Infection Prevention in 2016 – Responding to new threats and challenges

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The news over the last few years has been dominated by Ebola. Although this might seem disproportionate to the disease burden - in the affected West African countries, the almost 30,000 reported cases are put in context by the millions of cases of malaria reported in the same period - Ebola has required a special international response to overcome. While Australian hospitals might feel relatively protected by geography, the report of transmissions to two nurses caring for a patient who unexpectedly presented in Texas reinforces the need to be prepared. Similarly, the large outbreak of MERS coronavirus in South Korea was a salient reminder of the vulnerability of health systems to emerging infectious diseases. These challenges have been faced before – SARS coronavirus in 2003, pandemic influenza in 2009 - and each time Australia has been fortunate not to be seriously tested.

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Australia is one of very few countries in the developed world that does not have a national centre for disease control. We have a decentralised health system and each hospital develops its own response to crises like Ebola. If we had a national body whose job it was to co-ordinate our response to these situations by formulating a policy based on best evidence and deploying the necessary resources, we would be better able to ensure health and safety in a crisis. In most cases, centralised disease control agencies are established after a catastrophic failure in infection control. This happened in Canada, for example, after SARS was such a major disaster for their hospitals. My colleagues and I would like to see a national body for disease control set-up before the next serious infectious disease outbreak.

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Australia is one of very few countries in the developed world that does not have a national centre for disease control.

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The need to keep a close eye on emerging infectious diseases around the globe cannot be over-stressed. At the moment we are watching the MERS Corona virus. Up until recently, all cases of the disease were coming out of the Middle East. Now we have seen an outbreak in South Korea.
A more immediate threat is the advent of extremely drug resistant (XDR) organisms, particularly vanA vancomycin resistant enterococci (vanA VRE) and carbapenemase resistant enterobacteriaecae (CPE). Most cases of CPE had previously been associated with returning travellers from endemic countries in Asia, as well as from hospitals in the Middle East and southern Europe. However, more recently outbreaks of both organisms have been described in Australian hospitals, and have proved difficult to treat and control. With the description of strains of E. coli resistant to all antibiotics including colistin in China, we are truly entering the post-antibiotic age, where infection prevention services will play a vital role in protecting patients. We have been relatively safe up until now but Coronavirus with Australians traveling widely and often, it will be very difficult to control the spread of these organisms and we must remain vigilant. People most at risk of infection with an XDR are those who have been hospitalised overseas or have returned from overseas and had surgery within a six month period.
The incidence of Clostridium difficile (C.dfficile) infection appears to have peaked in recent years, but concern persists over the potential for “hypervirulent” strains to cause severe disease. It is unclear whether the increased reports of disease may be linked to increased awareness and testing, or more and possibly over-sensitive diagnostic tests, or whether it represents a true increase in incidence. It is clear, however, that C. difficile does appear to be an important cause of community-acquired diarrhoea following antibiotics, and can cause severe colitis in hospital inpatients. While there has been much discussion about the use of faecal transplantation, centres that have attempted this procedure have faced many practical issues such as finding suitable donors and effective screening processes. Although some of these will be addressed in an upcoming revision of an Australasian Society for Infectious Diseases guideline for the treatment of C. difficile, we await a palatable and convenient “poo delivery system” to restore patients to microbial health.
Infection prevention and control services have come a long way from the original brief to perform surveillance of surgical site infections and to promote good hygiene practices in hospital wards. Over recent years the National Safety and Quality Health Service Standards have put a number of new areas on the agenda for infection prevention services, including antimicrobial stewardship. This has led to collaborations with clinical pharmacists and many innovative approaches to education and training, to point-of-prescription decision support tools, to post-prescription audit and feedback processes. The collection of Australia’s fragmented surveillance systems under the Antimicrobial Use and Resistance in Australia (AURA) project is a step forward in providing useful information to guide national policy.
Those of us that work in infectious diseases are constantly learning about new diseases - HIV and hepatitis C in the 1980s, MRSA and VRE in the 1990s, SARS and pandemic influenza in the 2000s. A characteristic of Australian hospitals is the “ground up” approach to responses, which fosters innovation and strong clinician engagement. However, this does have its limitations and while hospitals have learned many lessons on how to respond to these challenges, an improved governance structure is required to better co-ordinate hospital and public health responses. A National Framework for Communicable Disease Control has been developed that provides a vision to improve the detection and response to all communicable diseases, as well as to improve the organisation and delivery of prevention and control. Might we dare dream of an Australian Centre for Disease Control?

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…with Australians traveling widely and often, it will be very difficult to control the spread of these organisms and we must remain vigilant.

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Allen Cheng
Allen Cheng is an infectious diseases physician at Alfred Health. He is Director of the Infection Prevention and Healthcare Epidemiology Unit at Alfred Health, and Professor of Infectious Diseases Epidemiology at the School of Public Health and Preventive Medicine at Monash University.