On the edge of the abyss

Dr Esther Robinson 1st March 2016

View from the clinical frontline

Postcard from the edgeInto the VoidBridging the Gap

It all starts with a patient…

Mr S, DOB xx.xx.xxSpecimen type: nephrostomy urineResult: E.coli isolatedCPE isolatedPositive for OXA-48, sent to reference laboratory for confirmation

Clinical questions

• Antibiotic treatment?

• Where did Mr S catch it from?

• Where will it go?

Alphabet soup

CRO

CPE

CRE

MDRO

MDRE

MDREc

ESBL

OXA

KPC

NDM

VIM

IMP

CTX-M

TEM

ROB

SHV

AMPC

Ward screening• Rectal swab PCR:• Index case: CPE OXA-48– 2 OXA-48 (not in same bay), 1 KPC

• None of them are E.coli• What does that mean?

Into the void

Rise of the resistance

2007-8

2008-9

2009-10

2010-11

2011-2

2012-3

2013-4

2014-5

0

10

20

30

40

50

60

70

MRSA bacteraemia rates per 100k populationE coli bacteraemia rate per 100k population

MRSA and E. coli bacteraemia rates E. coli antibiotic resistance

2002 2004 2006 2008 2010 2012 20130

10

20

30

40

50

60

70

80

coamoxamoxciproctxtzpmero

Selection pressure

www.openprescribing.net

Wider perspective

Nightmare bugs

Holding back the tide

• CPE screening: national policy, local variety in implementing (money)

• Infection control measures: failing?

• Stewardship: balancing on the edge of surviving sepsis and reducing antimicrobial use

Bridging the gap 1: teetering on the brink

• How do we use existing antibiotics optimally to retard resistance?

• Can new/ rapid diagnostics improve control of spread/ inform better antimicrobial use?

Bridging the gap 2: beyond the abyss

• New drugs: prevent spread of resistance – Can we cure plasmid in vivo or out-compete it? – Target drugs to site of infection: limit collateral

damage, selection pressure

• New drugs: conventional antibacterials and alternatives