A profound threat to Australian Public Health
October 2, 2023
Carbapenemase-producing enterobacterales: a threat to modern medicine
The emergence and propagation of antibiotic-resistant bacteria are formidable challenges to global health. Among the array of resistant microbes, Carbapenemase-producing Enterobacterales (CPE) have triggered significant concern due to their resilience and destructive potential. CPE are a group of bacteria within the Enterobacteriales order, which encompasses notorious genera such as Escherichia, Klebsiella, and Salmonella. CPE’s lethal prowess is attributed to acquired carbapenemase genes enabling them to dismantle carbapenem antibiotics, making conventional treatment protocols ineffective. The virulence of strains like Klebsiella pneumoniae carbapenemase (KPC) and New Delhi metallo-β-lactamase (NDM) is particularly alarming, having registered a rapid and extensive spread, fostering multidrug resistance, and in some cases, pan-resistance, leaving no effective antibiotic interventions for this bacteria.
CPE has a propensity for prolonged, symptomless colonisation in the gut, facilitating stealthy transmission within healthcare settings. The clinical treatments currently at our disposal are grossly unequipped to cover CPE, contributing to unfortunately elevated mortality rates. The economic repercussions of CPE outbreaks are substantial, with smaller outbreaks straining health care systems with millions in expenditures due to extended hospital stays and restrictive admissions. In Australia, individuals with asymptomatic CPE colonisation are witnessing a six-fold rise in health care costs compared to non-colonized counterparts, highlighting the looming financial implications of CPE spread.
Short and long term implications
There are many short term detriments of CPE, including these key 4:
Mortality and morbidity: CPE infections can lead to immediate life-threatening conditions like sepsis, significantly increasing mortality and morbidity rates, especially in vulnerable populations.
Treatment failure: due to their resistance to antibiotics, CPE infections can cause conventional treatment regimens to fail, making infections more difficult to control and cure.
Outbreaks and strain on healthcare systems: CPE outbreaks in healthcare settings can strain resources and services, leading to increased lengths of hospital stays, restrictive admissions, and heightened healthcare costs.
Increased financial burden: managing and controlling CPE infections incur significant costs for both healthcare providers and patients, including costs related to prolonged hospitalisation and the need for more expensive, last-resort antibiotics.
There are of course significant and concerning long term detriments, including but not limited to:
Endemic spread: in regions where CPE becomes endemic, there’s a continuous and ongoing risk of outbreaks, impacting long-term public health strategies and healthcare provisioning.
Economic burden on healthcare systems: the cumulative economic toll of managing recurring outbreaks, prolonged treatment, and preventive measures can be substantial, impacting healthcare budgets and economies at large.
Diminished efficacy of antibiotics: the widespread and uncontrolled presence of CPE can lead to a continued decrease in the efficacy of existing antibiotics, rendering them ineffective against evolving bacterial strains.
Development of pan-resistant strains: the prolonged existence and evolution of CPE can lead to the development of pan-resistant strains against which no effective antibiotic treatments are available, potentially leading to untreatable infections.
Stagnation in medical advancements: the rise in antibiotic-resistant strains can hinder progress in various medical fields, affecting surgeries, cancer therapies, and other medical procedures which rely on effective antibiotic treatments.
Global public health crisis: the long-term, unchecked spread of CPE has the potential to precipitate a global public health crisis, marked by uncontrolled infections, limited treatment options, and increased mortality.
Increased research and development costs: developing new antibiotics and treatment strategies to combat resistant strains will require significant investment and resources, impacting the global research landscape and potentially diverting funds from other crucial research areas.
Shift in microbial ecology: the persistent presence of CPE can alter microbial ecology, potentially disrupting the balance of microbial communities within the human body and the environment, which could have unforeseen repercussions on health and ecosystems.
Overall, addressing both short-term and long-term detriments of CPE requires concerted global efforts, including robust surveillance, research and development of new antibiotics, rational use of existing antibiotics, and implementation of stringent infection control measures.
Australia’s response to CPE
Australia has initiated countermeasures against CPE through systems like CARAlert, which has underscored a stark increase in CPE cases, predominantly in individuals aged 50 years and older. Despite the surge in reports, considering CPE merely as a hospital infection control problem can thwart the efficacy of our response strategies. The strategic blunder in underestimating the scope of CPE can lead to unchecked transmission in community settings and among vulnerable demographics like the elderly in aged care facilities.
While current estimates paint a relatively benign picture of Australia’s CPE burden, proactive, harmonised, and systematic strategies are imperative to stave off potential calamities. The inception of the Australian Centre for Disease Control (provided in this year’s budget) stands as a beacon of hope, projected to orchestrate a unified, evidence-based approach to CPE surveillance and public health action. A nationally consistent notification of CPE, fortified funding mechanisms for lab detection, structured sharing of comprehensive data across jurisdictions, and integration of surveillance data using a One Health framework are essential components in refining our response to CPE.
What’s next
The response to CPE underscores the importance of swift, collective efforts, scientific inquiry, and advancements in antibiotic solutions. The emphasis is on the consolidation of resources and knowledge to counteract the pervasive threats posed by such antibiotic-resistant entities. By adopting structured, collaborative, and science-driven strategies, there is potential to safeguard public health, optimise healthcare systems, and mitigate the economic repercussions related to CPE.
The establishment of the Australian Centre for Disease Control is a significant development, poised to play a pivotal role in orchestrating effective, evidence-based strategies against CPE. This initiative is expected to drive harmonised approaches and foster innovation in addressing antibiotic resistance. The Centre is anticipated to be at the forefront in advancing research, refining surveillance, and bolstering public health actions to manage and control CPE effectively.
Additionally, continued and enhanced research is paramount, especially among populations experiencing CPE cases. This requires consistent support for research initiatives, emphasising the development of novel antibiotics and interventions to counter antibiotic resistance.
It is crucial for medical professionals, researchers, and policymakers to remain informed about the evolving landscape, contribute to evolving scientific understanding, and collaboratively work to address the challenges posed by antibiotic-resistant bacteria like CPE. The integration of research, innovation, and coordinated action is fundamental to navigating the complexities of antibiotic resistance and ensuring the well-being of communities globally.
