Here’s a case I recently saw…
Whilst working in A&E I assessed a 76 year old farmer who presented with hyperactive delirium. He was normally fit and well and worked as a farmer all his life. According to his wife and daughter, he had been more withdrawn over the past week. He was eating less and sleeping much more than usual (he’s normally an early riser). He started to hallucinate the night before his admission becoming more aggressive and in the words of his own wife “unmanageable".” His wife called their daughter and despite their attempts he wouldn’t calm down. The patient kept alleging that his wife wanted to kill him - something that is difficult for anyone to hear.
On assessment, his observations were normal but he was certainly confused. He was confabulating and kept referring to me as a policeman (I was in scrubs). It took a long time for us to get some blood tests as he was very resistive but it’s a good thing we did. He had a raised white cell count and c-reactive protein (CRP). His urine dip also came back positive with nitrites, bloods and leukocytes. The diagnosis was quite clear…
So he had a UTI. Simple - I gave him some IV antibiotics and admitted him to the ward. However, things were much more complicated than initially imagined. He ended up having full blown sepsis. He developed a persistently low blood pressure, had a raging AKI and eventually required admission to intensive care (ICU). Despite having multiple rounds of intravenous antibiotics, his condition remained the same. In the end, his urinary culture came back which showed resistance to pretty much every antibiotic on the market except linezolid and amikacin.
At this moment, the patient is still in ICU - he remains unconcious as he walks the tightrope of life and death.
This made me think - antibiotic resistance is real.
The key to advertising any product, policy or service is to create some sort of image for it. Most people know what a stroke is because of the years of advertising showing the public how a patient looks when they are having a stroke. The same goes for a heart attack, the classic person clutching onto the left side of their chest is an image that is etched into the minds of all.
Whilst we can’t see covid19 with the naked eye, most of the public know what covid “looks like”. Loss of taste or smell, high fever and shortness of breath are the cardinal features and people throughout the last 2 years have shared their stories.
None of this applies to antibiotic resistance - there is no face, no imagery associated with it.
Here are some key points concerning the rising threat of antimicrobial resistance (AMR). Most of these have been taken from a recent interview with Dame Sally Davies, the UK envoy special envoy for AMR.
AMR in 2019 resulted in 1.2 million deaths globally. This is more than TB, HIV and malaria.
During the same period, 5 million people died due to other causes but also had AMR as a risk factor.
Increased use of antibiotics during COVID19 has enhanced antibiotic resistance.
The number of hospital admissions secondary to untreated infections secondary to AMR has increased.
AMR is multifactorial - antibiotic overuse in animals to prevent infections in poor farming conditions is a direct contributor to AMR.
There has been a real stagnation of antibiotic development over the past three decades due to lack of investment from countries. AMR is a global issue.
Solving AMR is multi institutional - It requires regulation of spaces (farming), shared investment by governments to drive antibiotic development, and early testing of organisms.
Some brilliant work has been done so far including the creation of a “One Health” fund by the WHO as well as testing of sewage and fertiliser to detect organisms and their resistance.
For clinicians, our role is to exercise our clinical judgement and really think about whether prescribing antibiotics will actually solve the problem at hand. Sometimes it is the easy way out, but we have to appreciate the implications of AMR.
Patient education, delayed prescriptions and taking cultures are tools at our disposal and we should not be afraid of saying no if required.
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