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Seventy-five years after the ‘wonder drug’ penicillin saved its first patients, we could be heading toward a post-antibiotic era in which common infections once again kill. Nurses have both a vested interest and a vital role in preventing this. FIONA CASSIE reports.

In January 1941 Mrs Elva Akers, a “pleasant” 50-year-old woman with terminal breast cancer, readily agreed to try a new medicine that could benefit others, though not herself.

The medicine was penicillin¹. A few weeks later, a 43-year-old policeman who was “desperately and pathetically ill” received the first therapeutic treatment of the drug. A sore on his lips had led to both staphylococcal and streptococcal septicaemia. He had multiple abscesses on his face and had lost one eye; the infection had also made its way into the bones of his right arm, there were abscesses in his lung and he was in great pain.

After the first day of treatment he felt “a little better”; by the fifth day he was “vastly better” with no fever, the abscesses healing and he was eating well². The golden age of antibiotics and modern medicine had begun.

Advance 75 years and the world’s health leaders are warning us that that golden age is at dire risk of being very short-lived.

Already 700,000 people a year die of antimicrobial resistant (AMR) infections (see definition) and this is estimated to rise to 10 million people a year by 2050. The British Government’s O’Neill Report earlier this year predicted not only this chilling human toll but also that by 2050 rapidly escalating AMR could have a gobsmacking potential US$100 trillion impact on the world’s economy.

It’s not like we weren’t warned. The very same year that penicillin made the policeman “vastly better” the first bacteria resistant to penicillin were identified. And as early as 1945 Sir Alexander Fleming, who first isolated the antibiotic substance from mould back in 1928, was speaking out about the consequences of “thoughtless” use of the resulting new wonder drug.

But despite the warnings the decades that followed have seen “systematic misuse and overuse of these drugs in human medicine and food production”, says the World Health Organization (WHO).

In response to this threat to modern medicine WHO last year launched a global action plan on AMR, stating: “Without harmonised and immediate action on a global scale, the world is heading towards a post-antibiotic era in which common infections could once again kill.”

Healthcare workers, says WHO, have “a vital role in preserving the power of antimicrobial medicines”. So what should and can nurses do?

What can nurses do?

Nurse leaders say that, whatever the causes of AMR, nurses definitely need to be part of the solution.

If they are not, and the spread of AMR continues as projected, nurses will no longer be able to nurse the way they do today, says Dr Frances Hughes, the New Zealander leading the International Council of Nurses – a federation of 130 national nurses associations representing 16 million nurses worldwide.

In March the Geneva-based chief executive put out a media release stressing the key role of nurses worldwide in reducing the impact and limiting the spread of this major threat to public health, after discussing the health workforce implications of AMR with other international professional organisations.

“We’ve legitimately got a role in this,” says Hughes. “As when antibiotics aren’t available for infections we will be the caregivers.” Entering a post-antibiotic era would force nursing practice to adapt to nursing infections and fevers that most nurses have never faced, says Hughes, and, maybe in the future, to do so in the community as hospitals try to protect themselves from antibiotic-resistant superbugs.

Dr Jane O’Malley, Chief Nursing Officer at the Ministry of Health, agrees nurses have a “huge” role to play in the campaign against AMR – both at the strategic level and at the practical frontline level because of how many patients they are in touch with over the course of a year.

Nurse practitioners have been prescribing in New Zealand since 2003 and new regulations passed this year will see many more specially trained and authorised registered nurses able to collaboratively and carefully, prescribe antibiotics.

But whether nurses are prescribers or – more commonly – administrators and advisors about medicines, O’Malley says one of nursing’s biggest roles is educating and advocating for better public understanding and awareness of when antibiotics are needed and when they are not.

Hughes agrees that nursing has a major role in health education and improving health literacy and says ICN is actively pushing for investment in educating nurses so that nurses can in turn put in place AMR strategies with consumers and patients around the world.

“Nurses are prescribers and we are administrators of medication,” says Hughes.

“We can and do inform on medication side effects. We are the ones that can educate patients about medication regularly because we are with the patients regularly. We can educate them about the difference between viral and bacterial infections. And about how else they can look after themselves and treat common ailments (without antibiotics).

“We are the ones that can vaccinate and immunise people so they don’t get common diseases that they shouldn’t get – like flus – that can lead to secondary infections. And we are the major players in infection control.”

What about now? What impact is AMR already making on how healthcare is delivered in
New Zealand? And how close has poor antibiotic practice brought us to the worse case scenario?

Ever more expensive and inconvenient treatments

One common infection experienced by most women and also, less commonly, men are urinary tract infections (UTIs).

Mark Thomas, an infectious disease physician at Auckland City Hospital, says once such infections – usually caused by E. coli (Escherichia coli) from the intestine making its way into the bladder – could all be treated with an oral antibiotic.

But the associate professor in the University of Auckland’s molecular medicine and pathology department says now about 5–6 per cent of E. coli found in women’s urine are “resistant to pretty much every oral antibiotic”.

So intravenous antibiotics and time in hospital are needed to knock back the resistant E. coli causing cystitis (bladder) or the less common pyelonephritis (kidney) infections.

“And we expect the proportion won’t be just 5–6 per cent – in two or three years it will be 7 or 8 or 10 per cent and that proportion will steadily rise so that common infection will more commonly require people to be in hospital having intravenous treatment.”

