CRK Practice News - July 2018 | C.R. Kennedy

CRK Practice News - July 2018

Inside this issue                                                               

  • Antimicrobial resistance
  • LCI for sessile serrated adenoma/polyp detection

Antimicrobial Resistance (AMR)

Antibiotics have delivered health and longevity for many people since the 1940s, but their continued effectiveness is now uncertain.  We are in an era that hangs dangerously in the balance and perilously close to seeing a return to scenes of the pre-antibiotic era; a time when even common garden variety bacterial infections could be relied upon to cause death and disarray: but this time, it will be known as the "post-antibiotic" era. 

It is mooted in many articles, reports, news items and professional talks that by 2050 the annual, global death rate from antimicrobial-resistant (AMR) bacterial infection will have risen from 700,000 deaths presently, to nearly 10 million; seeing antimicrobial resistance an alarming concern for everyone involved.
There are presently several bacteria that are resistant to one or more antibiotics (antimicrobials), and some critically so. 
It is suggested that almost 50% of E. Coli strains are resistant to one or more antibiotics, and extreme concern with critical priority, is held regarding Pseudomonas aeruginosa, Acinetobacter baumannii, and Enterobacteriaceae; all of which are gram-negative bacteria that are resistant to carbapenem - the antibiotic that is considered the last resort when all others have failed.

And we thought MRSA was a big deal!  Methicillin-resistant Staphylococcus Aureus is still a major concern but is quickly being overtaken.


Photo by Michael Schiffer on Unsplash

"Critical concern is held regarding several gram-negative bacteria that are resistant to carbapenem - the antibiotic that is considered the last resort when all others have failed"

Contributing to AMR is the over-prescribed, off-target (broad-spectrum) use of antibiotics and the fact that oftentimes people don't take the full course. 
These practices give bacteria exposure to antimicrobials, but not in the amounts that kills them: letting the bacteria adapt, morph, and gain resistance.

Far from prudent when it comes to prescribing and taking antibiotics, it appears that in Aotearoa New Zealand we still ingest a lot of antibiotics.  As this report released in 2017 by the Ministry of Health (MOH) and the Ministry for Primary Industries (MPI) states "New Zealand communities have increased their consumptions of antimicrobials by as much as 49% between 2006 and 2014".  And, according to the same report we are high up the ladder in relation to 29 European countries, being the 8th highest consumer of antibiotics.

The other part of the problem is that presently new antibiotics/antimicrobials are not being produced at any rate that looks to combat this crisis.  Would you believe that it has been about 30 years (the late 1980s) since the last truly new antibiotic was released?  Part of the reason: it simply isn't profitable researching and designing new antibiotics - especially if those drugs are going to be held back as a drug of last choice when all others have failed.

So, we certainly are in a predicament.

 "By 2050 the global death rate from AMR bacterial infection will rise from 700,000 deaths presently to nearly 10 million per annum"

Bacteria reside on the surface of and within the human body without concern; it is “normal” and provides a protective element. 

In the healthcare setting, when bacteria are transferred from one person to another, be it via personal contact or via hospital-acquired routes, it is concerning; especially in the immune suppressed, elderly, very young, or frail person. 
Likewise, bacteria entering an area of the body wherein it does not typically reside can also cause problems (think E. coli and urinary tract infections).
Hospital-acquired infections (HIAs) (formally known as nosocomial) are particularly worrying.  When a person enters our service and leaves with an infection acquired during their care we need to be asking “why and how did this happen?" 
It needs to prompt us to review what we are doing i.e our processes and address any issues that are found.

 “Superbugs will leave us with nowhere to turn if things do not change”

As this article shows, we still aren’t getting it right when it comes to basic activities that decrease the transfer of bacteria.  As recently as this year the study found that "10 major and large NSW hospitals fell below the national benchmark of 80% compliance with best practice", suggesting that when not watched or under scrutiny levels of hand hygiene falls away drastically.

Superbugs like the one mentioned in this article will leave us with nowhere to turn if things do not change, and while we aren’t going to be the ones designing the new era of antimicrobials we are the ones who will safeguard the future by maintaining excellence when it comes to hand hygiene, correct use of PPE, infection control processes, and of course, the best choices in medical devices and accessories, reprocessing and storage. 

As the saying goes: the future is on our hands.

UPDATE SEPTEMBER 2019: As this NZ report shows there is still much room for improvement as we aim to minimise the spread of bacteria in our healthcare environments

National hand hygiene compliance report: 1 April 2019 to 30 June 2019 

Jane Townsend RN RM PGDipHSc 2018 


LCI for sessile serrated adenoma/polyp detection

Colorectal cancer (CRC) related deaths are high throughout NZ and the world.
Detection and treatment of pre-malignant polyps is imperative in decreasing the number of deaths attributed to CRC. 
Presently it is thought that colorectal polyps are missed on colonoscopy nearly 28% of the time, with the right side colon being where most polyps are overlooked; this has lead to the search for innovative new technologies to try and mitigate this potential underdiagnosis.  Linked Colour Imaging (LCI) is one of these innovations.

research article recently out of Japan describes a study that examined the effectiveness of Fujifilm's Linked Colour Imaging in the detection of sessile serrated adenoma/polyps (SSA/Ps), in comparison to white light imaging (WLI), blue laser imaging (BLI), and BLI bright.

Expert and non-expert endoscopists read 200 images of the same locations taken using the 4 light modes: WLI, BLI, BLI bright, and LCI.

Linked Colour Imaging (LCI) was found to have a detection rate of SSA/Ps that was significantly higher than standard white light imaging (WLI).  Polyps that were not found under the gaze of WLI were subsequently found under LCI, to an increased rate of 21.6%. 
There were no further polyps found under WLI subsequent to LCI.

Additionally, the colour differential (redder becomes redder while the white becomes whiter) gained by the LCI appeared to give higher and more definitive recognition of differing mucosal and vessel patterning; thereby leading to a higher detection of SSA/Ps.

It was concluded that Linked Colour Imaging (LCI) is the most sensitive mode for the colonoscopic detection of sessile serrated adenoma/polyps.  

"We clearly showed that LCI (Linked Colour Imaging) is superior to conventional WLI with a significantly greater ability to detect SSA/P during colonoscopy" 

Fujimoto, D., Muguruma, N., Okamoto, K., Fujino, Y., Kagemoto, K., Okada, Y., . . . Takyama, T. (2018). Linked colour imaging enhances endoscopic detection of sessile serrated adenoma/polyps. Endoscopy International Open, 6, E322-E334. doi:10.1055/s-0043-124469

Jane Townsend RN RM PGDipHSc 2018