Has the World Entered the Post-Antibiotic Era?

Michael Gerchufsky, CMPP, ELS, is the managing editor of Consultant for Pediatricians and PediatricsConsultant360.com. E-mail him with thoughts on this post at editor@pediatricsconsultant360.com, or post comments directly below.

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It appears that the moment we all have feared might have arrived even sooner than we had expected, and the world might already have entered the post-antibiotic era.

According to recent news reports from New Zealand, that geographically isolated and tightly quarantined island country in July experienced its first case — and resulting death — of a patient infected with a bacterial pathogen resistant to every available antibiotic.

From a report in the New Zealand Herald¹:

In January, while he was teaching English in Vietnam, Mr (Brian) Pool suffered a brain haemorrhage and was operated on in a Vietnamese hospital.

He was flown to Wellington Hospital where tests found he was carrying the strain of bacterium known as KPC-Oxa 48 - an organism that rejects every kind of antibiotic.

Wellington Hospital clinical microbiologist Mark Jones told Fairfax (Media): "Nothing would touch it. Absolutely nothing.

"It's the first one that we've ever seen that is resistant to every single antibiotic known."

While New Zealand's case isn't the world's first outbreak of an OXA-48 carbapenemase-producing pathogen — this one was a strain of Klebsiella pneumoniae — it demonstrates the ready and rapid spread of the "superbugs" across borders.

After the first reported outbreak in Turkey in 2004,^2,3 the virulent pathogen, its variants, and others like it (particulary OXA-48 carbapenemase-producing Escherichia coli) have spread to Lebanon,⁴ Egypt,⁴ Belgium,⁴ France,⁵ Spain,⁶ Senegal,⁷ Israel,⁸ India,⁹ and beyond.

The Centers for Disease Control and Prevention estimates that more than 2 million people in the United States become infected each year with antibiotic-resistant bacteria, with at least 23,000 dying as a result. The estimates are based on conservative assumptions and are likely minimum estimates.¹⁰

The CDC has prioritized carbapenem-resistant Enterobacteriaceae as an urgent threat, along with Clostridium difficile and drug-resistant Neisseria gonorrhoeae.¹⁰ In fact, experts have called the spread of these bacteria a potential global catastrophe that should be regarded as seriously as terrorism.

And if you think that the concerns about the potential enormity of this situation have been exaggerated, read investigative journalist and author Maryn McKenna's sobering report, "Imagining a Post-Antibiotics Future,"¹¹ in which she writes:

Before antibiotics, five women died out of every 1,000 who gave birth. One out of nine people who got a skin infection died, even from something as simple as a scrape or an insect bite. Three out of ten people who contracted pneumonia died from it. Ear infections caused deafness; sore throats were followed by heart failure. In a post-antibiotic era, would you mess around with power tools? Let your kid climb a tree? Have another child?

Something to think about the next time a parent pressures you for a Z-PAK for his or her child's virus-related scratchy throat.

—Michael Gerchufsky

For more on antibiotic prescribing and pathogen resistance from Consultant and Consultant for Pediatricians:

• Prescribing Broad-Spectrum Antibiotics for Pediatric Patients

• Antibiotic Resistance: A Compelling Reason to Resist Patients' Requests, by Gregory W. Rutecki, MD

• What Hath Antibiotic Wrought? By Gregory W. Rutecki, MD

• FDA Warning May Affect How Physicians Prescribe Zithromax

• Methicillin-Resistant Staphylococcus aureus: How Best to Treat Now? By Russell W. Steele, MD

• Antibiotic Therapy: The Risks of Resistance, by Thomas Fekete, MD

• New Guidelines Discourage Antibiotic Use in Sinus Infections

References:

1. Quilliam R. Kiwi dies with bug no drug could beat. New Zealand Herald. November 18. 2013. http://m.nzherald.co.nz/nz/news/article.cfm?c_id=1&objectid=11159413. Accessed November 21, 2013.

2. Poirel L, Héritier C, Tolün V, Nordmann P. Emergence of oxacillinase-mediated resistance to imipenem in Klebsiella pneumoniae. Antimicrob Agents Chemother. 2004;48(1):15-22.

3. Carrër A, Poirel L, Eraksoy H, Cagatay AA, Badur S, Nordmann P. Spread of OXA-48-positive carbapenem-resistant Klebsiella pneumoniae isolates in Istanbul, Turkey. Antimicrob Agents Chemother. 2008;52(8):2950-2954.

4. Carrër A, Poirel L, Yilmaz M, et al. Spread of OXA-48-encoding plasmid in Turkey and beyond. Antimicrob Agents Chemother. 2010;54(3):1369-1373.

5. Cuzon G, Ouanich J, Gondret R, Naas T, Nordmann P. Outbreak of OXA-48-positive carbapenem-resistant Klebsiella pneumoniae isolates in France. Antimicrob Agents Chemother. 2011;55(5):2420-2423.

6. Pitart C, Solé M, Roca I, Fàbrega A, Vila J, Marco F. First outbreak of a plasmid-mediated carbapenem-hydrolyzing OXA-48 beta-lactamase in Klebsiella pneumoniae in Spain. Antimicrob Agents Chemother. 2011;55(9):4398-4401.

7. Moquet O, Bouchiat C, Kinana A, et al. Class D OXA-48 carbapenemase in multidrug-resistant enterobacteria, Senegal. Emerg Infect Dis. 2011;17(1):143-144.

8. Goren MG, Chmelnitsky I, Carmeli Y, Navon-Venezia S. Plasmid-encoded OXA-48 carbapenemase in Escherichia coli from Israel. J Antimicrob Chemother. 2011;66(3):672-673.

9. Poirel L, Potron A, Nordmann P. OXA-48-like carbapenemases: the phantom menace. J Antimicrob Chemother. 2012;67(7):1597-1606.

10. Centers for Disease Control and Prevention. Antibiotic Resistance Threats in the United States, 2013. Atlanta, GA: Centers for Disease Control and Prevention, US Dept of Health and Human Services; 2013. http://www.cdc.gov/drugresistance/threat-report-2013/pdf/ar-threats-2013-508.pdf. Accessed November 21, 2013.

11. McKenna M; FERNnews. Imagining a post-antibiotics future. https://medium.com/p/892b57499e77. Published November 20, 2013. Accessed November 21, 2013.