Reading through several articles and reports on antimicrobial resistance, I came across a news story about a multidrug-resistant Pseudomonas outbreak linked to duodenoscopes at Huntington Memorial Hospital in the U.S.A. This is not the only outbreak linked to endoscopes this year – the more noteworthy event occurred at the Ronald Reagan UCLA Medical Centre, with 7 ill and 2 dead (and potentially 179 infected) from carbapenem-resistant Enterobacteriaceae (CRE) infection after having undergone endoscopy. Endoscopes used for endoscopic retrograde cholangio-pancreatography (ERCP) were also responsible for spreading NDM-1-producing Escherichia coli and Klebsiella pneumoniae at the Advocate Lutheran General Hospital at Illinois, U.S.A. The fault in these cases appears straightforward – the design of the endoscopes was such that it might not have been disinfected properly despite all the appropriate steps being taken. The failure of infection prevention could not have been laid at the door of the hospitals, patients or medical staff. The publicity is also good, highlighting the problem for both the general public and medical staff, as well as reinforcing the issue of antimicrobial resistance in the minds of the public.

We probably use similar if not the same endoscopes in Singapore. I am unsure if there has been similar transmission of antimicrobial-resistant pathogens via endoscopy in Singapore, as our hospitals are rather more publicity shy (especially with regards to negative publicity) compared to the U.S., but the Infection Control Association (Singapore) did highlight the issue in a pre-conference workshop during their annual congress in January this year. At the start of the month, U.S. FDA had issued supplemental measures for re-processing endoscopes in order to reduce the spread of such pathogens, which hopefully local hospitals are also attempting to adhere to.

What about the more “routine” selection and transmission of antimicrobial-resistant pathogens a.k.a. superbugs? Here, it gets more tricky. Who is at fault and should take responsibility if (as an example) my aged relative were to be admitted for an acute myocardial infarction and then develop pneumonia caused by a superbug like Acinetobacter baumannii or NDM-producing Klebsiella pneumoniae? The list is fairly long:

  1. My aged relative – for being ill and going to the hospital where this is a known risk (but perhaps only known to the hospital staff).
  2. The neighbouring patient who was colonised with the superbug and is indirectly spreading it to other patients.
  3. Her managing team of medical staff for not ensuring her room was cleaned properly or who had failed to observe proper hand hygiene and had thus passed the bug to her (from the neighbouring patient).
  4. The hospital infection control team for not doing its job properly.
  5. The hospital for not ensuring that the infection control team is doing its job and that superbugs are kept under control or eliminated entirely.
  6. The regulatory authority for failing to ensure that the hospitals are clean of superbugs.

At each level, there will be mitigating factors or reasons for the failure, such that it is impossible to find a sole cause or even a “scapegoat”, so to speak. Nor, objectively, is there really one single cause. But it is clear who pays for the superbug infection:

  • The sick patient, with a risk of death, prolonged hospital stay, and increased morbidity.
  • Her direct caregivers.
  • Financially, the cost of treating the infection falls squarely on the patient, the insurers (if a good insurance package was purchased), or taxpayers.

In Singapore at least, many patients and their relatives are even unaware that the patients have had a superbug infection, or else accept it as their lot if this was made known to them. The hospitals do not suffer any serious “hit” to their reputations or finances (patients have to pay for increased length of hospital stay and more costly antimicrobial drugs). The regulatory authority can afford to move slower on tackling this issue, because there are other more urgent matters in the public eye, and also because the Gordian knot of antimicrobial resistance in local hospitals is extremely difficult to untangle. The agitation for action with regards to dealing with antimicrobial resistance in local hospitals has largely come from local medical personnel. But here, it also gets tricky. If one is an infection control expert in charge of these matters in a hospital, speaking up implies that one is not up to the job, and acknowledging one’s failure. There is also a question of perceived “disloyalty” to the hospital, and it seems senseless to whistle-blow if every other local hospital is in a similar state, and actually better in terms of antimicrobial resistance control than many other hospitals in the region.

Taken collectively, it is easy to understand why there is a kind of ennui about addressing the problem of antimicrobial resistance locally (and perhaps also in other parts of the world). There are many places to start (better prescribing of antibiotics, better infection control, better health education, etc.), but each comes with its own issues and downsides, whereas the impact is often less than what one might expect individually. As an example, when we started implementing antimicrobial stewardship programmes (this should actually be a future separate post) locally in order to reduce inappropriate broad-spectrum antibiotic prescription, the pain of implementation was tremendous and resistance from clinicians – even infectious diseases experts – was high. The upshot after several years is that these programmes have become widely accepted in the public sector hospitals and a lot of human labour have gone into “bending” the rising curve of carbapenem prescription, but their impact on antimicrobial resistance rates have been limited.

Who should take responsibility is also an important issue to determine besides just mapping out new initiatives to control antimicrobial resistance. If no one is really responsible, then it is clear that most efforts will be half-hearted, and we will all continue to pay more ultimately. As it stands now, patients and payors continue (mostly) to accept and pay, infection control specialists’ jobs are unaffected by whether superbugs’ rates trend up or down, hospitals’ bottom lines are untouched by the rise of superbugs, and the regulatory authority undoubtedly prefers to move cautiously because the situation is indeed complex.

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