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HPA recommendations
The Health Protection
Agency recommends that:
· GPs, admitting hospital physicians and junior medical staff
should be provided with local updates of microbial resistance patterns,
and NHS trusts should inform consultants in communicable disease
control if serious infections with extended-spectrum beta-lactamase
(ESBL)-producing Escherichia coli occur in hospital or in the community
· There should be improved guidance for GPs on the submission of
urinary specimens to laboratories — especially where ESBL
producers are prevalent locally
· Surveillance should be extended to include urinary tract infections
in the community to gain a better understanding of the problem
· All diagnostic laboratories should be able to recognise ESBL-producers
· Laboratories test a wider, standardised range of antibiotics
so that emerging resistance is detected earlier
· The level of person-to-person spread of the disorder within the
community and hospitals is assessed more effectively
· Since the food chain is a possible source of ESBL-producing E
coli, collaboration with the Department for Environment, Food and
Rural Affairs, the Veterinary Laboratories Agency and the Food
Standards Agency is needed
· Priorities for research and development include a further definition
of the risk factors for infection with ESBL-producers; a definition
of the extent of community-acquired infection with ESBL; a definition
of the extent of gut carriage of ESBL-producers in the normal population
and of transmission between individuals; a definition of attributable
mortality in relation to therapy received and, lastly, a definition
of the efficacy of infection control measures and molecular investigation
of the uro-pathogenicity traits among successful ESBL-producing
E coli strains |
Infection control specialists have called on GPs and other community
health care professionals to be more vigilant against new and highly
infectious strains of extended-spectrum beta-lactamase (ESBL) Escherichia
coli, now regarded as a serious threat to public health in many parts
of the UK.
Although ESBL-producing pathogens were first recognised in the 1980s,
new CTX-M strains can produce a particular type of ESBL that are able
to break down a wider range of antibiotics. They are now causing an alarming
increase in the incidence of
both hospital and community infections in the UK, typically, urinary
tract infections (UTIs).
The Health Protection Agency (HPA) says that CTX-M beta-lactamases have
spread extensively in E coli in a short time, and are exceptionally resistant
to conventional antibiotics such as cephalosporins, penicillins, fluoroquinolones,
trimethoprim and tetracycline, leaving few options for oral antibiotic
protection in primary care.
There is evidence that ESBL-producing bacteria are carried in faeces,
which may imply a spread via the food chain producing a reservoir of
multiresistant bacteria in the gut that can cause UTIs in vulnerable
patients.
According to a recent HPA report, “Investigations into multi-drug
resistant ESBL-producing Escherichia coli strains causing infections
in England”, there has been a year-on-year increase in the incidence
of ESBL-producing E coli infections: the number of ESBL-related bacteraemias
has more than doubled in the past decade from 8,640 in 1994 to 17,416
in 2004.
The percentage of bacteraemias that are multiresistant to antibiotics
and therefore likely to be ESBL-associated was 2 per cent in 2001, 3
per cent in 2002 and 4 per cent in 2003.
One of the UK’s leading communicable disease experts, Peter Hawkey,
professor of public health bacteriology, University of Birmingham, is
becoming increasingly concerned at the emerging threat posed by ESBL-associated
infection.
Professor Hawkey told health care professionals at a recent Federation
of Infection Societies’ scientific meeting: “Clinicians must
be more alert to the fact that ESBLs are causing increasing cross-infection
between hospitals and the community. We could be on the verge of a new
superbug — but this time coming not just from hospitals but also
spread from within the community.”
David Livermore, director of the HPA antimicrobial resistance monitoring
and reference laboratory, says that inappropriate antibiotic prescribing
may be contributing to the emerging problem with ESBLs. He commented: “It
is important that antibiotics are only used when necessary, in the right
dose and for the correct duration.”
Georgia Duckworth, director of the HPA department of healthcare-associated
infections, said: “The majority of ESBL-producing E coli infections
seen are sporadic cases, both in the community and in hospitals and this
highlights the fact that E coli bacteria causing these infections are
generally becoming more resistant to antibiotics.”
She added: “Currently, there is no comprehensive surveillance of
UTIs in the community, so there is no reliable estimate of the number
of infections caused by ESBL-producing E coli strains in the community.”
Dr Duckworth stressed: “Most of the infections have been in elderly
people who are already sick with other underlying medical conditions,
or other vulnerable patients. It occurs mainly in those who have been
taking antibiotics or who have been in hospital
previously.”
Concern over these emerging strains of resistant gram-negative bacilli
have been echoed by two leading hospital pharmacists.
Jonathan Cooke, clinical director of pharmacy and medicines management,
and director of research and development at Wythenshawe Hospital, Manchester,
said: “Certainly, we are aware of a potential threat. The problems
of these so called potential superbugs should not be taken lightly. We
need to change our behaviour towards the prescription of antibiotics.
We are all carrying around millions of bugs in our guts and clinicians
should be aware of changing patterns.”
He emphasised: “Antibiotics should only be prescribed in short
courses and there should be better control of infection
policies.”
Matthew Lowery, senior clinical pharmacist in the department of microbiology
at the Freeman Hospital in Newcastle upon Tyne, said: “We need
to raise awareness about this threat. It’s not a matter of ‘if’;
it’s a matter of ‘when’ an outbreak will occur.”
He added: “There must be an overhaul of the rational use of antibiotics
and there needs to be a central mechanism put in place to alert relevant
personnel to information and case notes between hospitals and the community
updated regularly.”
The HPA is attempting to respond to the threat and has advised that primary
health care professionals and other front line clinicians should be made
more aware that the nature of this common bacterial menace is changing
and that therapy needs to change in line with that threat.
Commenting on the situation, Pat Troop, chief executive of the HPA, said: “This
is the first report of its kind. Since the agency identified the resistance
in this bug, our scientists have been working with laboratories to enable
better diagnoses of the infections it causes. They provide advice to
those investigating outbreaks, carry out surveys to establish the extent
of the problem and advise on appropriate treatment.”
Professor Troop added: “Our report on antimicrobial resistance
looks at the inevitability of antibiotic and antiviral resistance and
how this can be best managed. The use of antibiotics by both the medical
and veterinary professions is one contribution to the appearance of new
antibiotic-resistant bacteria in the community and in hospitals. It is
important that antibiotics are only used when necessary, in the right
dose and for the correct duration.”
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The
Pharmaceutical Journal