Antibiotic resistance still poses substantial risk despite fall in antibiotic use, report finds

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The most comprehensive report produced on Australian antimicrobial use and resistance trends has found that antimicrobial use in the community is falling, but they continue to be overprescribed, while some dangerous bacteria are growing increasingly resistant to common antibiotics.

Neisseria gonorrhoeae are among several organisms becoming increasingly resistant

The third annual surveillance report Antimicrobial Use and Resistance in Australia 2019: Third Australian report on antimicrobial use and resistance in human health (AURA 2019)  from the Australian Commission on Safety and Quality in Healthcare warned that antibiotic resistance showed little sign of diminishing — and posed an ongoing and "substantial" risk to patient safety.

The report warns that antimicrobial resistance shows little sign of abating and poses an ongoing risk to patient safety, with common pathogens such as E. coli, Salmonella, Neisseria gonorrhoeae and Neisseria meningitidis becoming increasingly resistant to major drug classes, and some organisms resistant to last-resort treatments.

Antimicrobial resistance is driven by the overuse and misuse of antibiotics. Encouragingly, AURA 2019 found that overall use of antibiotics in the community fell between 2015 and 2017 – the first decline in 20 years. This suggests ongoing and coordinated campaigns targeting GPs and consumers on the risks of using antibiotics inappropriately are beginning to cut through. The report found that in 2017, more than 10 million Australians had a least one antibiotic dispensed in the community and more than 26.5 million prescriptions for antimicrobials were dispensed.

“While the downward shift in prescribing will help to slow the spread of resistance, these latest AURA findings indicate that the levels of inappropriate prescribing of antibiotics in hospitals and the community are still too high and there is more work to be done,” said Dr Kathryn Daveson, the AURA Clinical Director.

“AURA 2019 also identifies focus areas that need increased attention – including reducing inappropriate prescribing of broad spectrum antibiotics, particularly for urinary tract and skin infections; and improving the appropriateness of antibiotic prescribing for chronic obstructive pulmonary disease and other respiratory infections,” Dr Daveson said.

Despite these gains, almost half the samples of enterococci tested across Australia were resistant to the antibiotic vancomycin – a level higher than seen in any European country. AURA 2019 also found that community-associated methicillin-resistant Staphylococcus aureus (MRSA) has become the most common type of MRSA infection, particularly in aged care homes and remote regions.

More work is needed to reduce the inappropriate use of antibiotics, particularly in aged care homes and hospitals, according to John Turnidge, senior medical advisor at AURA. “Australians are still very high users of antibiotics - and we've got a long way to go to catch up to countries like the Netherlands, which we consider the benchmark," he said.

Resistance rises in community

Of particular concern, Professor Turnidge said, is drug-resistant Staphylococcus aureus — better known as golden staph. The common bacterium, which lives on people's skin and is mostly harmless, can cause a range of mild to severe infections, including meningitis and pneumonia.

"Everybody thinks of drug-resistant golden staph as a hospital problem. But now it's flipped on its head; it's actually a community problem," Professor Turnidge said.

The report found that although drug-resistant strains of golden staph had dropped in hospitals, they had increased elsewhere, particularly in aged care homes and remote regions. "We've still got a number of antibiotics that we can use. But we know from experience that through the passage of time, resistant bugs pick up even more resistance," he said.

Professor Turnidge added that E. coli, the most common cause of urinary tract infections (UTIs), was also becoming "slowly resistant" to antibiotics, including to some reserve drugs. "We don't want to end up in the situation where somebody with a common infection has to go to hospital to get intravenous antibiotics because there's nothing available in the community," he said.

But Dr Trent Yarwood, an infectious diseases physician and director of the Queensland Antimicrobial Stewardship Program, said that was already happening. "Everybody who works in infection has seen patients who have needed to be admitted to hospital or put on an intravenous antibiotic because there were no tablets available to treat those UTIs," Dr Yarwood said. "It used to be that if you picked up one of those germs, it was likely from hospital. But we're seeing a lot more of these come in from the community now."

Professor Turnidge said if the rise in antibiotic resistance continued to increase in the community, hospitals would come under further pressure to take care of people when pharmacy medications failed. "It's not people dropping dead that's the big problem; it's people not being able to be treated in the community anymore."

Containing resistance is crucial

In addition to ensuring antibiotics are only given to people who absolutely need them, Professor Turnidge said good hygiene practices would continue to go a long way in containing the spread of antibiotic resistance. "Hand washing is still very important to reduce risk of transmission of bugs, and therefore superbugs, from one person to another," he said.

According to the OECD, an average of 290 people die in Australia each year as a result of infections from eight drug-resistant bacteria.

Dr Yarwood stressed that efforts to contain the spread of antibiotic resistance were critical to modern medical care. "People don't realise just how much of hospital care really revolves around antibiotics. There's this perception that we can just use a new antibiotic or a different antibiotic — that the drug companies will just sort it out," he said.

But Dr Yarwood said there wasn't as much antibiotic development happening as people thought, despite global need for new drugs. "We don't have a lot of extra options up our sleeve, which is why it's really important that we preserve the antibiotics that we do have, and make sure they're effective as long possible."