War waged on superbugs

Due to a combination of illegal practices and poor education, the prevalence of drug-resistant bacteria has reached a new peak throughout the countries of the GCC. Greg Noone talks to Dr Manaf Al Qahtani, a consultant infectious diseases and clinical microbiologist at the Royal Medical Services, Bahrain Defence Force Hospital, about the regional situation and how his antibiotic stewardship programme is slowly reclaiming ground in the fight against superbugs.

Methicillin-resistant Staphylococcus aureus (MRSA) is typically encountered in the respiratory tracts of the body. After 72 hours of gestation, the bacterium will cause small bumps resembling spider bites to emerge on the patient's skin. Over the following days, these will increase in size, eventually swelling into boils. If untreated, the resulting infection may spread to the vital organs, causing sepsis, pneumonia and toxic shock.

MRSA is arguably the most notorious of the bacterium known as the 'superbugs', that were so christened because of their resistance to a vast swathe of conventional antibiotics. In the 2000s, what were considered to be a high number of cases involving MRSA in Western Europe and Scandinavia were regarded as symptomatic of poor hospital hygiene and lax infection-prevention policies. In response, national health authorities rigorously raised hygiene standards and tightened the prescription of antibiotics. As a result, infection levels have dropped to levels where mention of MRSA only occasionally intrudes into the day's headlines.

In the Middle East, the situation is indisputably graver. Although the data available remains fragmentary, the indication from surveys conducted in Qatar, Saudi Arabia and the UAE displays an alarming trend in the prevalence of drug-resistant bacteria. In July 2013, it was reported in UAE newspaper The National that instances of bacteria immune to Carbapenem antibiotics had leapt in prevalence in the UAE by 90% over the previous two decades. In 2014, the World Health Organization released a report showing that between 27-40% of E coli samples collected in Qatar were resistant to fluoroquinolones and cephalosporins.

Last April, a study published in the Journal of Clinical Microbiology found that identical iterations of drug-resistant Acinetobacter baumannii had been found in Saudi Arabia, Kuwait and across the Wider Gulf region.

A similar situation is apparent in Bahrain, if not discerned through the country's sparse statistics on the issue, then via the lived experience of its medical practitioners. "Here, the only available data we have on MRSA infections comes from the study I conducted in 2013," says Dr Manaf Al Qahtani, a physician at the Bahrain Defence Force Hospital and one of the country's leading microbiologists.

Lack of education
The factors that have led afflicted Bahrain with a superfluity of drug-resistant bacteriological infections are largely the same as those throughout the Gulf. It began with the lax enforcement of prescription practices by pharmacists. "Until recently, you could go to any pharmacy here and purchase a prescription antibiotic without a physician's signature," says Al Qahtani. "Since early this year, the [Bahraini] National Health Regulatory Authority implemented new rules for prescriptions. A similar rule had been in place since the early 1990s, but it had not been enforced."

This problem is matched by a disturbing lack of education among the general populace as to the correct administration of antibiotics. A survey published in April by the University of Bahrain found that a large minority of respondents thought that antibiotics were just as safe when taken with milk. Further misconceptions about appropriate dosage, stopping times and the reusability of certain drugs were also uncovered. Another survey conducted in the UAE in 2009 encountered a similar phenomenon, with 56.3% of respondents admitting to self-medicating with antibiotics bought over the counter. Last year, a similar study conducted in the Al-Ahsa region of Saudi Arabia, found that 73.7% of respondents answered in the affirmative to the same question.

An issue upon which this lack of education has directly impacted is in the treatment of foot and limb infections deriving from diabetes, of which Bahrain ranks within the global top ten according to prevalence. Knowledge on appropriate foot care in this area remains low, meaning that infections that could normally be treated with a round of antibiotics in their early stages, instead often lead to patients only submitting to care when their symptoms are at their severest. As such, amputation of the affected limb is a depressingly common occurrence in Bahrain.

A survey published in the Bahrain Medical Bulletin in 2014 found that out of 87 patients admitted to the Salmaniyya Medical Complex that year, a quarter underwent lower-limb amputations. According to Al Qahtani, the subset of infections involving complications with MRSA result in even more serious consequences for the patient. "I can tell you that at least once a week we're seeing five cases of MRSA diabetic-foot infection at the Bahrain Defence Force Hospital," he explains. "The majority of them are going to require amputation."

