Winning Against Multi-Drug Resistant Pseudomonas

Not healing from wound or disease that should have been easy to cure is a serious challenge for both the physician and the patient. When antibiotics fail to work against simple infections, it brings us to the post antibiotic era which is a time when a number of infectious diseases cause prolonged suffering, death, and even lead to fatal outbreaks. This is the healthcare problem posed by a phenomenon characterized by drugs’ lessening efficacy known as antimicrobial resistance (AMR) where infectious microorganisms previously susceptible and responsive to a certain treatment become resistant to it.

According to the World Health Organization, resistant infections currently claim at least 50,000 lives annually across Europe and in the United States. Its data also indicated that in the Philippines, over 14,000 cases of drug resistant infections were detected in 2015, and by 2050, AMR could lead to 10 million deaths every year.

AMR is largely & often caused by misuse or abuse of antimicrobial drugs, and it can also be acquired through other factors such as extended hospital stays because of patients’ increased exposure to resistant pathogens.

This threat of AMR has continued to grow in the Philippines particularly with the burden caused by multi-drug resistant (MDR) bacteria Pseudomonas aeruginosa, which the WHO highlights as critical priority pathogen. Elderly patients, people being treated with antibiotics, diabetics, residents of healthcare facilities, and those with previous histories of infection are especially in danger of acquiring the deadly MDR pathogen.

In a media forum entitled, “Fighting Multi-Drug Resistant Infections” held at the Manila Diamond Hotel, Dr. Adrian Brink, Clinical Microbiologist of Ampath National Laboratory Services in Milpark Hospital, Johannesburg, South Africa, discussed the risks and implications caused by Pseudomonas.

Dr. Brink explained that Pseudomonas is an opportunistic pathogen that causes a wide range of infections. It is the leading cause of pneumonia, the third top cause or urinary tract infections, the eight leading contributor to bloodstream infections, and is usually responsible for acute and chronic infections in burn or immunocompromised patients.

Multi-drug resistance in Pseudomonas is common. In fact, it is becoming increasingly resistant to carbapenems which are often referred to as “antibiotics of last resort”. The Philippines, being a country in Southeast Asia, is in more of a threat to carbapanem-resistant Pseudomonas given that the prevalence in the region is from 31 to 50 percent. This number is significantly higher versus the Americas, Europe and Western Pacific, which tallies 16 to 30 percent, based on a WHO report on 1Prioritization of Pathogens.

MDR Pseudomonas causes more death and has the shortest time to mortality than most pathogens. To give an example, there are 51,000 Pseudomonas aeruginosa infections per year, about 6,700 of which are MDR Pseudomonas infections which cause around 440 deaths in the United States. Hence, controlling the spread of this organism is crucial, according to Dr. Brink.

In the country, 6,114 Pseudomonas isolates were identified, which were most commonly from respiratory, wound, urine, tissue and blood specimens, based from the Department of Health’s (DOH) Antimicrobial Resistance Surveillance Program (ARSP)’s 2016 Data Summary Report.

Just last year, three victims of a Cavite factory fire experienced the devastating effects of the MDR pathogen firsthand as they suffered severe burns in their body. They had their injuries aggravated with Pseudomonas infection and were discharged only after a novel anti-Pseudomonas cephalosporin, ceftolozane paired with tazobactam was introduced as treatment initially indicated for complicated urinary tract and intra-abdominal infections, but had a broader coverage of combating other disease-causing pathogens.

Fighting Pseudomonas in Resource-Limited Settings

According to Dr. Brink, controlling MDR pathogens such as Pseudomonas is particularly a challenge in low income countries that has shortage of disease specialists and clinical pharmacologists, hospital administration support, and existing resources such as AMR data.

He cited the Antimicrobial Stewardship Program (ASP) model in South Africa as an example of good Antimicrobial Stewardship (AMS) implementation in resource-constrained settings. Multidisciplinary teams intervened through “care bundles” or small sets of evidence-based interventions for a defined patient segment. The “care bundles” model was launched across 47 hospitals during a period of five years. Hospital processes and practices were improved and overall antibiotic consumption was reduced by 15 percent. During 104 weeks of standardized measurement, 116,662 patients on antibiotics were reviewed with 7,934 interventions recorded in South Africa.

Similar to South Africa, the Philippines is a resource-limited setting where AMR prevalence continuously inflates healthcare costs and threatens lives.

Recognizing the need to regulate antibiotic stewardship practices and keep research information on antibiotics updated, the DOH established an AMR surveillance program that tests antibiotic susceptibility, and analyzes and disseminates AMR trends in the Philippines.

Members of the private sector also strengthened collaborative efforts with the DOH to fight AMR. Global healthcare company MSD in the Philippines for instance has supported 15 government and private hospitals in the implementation of their AMS program and last year rolled out an eAMS application to Manila Doctors Hospital that contained digitized protocol AMS booklets to bring the advocacy closer to healthcare professionals and to patients.

These collaborative efforts combined enforce that strengthening multi-stakeholder collaboration is still the most effective healthcare intervention in fighting the public health burden posed by antibiotics’ losing efficacy to pathogens like Pseudomonas in a resource-constrained country such as the Philippines.