Firmer regulations on antibiotics need to be in place

  • Nation
  • Sunday, 09 Dec 2018

KUALA LUMPUR: It all started with a difficulty in urinating, the result of an enlarged prostate blocking the urine flow.

The doctor gave the patient, who was in his mid 60s, medication (alpha blockers) to ease the urine flow and subsequently stop the use of the urinary catheter.

But after a month, he still could not urinate and was told that a surgical procedure was needed to remove part of his prostate.

The doctor told him that the surgery would be deemed high risk because he was a smoker and suffered from ischaemic heart disease and chronic obstructive pulmonary disease.

But if he declined surgery, he would require prolonged use of the urinary catheter and this would expose him to recurrent urinary tract infection (UTI).

He was also told that the UTI would require the use of multiple antibiotics which might lead to the development of multi-drug resistant (MDR) organisms. This is where antibiotics resistance occurs as they no longer work because bacteria have become resistant to them.

The patient chose not to go for the surgery.

A few weeks later, the patient noticed turbid urine in his urinary catheter. He was admitted to hospital for UTI. A culture test showed E. coli infection.

His catheter was changed and he was given a course of simple antibiotics to treat the infection. The patient was again advised to go for the prostate resection but he declined.

Two months later, after three courses of different antibiotics and catheter changes due to recurrent UTI, he started having fever and pus was coming out of his urinary catheter.

He was admitted into hospital and his urine was tested and found to have carbapenem-resistant Enterobac­teriaceae (CRE), a multidrug-resistant organism or simply known as a superbug.

He was put on the toxic Polymyxin antibiotics but the patient did not respond to the last line of drug treatment and died of sepsis from his UTI a week after admission.

Recently, The Star reported that figures from the Health Ministry showed that deaths from CRE went up from 15 in 2013 to 150 last year.

Hospital Kuala Lumpur infectious disease physician Dr Leong Chee Loon said doctors need to pay attention to two important things that could prevent the development of antimicrobial resistance (AMR).

First, they need to identify the source of infection and remove it.

Sometimes, surgery is needed if the infection is not responding to antibiotics, especially if the infection is huge such as liver abscess or renal abscess which are multiloculated and unable to drain adequately without surgical intervention, he said.

“If doctors do not remove the source of infection and keep giving antibiotics, it will lead to AMR.”

Dr Leong also said doctors must give accurate diagnosis and treatment to patients as fast as possible, which may require multidisciplinary collaborations, otherwise failed treatments could prolong hospital stay and expose patients to higher risk of infection from the use of invasive procedures.

“If patients get a multi-drug resistant bacteria, they could die quickly for the lack of drugs to treat,” he said.

Those prone to superbugs are patients who require prolonged hospitalisation, use of mechanical ventilation and intravenous central line, and prolonged urinary catheterisation or urinary stenting.

Health Ministry’s infectious disease national head Datuk Dr Christopher Lee cited another AMR fatal case.

A 67-year-old woman admitted for an elective spinal operation later developed surgical site infection after surgery.

She required intensive rehabilitation, nursing care and prolonged antibiotics to cure the infection.

She was ready to be discharged but developed blood stream infection from the intravenous line that was previously inserted to administer antibiotics.

The infection was due to CRE and she was treated with colistin, a powerful antibiotic used as a last resort to treat infections when other medicines do not work.

But due to the aggressive nature of the infection, she succumbed to the disease.

Dr Lee said to reduce the rising incidence in drug resistant infections, strong antibiotic stewardship programmes and infection control have to be implemented to minimise its unnecessary or inappropriate use.

“We also advocate using more targeted antibiotic choice (narrow spectrum) and less broad spectrum antibiotics, which tends to drive more resistance,” he said, adding that the spread of infections in the clinical setting needed to be minimised too.

Universiti Malaya Medical Centre head of Infection Control Assoc Prof Dr P. Sasheela said more comprehensive surveillance needed to be done.

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