We have read, through the past instalments of this series, about sepsis and its multifaceted presentation. This month, in conjunction with the WHO’s World Antibiotic Awareness Week (#WAAW) on Nov 18 to 24, we will discuss about sepsis and its connection with antibiotic resistance.
Key to prevent sepsis is time
We know now that sepsis is a condition caused by the body’s overwhelming response and life-threatening response to an infection; the infection can be in any form including infected wounds, pneumonia, influenza, and urinary tract infections.
Sepsis requires rapid intervention and patients must be admitted to hospitals. Upon hospital admission, the ‘golden hour of sepsis’ refers to the importance of timely initiation of antibiotic for the patient and its associated outcome.
According to studies, each hour of delay in antibiotic treatment will reduce sepsis survival by more than 7 per cent. Therefore, doctors will usually prescribe broad-spectrum antibiotics (antibiotics that will kill a wide range of bacteria) for sepsis patients upon admission.
Most of us are aware that exposure of bacteria to antibiotics for a long duration might lead to the phenomenon of resistance. In addition, viral sepsis (sepsis caused by viruses, such as dengue fever and viral pneumonia) will not respond to antibiotic treatment; the antibiotic given will only eliminate natural protective flora of our body and not the virus.
More control over antibiotic administration
Some might reason that initial administration of broad-spectrum antibiotics, especially during the ‘golden hour of sepsis’, is crucial to save lives, regardless of the infectious agent. Most doctors now agree in having a good antibiotic “stewardship” strategy for managing sepsis.
A broad-spectrum antibiotic will be administered during the ‘golden hour’ and perhaps a little longer, until the identity of the infectious agent (bacteria or virus), and its susceptibility towards specific antibiotics could be determined.
This will be followed by discontinuation of antibiotic in cases of viral sepsis, or a ‘de-escalation’ process in bacterial sepsis, where doses of the antibiotic is reduced, or changed to a narrow spectrum antibiotic which only targets the infecting bacteria. This approach of ‘stewardship’ will help in reducing the risk of antibiotic resistance.
Knowledge equals better outcome
Another aspect to sepsis and its connection to antibiotic resistance can be traced to the early days of civilization before antibiotics were discovered (termed as the ‘pre-antibiotic era’).
At that time, without proper knowledge of wound-cleaning and hygiene, infections mostly lead to sepsis and, inevitably, deaths. Only around 60 per cent of mothers and their babies survive child birth; simple cuts and wounds might lead to sepsis.
With the phenomenon of antibiotic resistance on the rise, now many scientists are concerned with the possibility of a ‘post-antibiotic era’, where bacteria become resistant to all available antibiotics.
Rise of the ‘superbugs’
One example of this scenario was a recent case in October, at the All India Institute of Medical Sciences (AIIMS). Ten out of 22 patients who were infected with bacteria resistant to all available antibiotics, died. In the post-antibiotic era, infectious diseases and sepsis will kill more people compared to cancer, diabetes and road accidents combined.
How do we keep antibiotic resistance at bay and prevent a post-antibiotic era? WHO recommends three very simple steps: practising good hygiene and preventing ourselves from falling sick; if we fall sick, do not share antibiotics; to consult a doctor if we feel there is a need for antibiotic prescription. Antibiotics are a precious resource, everyone has an important role to ensure they remain efficacious into the future. — The Health
Assoc Prof Dr Tan Toh Leong is a Consultant Emergency Physician, Faculty of Medicine of UKM and the Founder and President of the Malaysian Sepsis Alliance (MySepsis)
Assoc Prof Dr Neoh Hui-min is a Senior Research Fellow at the UKM Medical Molecular Biology Institute (UMBI), UKM and the Secretary of the Malaysian Sepsis Alliance (MySepsis)
What does antibiotic resistance mean?
Antibiotics are medicines used to prevent and treat bacterial infections. Antibiotic resistance occurs when bacteria change in response to the use of these medicines.
Bacteria, not humans or animals, become antibiotic-resistant. These bacteria may infect humans and animals, and the infections they cause are harder to treat than those caused by non-resistant bacteria.
Antibiotic resistance leads to higher medical costs, prolonged hospital stays, and increased mortality.
The world urgently needs to change the way it prescribes and uses antibiotics. Even if new medicines are developed, without behaviour change, antibiotic resistance will remain a major
threat. Behaviour changes must also include actions to reduce the spread of infections through vaccination, hand washing, practising safer sex, and good food hygiene.
Prevention and control
To prevent and control the spread of antibiotic resistance, individuals can:
• Only use antibiotics when prescribed by a certified health professional.
• Never demand antibiotics if your health worker says you don’t need them.
• Always follow your health worker’s advice when using antibiotics.
• Never share or use leftover antibiotics.
• Prevent infections by regularly washing hands, preparing food hygienically, avoiding close contact with sick people, practising safer sex, and keeping vaccinations up to date.
• Prepare food hygienically, following the WHO Five Keys to Safer Food (keep clean, separate raw and cooked, cook thoroughly, keep food at safe temperatures, use safe water and raw materials) and choose foods that have been produced without the use of antibiotics for growth promotion or disease prevention in healthy animals.
To prevent and control the spread of antibiotic resistance, policy makers can:
• Ensure a robust national action plan to tackle antibiotic resistance is in place.
• Improve surveillance of antibiotic-resistant infections.
• Strengthen policies, programmes, and implementation of infection prevention and control measures.
• Regulate and promote the appropriate use and disposal of quality medicines.
• Make information available on the impact of antibiotic resistance.
To prevent and control the spread of antibiotic resistance, health professionals can:
• Prevent infections by ensuring your hands, instruments, and environment are clean.
• Only prescribe and dispense antibiotics when they are needed, according to current guidelines.
• Report antibiotic-resistant infections to surveillance teams.
• Talk to your patients about how to take antibiotics correctly, antibiotic resistance and the dangers of misuse.
• Talk to your patients about preventing infections (for example, vaccination, hand washing, safer sex, and covering nose and mouth when sneezing). — The Health
Broad-spectrum antibiotics is the type commonly used to treat bacterial infection, although many strains of bacteria are now found to be resistant to them.