Methicillin-resistant Staphylococcus Aureus 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 best known of the ‘superbug’ bacterium, so christened because of their resistance to a vast swathe of conventional antibiotics. In the 2000s, what was 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 heath authorities rigorously tightened hygiene standards and the prescription of antibiotics. As a result, infection levels have dropped to levels where mention of MRSA only occasionally intrudes onto 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 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, WHO released a report showing that between 27–40% of Ecoli samples collected in Qatar were resistant to fluoroquinolones and cephalosporins. And this April, a study published in the Journal of Clinical Microbiology found that identical iterations of drug-resistant Acinetobacter baumannii had been found Saudi Arabia, Kuwait and across the wider Gulf region.
Community care
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 Alqahtani, a physician at the Bahrain Defence Force Hospital and one of the country’s leading microbiologists. The factors that have led afflicted Bahrain with a superfluity of drug-resistant bacteriological infections are largely those present throughout the Gulf. It began with the lax enforcement of prescription practices.
“Until recently, you could go to any pharmacy here and purchase a prescription antibiotic without a physician’s signature,” says Alqahtani. “Since early this year, the [Bahraini] National Health Regulatory Authority implemented new rules for prescriptions.”
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 minority of respondents thought antibiotics were just as safe when taken with milk. Misconceptions about appropriate dosage, stopping times and drug reusability were also uncovered. Another survey conducted in 2009 showed 56.3% of respondents admitting to self-medicating themselves 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.
One area in which this lack of education has a direct impact is in the treatment of imb 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 foot infections that could normally be treated with antibiotics in early stages instead often see patients only submitting to care when 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 Alqahtani, the subset of infections involving complications with MRSA result in even more serious consequences for the patient. “We’re seeing five cases of MRSA diabetic foot infection a week at the Bahrain Defence Force Hospital,” he explains. “The majority of them are going to require amputation.”
Another problem that has been identified is the growing presence of Carbapenem-resistant bacterium (CRE) – a family of germs that are difficult to treat and can be deadly, due to high resistance to antibiotics. CRE infections most commonly appear as healthcare-related infections. “They’re resistant to some of the strongest antibiotics, like Meropenem,” confirms Alqahtani. “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.”
Antibiotic stewardship
Since December 2014, the Bahraini authorities have been conducting a survey to determine the prevalence and molecular structure of CRE.
“So far, 62 isolates that screened positive for potential carbapenemase production have been assessed,” adds Alqahtani. “45 were found to produce it. 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.”
With the scale of antibiotic resistance having reached intolerable levels throughout the region, the need for health authorities to take concerted action has become self-evident. One of the first fronts being opened 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, IT 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.
Power balance
After leading the country’s first outpatient parenteral antimicrobial therapy programme in February 2012, Alqahtani 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. He joined the Bahrain Defence Force Hospital in 2010 after conducting his Fellow of The Royal College of Physicians of Canada degree in North America. Alqahtani’s thesis was on the potential utility of an ASP in his homeland.
An initial challenge came in persuading hospital staff to trust in his restrictions on prescribing antibiotics.
“One of the major barriers in implanting the programmes has actually been to convince them that I’m not taking their powers away from them,” says Alqahtani. “It is the first time we have worked together as a team on this issue. And I think that’s the most enjoyable thing. You work with the nurse, with a pharmacist, with a microbiologist, 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.”
The programme also has the added benefit of collecting the data on infection and antibiotic resistance rates that has 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 Alqahtani. “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.”
A local lead
Efforts within the region are also under way to enable national health authorities 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. “We regularly have patients coming in from Saudi Arabia to Bahrain, for example,” says Alqahtani. “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 defend against the rise in the number of superbug infections. Global pharmaceutical companies are essentially 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 the initiative of doctors such as Alqahtani and his colleagues that will serve to prevent future outbreaks and safeguard the state of clinical hygiene not only in Bahrain, but also across the GCC.
