How the latest resistance patterns are shaping IPC

Professor Peter Collignon* AM and Conjoint Associate Professor Carolyn Hullick** from the Australian Commission on Safety and Quality in Health Care detail why we need to pay attention to the latest trends in antimicrobial use and resistance.

The Australian Commission on Safety and Quality in Health Care (the Commission) released the First Australian report on antimicrobial use and resistance in human health in 2016, to monitor trends over time and inform what actions are needed in our health system to prevent the rise of antimicrobial resistance (AMR).

Since then, the AURA reports analysing data from the Antimicrobial Use and Resistance in Australia Surveillance System (AURA), have highlighted the concerning growth in rates of resistance and the magnitude of the impact of AMR in Australia.

There is no question that prevention and control of infections and the spread of resistance is a key pillar of the Australian response to AMR. It is one of the seven priorities for action in Australia’s National Antimicrobial Resistance Strategy – 2020 and beyond.

Those of us operating within the healthcare system understand that preventing infections is critical because it helps to stop the development of AMR by decreasing the need for treatment of infections.

Infection prevention and control also contributes to improving the sustainability of the health system. Patients who do not get an infection whilst receiving health care have shorter lengths of stay than those who do, and also have less intense healthcare needs.

Antibiotics are an essential component of modern health care as they cure illnesses that were previously untreatable. But using antibiotics is not without risk. Antibiotics kill the good bacteria that keep you healthy as well as those that cause serious infections, and they have side effects such as allergic reactions and diarrhoea.

There is also a growing body of evidence that taking antibiotics can increase the risk of chronic illness for adults and children. Additionally, antibiotic use drives antimicrobial resistance.

Resistance patterns and infection sources

Released in November, the Fifth Australian report on antimicrobial use and resistance in human health, AURA 2023, published by the Commission, highlights priorities for minimising infection and resistance risks.

The report reveals that while national rates of resistance for many organisms have not changed substantially since 2019, there are several concerning variations nationally in rates and patterns of resistance and the sources of infections.

These recent trends in resistance shine a spotlight on important considerations for infection prevention and control, particularly in the hospital environment.

AURA 2023 shows that resistance to carbapenems, one of our most important last line antibiotics, remains uncommon and was found more often in Enterobacter cloacae complex than in the much more common pathogens such as Escherichia coli or Klebsiella pneumoniae.

However, it is concerning that there are increasing rates of carbapenemase-producing Enterobacterales (CPE) in hospitals. A useful resource for health services that are managing CPE is the Recommendations for the control of carbapenemase-producing Enterobacterales (CPE): A guide for acute care health service organisations and local guidance.

Vancomycin resistance rates in Enterococcus faecium (VRE) increased from 2020 to 2021. We must all take steps to optimise VRE prevention and control, to respond effectively to resistance in E. faecium in Australia and to preserve antimicrobial treatment options for serious infections with this organism.

Urinary tract infection (UTI) remains the most common origin of bloodstream infections involving Enterobacterales, Pseudomonas aeruginosa and E. faecalis. For Enterobacterales, device-related UTIs remain more common for hospital-onset than community-onset bloodstream infections.

Strategies to reduce infection risk

We need to consistently reinforce standard precautions including hand hygiene, environmental cleaning and aseptic technique to reduce the risk of infections.

Other strategies that can reduce the risk of infections that may require antimicrobial treatment are consideration of ventilation, respiratory etiquette, appropriate face mask use, staying home when you are unwell and being fully vaccinated.

Minimising the use and often unnecessary extended use of invasive devices such as urinary and intravenous catheters will also reduce infections and the need for antibiotics. The Commission has developed the Management of Peripheral Intravenous Catheters Clinical Care Standard to assist with minimising this risk for this type of catheter. Device-related bloodstream infections accounted for about 10% of all bloodstream infections reported by the Australian Group on Antimicrobial Resistance.

AURA 2023 also showed that community-onset Clostridioides difficile infection (CDI) — which is often a complication following antimicrobial use — is a larger health concern in Australia than was previously recognised.

Hospital separations with a CDI diagnosis increased by 29% from 2020 to 2021. Community-onset CDI accounted for over 80% of hospitals separations with a CDI diagnosis. Promoting early detection and treatment of CDI is important to reduce the risk of it spreading in healthcare settings.

We know that infection prevention and control programs are essential to prevent and minimise the risk of infections — and therefore the need for antibiotics. The National Safety and Quality Health Service Standards and the Australian Guidelines for the Prevention and Control of Infections in Healthcare provide the framework for preventing and controlling infections in the health system.

By supporting healthcare professionals to reduce the gaps in infection prevention and control in our hospitals, we will help suppress the spread of these organisms as we fight this immense global health threat.

For more information on AURA 2023 findings, visit safetyandquality.gov.au/aura2023 and see the highlights fact sheet for infection prevention and control.

This article was developed with Kristin Xenos from the Commission’s AURA team.

*Professor Peter Collignon AM is Senior Medical Advisor for the Commission and an infectious diseases physician and clinical microbiologist. He is a physician at Canberra Hospital, a Professor at the Australian National University (ANU) Medical School and has a particular interest in antibiotic resistance, infection prevention and control, and hospital acquired infections.
 

**Conjoint Associate Professor Carolyn Hullick FACEM is Chief Medical Officer for the Commission and an emergency physician in Newcastle, NSW. She has geriatric leadership roles with the Australasian College and the International Federation for Emergency Medicine and has expertise in geriatric emergency medicine.

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