsGP the research findings add to a growing body of evidence related to prescribing patterns.  
 
Dr Marinucci says that prioritising antimicrobial stewardship programs that promote ‘careful and responsible management of medications used to treat or prevent infections’ is key in addressing the issue.
 
‘Successive Aged Care National Antimicrobial Prescribing Survey reports show that antimicrobials are being used in aged care for conditions where they are not required, of inappropriate duration or for prevention of infection, all leading to an increased risk of antimicrobial resistance,’ he said.
 
‘Further, we have evidence that antimicrobial resistance rates are higher in aged care services than in hospitals.
 
‘Antimicrobial stewardship is a multidisciplinary approach to promoting and supporting best practice antimicrobial prescribing [and] should remain a focus for quality improvement in aged care.’
 
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Dr Robert Hoffman   6/10/2023 9:58:37 AM

I have a large nursing home practice. there is a constant use of Full Ward urine tests - "we do them every month", "a carer thought this lady was more confused than usual" or "family requested it.' When probed there is nevi a question such as are there any hard symptoms or a UTI. An MSU usually results, which is usually positive. A locum is called, it night or the weekend and urgent, and an antibiotic has been prescribed.
I and other GP's who work in Aged care are very unhappy as this is the cause of much antibiotic resistance.

Dr Rob Hoffman


Dr Jennifer Jean Brownless   6/10/2023 12:48:26 PM

And how does pharmacist prescribing antibiotics for presumed UTIs fit in?


A.Prof Christopher David Hogan   6/10/2023 1:08:47 PM

I agree completely with Dr Hoffman. Antibiotic stewardship in Aged Care needs a holisitc approach.
The difference between bacteruria & UTI is complex & can often be undermined by locum care staff.
Rapid reagent tests can now be used to differentiate between many viral & bacterial chest infections.
Dry mucus membranes - eye, nose, mouth & oesophagus can affect up to a third of aged care residentsand have significant impact on them.
Dry eye with crusting of the eyelids can often be mistaken for bacterial conjunctivitis. An apparent response to bacterial eye ointment may be purely from lubrication.
The holistic approach would involve a series of lectures for the relatives of the residents and for nurses & all care staff, audits of antibiotic use (often triggered by after hours staff) & brainstorming to reduce inappropriate antibiotic use. It would involve all doctors attending the facility.
I also have an interest in the manipulation of the gut biome.


Dr Robert Hoffman   6/10/2023 1:11:16 PM

I have a large nursing home practice. there is a constant use of Full Ward urine tests - "we do them every month", "a carer thought this lady was more confused than usual" or "family requested it.' When probed there is nevi a question such as are there any hard symptoms or a UTI. An MSU usually results, which is usually positive. A locum is called, it night or the weekend and urgent, and an antibiotic has been prescribed.
I and other GP's who work in Aged care are very unhappy as this is the cause of much antibiotic resistance.

Dr Rob Hoffman


Dr Stephen Bernard Shorey   6/10/2023 4:21:11 PM

Maybe they’re feeding the residents chicken? Or even worse: Turkey at Christmas time. I believe most of the antimicrobial resistance is coming from food rather than doctors inappropriately prescribing in the nursing homes.

BMC Microbiol. 2018; 18: 174.
Published online 2018 Nov 3. doi: 10.1186/s12866-018-1322-5
PMCID: PMC6215666
PMID: 30390618
Antibiotic-resistant Escherichia coli from retail poultry meat with different antibiotic use claims
Gregg S. Davis, et al.
Resistance was detected to the majority (9/12) of antibiotics tested but varied by meat type. Resistance prevalence was highest among E. coli isolated from turkey for nearly all antibiotics tested, with greater than half of all isolates resistant to classes of antibiotics that are routinely used in medicine
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6215666/


Dr Angela Maree Roche   6/10/2023 4:34:28 PM

November 2021 - World Health Organisation has declared Antimicrobial Resistance as one of the top 10 global public health threats facing humanity .
2023 - makes perfect sense for governments to allow pharmacists to hand over antibiotics to customers that self declare that they have a urinary tract infection .