Crossing the Communication Chasm to Fight Antimicrobial Resistance & Ensure A Safer Future

As the world continues to run out of effective antibiotics, the threat of antibiotic resistance continues to grow. The rapid spread of resistance mechanisms has led to concerns that eventually there will be no effective treatment options left to fight communicable diseases.

In the Opening Plenary session of the SHEA Spring 2018 Conference, Zintars Beldovs, Section Manager of Acute and Communicable Disease Prevention at the Oregon Health Authority, stressed that in order to avoid a post-antimicrobial apocalypse, communication and collaboration are desperately needed.

According to Beldovs, every year, 700,000 individuals die from antimicrobial-resistant infections. “I happened to coincidentally realize that 700,000 people is just about the same amount of people that we have in this one popular city, Portland, Oregon,” he illustrated for conference goers. “And so, I think about that figure of 700,000 as imagining every single person in this wonderful city becoming ill from an antimicrobial-resistant pathogen and dying over the course of a year.”

He went on to say that by the year 2050, that number could rise to 10 million with costs escalating to $100 trillion dollars, annually. To put these numbers into perspective, the possible loss of life would be equivalent to the entire state of Oregon as well as most of Washington state. “It’s a very dramatic and concerning future that we obviously don’t want to get to,” Beldovs stressed.

Providing a snapshot of some of the most concerning resistant pathogens that are rapidly spreading throughout the United States, Beldovs noted that Klebsiella pneumoniae carbapenemase (KPC) producing carbapenem-resistant Enterobacteriaceae (CRE) at the top of the list. In 2001, only 2 states had identified cases of KPC CRE; however, a little over a decade later, in 2017, KPC CRE had been reported in all 50 states.

Other concerning resistance mechanisms have emerged, such as the MCR 1, 2, and 3 genes, which were first reported in China in 2015. Now, just 3 years later, 30 countries have reported bacteria with these genes and their presence is already pretty widespread in the United States. Furthermore, there is the growing threat of Candida auris, something that Beldovs finds “both parts equally terrifying and fascinating,” as “it’s hard to identify and other concerning aspects are that there are high levels of resistance, high levels of mortality, and increasingly, we’re seeing it in health care-associated infection outbreaks. It has the capacity to rapidly transmit in health care settings.”

Although many of the different contributing factors that encourage antimicrobial resistance are pretty well known at this point, what’s missing is a greater focus on the fact that we’re living in an increasingly interconnected world. Individuals are moving at a rapid pace throughout the world, receiving medical care in all different places, and that increases the chance of an endemic pathogen from one area spreading to a non-endemic area.

The best way to prevent infectious diseases from being spread? Communication, plain and simple, according to Beldovs.

When communication between medical facilities isn’t happening, outbreaks occur, he stressed, highlighting an example of an extremely drug-resistant (XDR) Acinetobacter baumannii outbreak in May 2012, when patients who had been admitted to a long-term acute care hospital who had peripherally-inserted central catheters developed sepsis after 25 days and tested positive for A. baumannii. When the patients were then transferred for rehabilitation, there was no communication between facilities, and over the next several of years, 21 different patients in 7 different facilities throughout the entire state of Oregon ended up with the resistant infection.

“I am entirely convinced that the whole situation could have been completely avoided if we had better channels for communication in place on all levels,” stated Beldovs.

When patients are transferred from 1 facility to another, the risk of transmission increases. In order to reduce this risk, effective communication is needed. Otherwise, it’s like playing catch while blindfolded, stressed Beldovs. “It’s kind of like these things can be coming from any direction and we have no idea if they are there or not,” he said. “But if we take the blindfold off we can actually see what’s happening.” Effective communication can help the receiving facility make informed actions.

Beldovs suspects that we’re only seeing the tip of the iceberg when it comes to infectious disease outbreaks. The rapid spread of multidrug-resistant organisms (MDROs) is a global issue and lack of communication on all levels just adds to the issue. As such, he stressed the importance of orchestrating a coordinated approach to prevent health care-associated infections.

“We could prevent up to 619,000 health care-associated infections over 5 years in the United States if we act together,” he said. “Instead of what is typically happening where health care facilities have to work by themselves and try to understand if there’s any potential disease transmission in their own facilities, the whole idea is that all facilities are then working together within a region, and the public health department can act as a nexus and help potentially reduce the likelihood of larger scale transmission events or help facilities in under-resourced settings prevent transmission of these organisms.” This also needs to be coupled with early aggressive action.

To increase communication between health facilities, Oregon initiated a requirement in 2014 which called for a mandatory inter-facility transfer notification, meaning that all facilities, regardless of what type, had to notify every receiving facility in the state if a patient has an MDRO or any disease requiring transmission-based precautions.

“It looks like this requirement is having some benefit,” shared Beldovs. “I don’t think it’s enough, but we do see a significant rise in the percentage of physicians in hospitals and other skilled nursing facilities that say that they are receiving notification,” which is a step in the right direction.

Defining what an ideal system would look like for preventing the transmission of these resistant organisms is the next step. An ideal system would include the following:

• Collaboration—getting everyone at the table (public health, US Centers for Disease Control and Prevention, state and local health departments, hospitals, long-term acute care facilities, laboratories, etc.)
• Establishing standard definitions and clear guidance—to communicate, everyone needs to speak the same language. Guidance needs to be tailored to all the different facility types.
• Setting up a system in terms of toolkits and educational efforts.
• Legal requirements—ensuring that everyone participates in the effort.
• Automation—Some kind of a registry is needed to improve communication between facilities. We need to automate communication within health departments and laboratories as well.
• Enhanced antimicrobial resistance laboratory surveillance—the ability to identify resistant organisms and get that information to the right people in public health is needed to stop transmission and prevent outbreaks from springing up.

“I just want to state that there are all kinds of different forms of communication. Communication is what happens; it’s inevitable,” Beldovs concluded. “My question to all of us is: do we want to leave that communication to microorganisms that randomly transmit disease throughout the world or do we want to take the reins of communication into our own hands and work to help our own future safety?”