Another problem has been identified in the growing presence of Carbapenem-resident bacterium (CRE). "They're resistant to some of the strongest antibiotics, like Meropenem," says Al Qahtani. "With the screening system we have in place, we found from 2014 that at least 7% of the visitors to my hospital are carriers of these bacteria."

Since December 2014, the Bahraini authorities have been conducting a survey to determine their prevalence and molecular structure. "So far 62 isolates, which screened positive for potential carbapenemase production, were assessed [and] 45 were found to produce it," Al Qahtani says. "The most common were of NDM types, in addition to the presence of OXA-48 and VIM. To my knowledge, there has been no surveillance on the molecular genetics of CRE of this type in Bahrain before, and only very limited efforts in the rest of the GCC."

Antibiotic stewardship
With the scale of antibiotic resistance having reached intolerable levels in the region, the need for health authorities to take concerted action has become evident. One of the first fronts being readied is in hospitals themselves, with the increasing provision of antibiotic stewardship programmes (ASPs) across the GCC. These are projects that monitor and, where necessary, amend normal prescription practices involving antibiotics at several stages in the treatment of the patient. Formed through partnerships between doctors, information technology support staff and hospital pharmacists, they work together with hospital preventionists and epidemiologists to gather data on the intake of antibiotics across the given hospital. Staff at all levels of the programme are then better able to vary prescriptions at the appropriate time for the patient, reducing costs over time and instigating a drop in the cases of related infections.

After leading the country's first outpatient parenteral antimicrobial therapy programme in February 2012, Al Qahtani has now been tasked with organising Bahrain's first concerted ASP. His leading the programme is partly testament to his extensive theoretical work in epidemiology pertaining to Bahrain. A clinical microbiologist at the Bahrain Defence Force Hospital in Bahrain, he joined the facility in 2010 after conducting his FRCPC degree in Canada. Al Qahtani's thesis was on the potential utility of an ASP in his homeland.

An initial challenge was persuading hospital staff to trust his restrictions when prescribing antibiotics. "One of the major barriers in implanting the programmes has been to convince them that I'm not taking their powers away from them," says Al Qahtani. "It is the first time we have worked together as a team on this issue. And I think that is the most enjoyable thing. You work with the nurse, a pharmacist, a microbiologist, you work with IT. The policy comes from a team, and I think that's the best way people can accept it, rather than coming from individual person."

The microbiologist likens his programme to the system of security checks passengers have to undergo at an airport. "When you book a ticket and go to the airport, there are a set of checklists," he explains. "You have to go through them to make sure that you're safe upon entering the airplane. This is exactly what's happening now with the antimicrobial programme. There's a set checklist, and we're making sure that when they're entering the hospital the building is clean. I don't want myself, let alone my patients, contracting an unnecessary infection."

Creating own data
The programme has the added benefit of collecting the data on infection and antibiotic resistance rates that have thus far eluded the GCC medical community. "By conducting our programme we're creating our own data to know exactly where the problems lie," says Al Qahtani. "Along with this, there's a need to keep the wider community aware of our efforts. The next step is involving both the patients and their relatives in an effort to incorporate their experiences into the programme."

Efforts within the region are underway to enable national health authorities who are already conducting similar surveys to more easily communicate their findings to one another. This is essential in tracing the source of foreign outbreaks, a significant problem in the GCC and the wider Middle East. "By knowing your local epidemiology, you can compare it with that of the foreign country, and ascertain which antibiotic you can use for that infection."

Although encouraging, these efforts underline the fact that only the actions of health authorities to tighten existing controls and share information can presently defend against the rise in the number of superbug infections. Global pharmaceutical companies are reluctant to pursue research into new antibiotics, not only because of the long lead time between an initial breakthrough and getting a drug to market, but because of the lack of profit to be made in manufacturing such a high-volume product. Until that situation changes, it will be in the initiative of doctors such as Al Qahtani and his colleagues that will serve to prevent future outbreaks and safeguard the state of clinical hygiene not only in Bahrain, but across the GCC.