The source of the problem is well known. The world’s wide use of antibiotics knocks back the normal, dominant strains of a bacteria causing infection, creating environments where the resistant, minority strains of a bacteria can multiply and spread in a way not possible in pre-antibiotic days. WHO says these drug-resistant bacteria – created by antibiotic overuse in medicine and, food production – can then circulate in human and animal populations and through food, water and the environment, helped along by trade, travel and migration.

Thomas says what does remain mysterious is that some bacteria very quickly become resistant to antibiotic treatment and others do not. For instance, the group A Streptococcus bacteria that causes strep throat and can lead on to rheumatic fever has never become resistant to penicillin, despite decades of penicillin use.

But increasing resistance to antibiotics by other bacterial infections and diseases means ever more expensive and inconvenient treatments.

He says a great example is gonorrhoea – once simply treated by an oral antibiotic, increased AMR means it now requires an intramuscular antibiotic plus an oral antibiotic.

Another is New Zealand’s internationally very high use of topical antibiotics – like fusidic acid (Foban) or mupirocin (Bactroban) – for impetigo (school sores) and other skin infections – has seen us end up with a high proportion of S. aureus (Staphylococcus aureus) infections that are resistant to antibiotic ointments.

Overseas – luckily very rarely here – there has developed not only a MDR-TB (multi-drug-resistant tuberculosis that is resistant to two drugs) but also XDR-TB (extensively drug-resistant TB).

Then there is the new generation of superbugs – those resistant bacteria strains that develop faster than new classes of antibiotics can be developed to fight them.

Thomas says at present New Zealand only sees the occasional patient turn up – often having been in a hospital overseas – who has an infection that is essentially impossible to treat, and sometimes these patients die.

“They are usually patients who have got horrible health problems – they’ve had a transplant or repeated surgery or have had something that has led to them having lots of courses of antibiotics.”

Those superbug patients are still very rare in New Zealand – Thomas estimates the number lost to a completely untreatable infection is around one or two a year – a lot fewer than overseas countries that use a lot more antibiotics than we do.

So on the world scale New Zealand’s AMR situation could be worse. But Thomas says we could also be much, much better with still far greater antibiotic consumption in New Zealand than in careful, prudent countries we should be modeling ourselves on, such as the Netherlands and Sweden.

Thomas, who is a member of a Ministry of Health and Ministry of Primary Industries working group helping to develop New Zealand’s own AMR Action Plan, believes that New Zealand’s farming use of antibiotics is not the biggest issue. Neither is it hospitals. Instead it is in the community, with 95 per cent of human antibiotics used outside of hospitals.

Therefore, a major focus, he believes, for health professionals should be educating the public about AMR and doing their best to reduce both unnecessary antibiotic use and unnecessary infections.

Changing the habits of a lifetime

The public definitely has a role to play in AMR, says chief nursing advisor Dr Jane O’Malley, by not expecting an antibiotic every time they rock up to their GP or NP with a cough, cold or flu.

 Educating the public why antibiotics aren’t the answer when they have a viral or minor infection is a key role for nurses – the health professional who often spends the most time with patients, says O’Malley. (See sidebar for more suggestions.)

Thomas agrees. “The most common infections that people go to their general practice about are respiratory tract infections (RTIs): colds, coughs, sore ears and sore throats,” says Thomas. “And for most people those infections are relatively trivial.” (The exception to this is Māori or Pacific children and young people with sore throats because of the rheumatic fever risk.)

“If we were to stop taking antibiotics for those RTIs – and there are endless guidelines around the world saying that’s what we should do – then we could dramatically reduce the antibiotics we are using and make a big difference to the selective pressure for antibiotic-resistant germs.

Waverley Newson, a Lakes District Health Board’s infection control nurse specialist, agrees, saying the fact that antibiotic prescribing data shows a seasonal upswing is concerning.

“It makes you think that antibiotics are being prescribed for viral illnesses over winter  – antibiotics can be appropriate to use for a secondary bacterial infection – but the quantities make you suspicious that isn’t the only reason they are being prescribed.”

Newson sits alongside Thomas on the national AMR Action Plan group, representing the Infection Prevention and Control Nurses College, NZNO, and with Dr Deborah Jowitt (see other article) is one of three nurses on the working group. O’Malley says the Action Plan group started meeting this year in response to WHO’s strong call for all member countries to have a national AMR strategic plan in place by May 2017.

“And the Ministry of Health is working with the Ministry of Primary Industries on a One Health approach, as obviously the use of antibiotics for agriculture, horticulture and aquaculture does happen in New Zealand,” says O’Malley.  It is hoped a draft strategic plan will be available to the Ministers before the end of year ready for consultation in the New Year.

“So we are moving in the right direction,” says O’Malley, who once again stresses the importance of nursing’s role in both the strategic and frontline response to fighting AMR.

And 75 years after Mrs Elva Akers agreed to be the first human tested with penicillin, in the hope that it “could be of value to many¹”, it also seems respectful to honour this “pleasant” woman’s legacy to modern medicine by ensuring the wonder drug’s influence is not cut any shorter by thoughtless use. :

1. Charles Fletcher. First clinical use of penicillin, BMJ, 289, 1984

2. Fletcher reports that the research team’s quantities of penicillin were so limited that supplies were exhausted on the fifth day and sadly the policeman deteriorated and died.

Frances Hughes	Mark Thomas	Pamela Woods	Waverley Newson	Jane O'Malley

SEE ALSO RELATED STORIES: Antibiotic resistance: nursing stories of before & after antibiotics