A girl plays with Paddington the rat at the Royal Easter Show in Sydney, Australia. Picture: Justin Lloyd Source: Herald Sun

In my 18 months of taking my turn overseeing the Vancouver Island Health Authority diagnostic microbiology laboratory I have been involved in the diagnosis of 3 cases of Streptobacillus moniliformis infection.

All three were quite serious requiring several days of hospital care. All three involved pet rats. At least 2 of them were not associated with a bite but were associated with very intimate “face to face” contact with the rat. I believe there have been four more cases within the last 3 years diagnosed in our lab. Seven cases in one small city in three years associated with pet rats without bites.

Rat bite fever is a serious infection that can be fatal. All rats have S. moniliformis in their mouths. All rat owners are at risk. It is clear that close contact without a bite can transmit this infection. It seems reasonable that an attempt be made to inform rat buyers of the risk and that there is a role for public health.

Likewise physicians need to be aware of the possibility and ask febrile patients specifically about rat contact.

The most recent case is summarized here Rat Bite Fever

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public service noun

1. : the business of supplying a commodity (as electricity or gas) or service (as transportation) to any or all members of a community
2. : a service rendered in the public interest

It fulfills both of these dictionary definitions perfectly. Stewardship programs provide a service to members of communities — The community of healthcare providers to aid in their provision of care and to the community at large to provide the ongoing benefits of the availability of effective antimicrobials. This is very much in the public interest.

More established public services such as the police, fire fighting and waste removal are easy to conceptualize and understand. Others such as fisheries and forest management are more difficult. Few would dispute that the management of common resources is important, however. Common to all are several elements.

Information
Could the Department of Fisheries perform its’ functions without information? Of course not. Just as information about fish stocks is necessary to define sustainable fish harvest quotas, information is necessary to manage antibiotics. Fortunately, much of the information needed to manage antibiotic use is readily available. Millions of susceptibility tests are performed and all antibiotics distributed for human use are under prescription and have records associated. We haven’t yet done a good job of collation, redistribution and display but it is only a small amount of idea and resource away.

Manpower
Nothing ever prospers as a “side of the desk” endeavour. Why would Antimicrobial Stewardship be any different? It needs dedicated thoughtful people with appropriate skill sets – just like anything else. The good news is that evaluations of established AS programs have shown cost savings even after taking account the increased expenditures on manpower. Antimicrobials have been so poorly managed that there is much wasted resource. There is a large potential to turn misused antimicrobials into excellent, well-paid, stable jobs for Canadians.

Policies and Procedures
Policies are informed by principles and guide procedures. Goal statements and metrics for evaluation are central. Nothing unusual about this. However, this is new in Canada and much trial and error is to be expected. The principles should be firmly established but procedures will necessarily be diverse as Canadian health delivery is diverse.

Education
The cornerstone of sustainability. All established conservation programs become easier to enact as the benefits are recognized by more and more people. They become the norm.

Canada is poised for a Antimicrobial Stewardship revolution. We have the enthusiasm, the people and the need. We just need some structure.

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IE7 Favorite Bar HD from Jim Hutchinson on Vimeo.

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After a reasonably long and patient courtship with Drupal, we have cast it aside in favour of WordPress. Terry (the web design master) and I think infectionNet scrubs up quite well with her new content management software. There is a bit of tweaking yet to do so don’t fret over a bit of messed up formatting.

The elements are all still there – articles, notes from medical school lectures and laboratory protocols and I have added some important new sections. Therapy guidelines are derived from the Vancouver Island Health Authority’s Antimicrobial Review Committee’s empiric guidelines that were produced during a recent collaborative antibiotic stewardship effort at Cowichan District Hospital.

The Discussions section has been revamped and, hopefully, is a more user-friendly way of finding answers to your questions and to interact with peers. It is now easy to sign up with your Facebook or Google IDs and have your say.

The Cases section is very lean on content at present but there are plenty of interesting cases and they need display. Keep checking back, or better yet tell me about yours.

Be sure to sign up for email updates, and follow us on twitter as infectionNet is going to be much more proactive and interactive. If you have any suggestions at all please let me know using the contact form.

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In 2005 the first ministers conference saw a plea for a national pharmacare plan endorsed by all premiers. It was widely discredited as a provincial grab for federal money as a response to pharmaceuticals being the most rapidly expanding sector of healthcare expenditure. It was scoffed at by the federal government and deemed to be “too expensive” for consideration. This despite overwhelming evidence that the buying power and reduced bureaucracy afforded by cooperation would result in significant savings.

How about just antimicrobials? The federal expense would not be prohibitive. Outpatient antimicrobials total less than a billion dollars annually. It could lay the groundwork for future expansion to other classes and most importantly it would distinguish antimicrobials as needing special regulatory attention.

A National Antimicrobial Pharmacare plan is a sensible approach to the ever-expanding problem of antimicrobial resistance.

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Stewardship is entirely different. It is an ethic that embodies cooperative planning and management of resources and conjures the notion of help and guidance. One who prescribes antibiotics poorly needs guidance.

I think this subtle shift in the language of antibiotic policy may help us immensely. Rather than demanding prudent use regulations that imply the stamping out of immorality we can offer frameworks for regulatory bodies to cooperatively guide prescribers. That guidance may necessarily have to include restrictive policies but with the restrictions arrived at in a more consensual fashion.

If you are interested in Antimicrobial Stewardship check out the International Society of Chemotherapy’s new Inventory of Antimicrobial Stewardship projects.

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This graph show the changes in the individual classes of 4 C’s. Very impressive reductions demonstrating the power of organized stewardship efforts.

Thanks to Dr. Ian Gould for sharing this. This project was specifically designed to reduce the incidence of C. difficile by reducing the use of antibiotics most associated with C. difficile disease. Read more about The 4 C’s Project here at the International Society for Chemotherapy’s World Inventory of Antimicrobial Stewardship site.

It appears that Scotland is making great strides in organized antimicrobial stewardship having established a country-wide multidisciplinary forum in 2008 referred to as the Scottish Antimicrobial Prescribing Group (SAPG). Read more about their efforts here at the SAPG website.

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Solution
InfectionNet/Lab. Modern, web-based, well-displayed information accessible to all. One version. Controlled creation and editing. Easily enhanced.

In two short months this means of creating and displaying microbiology laboratory protocol information has been not only accepted but very actively embraced by Eastern Health laboratory staff. They have discussed, suggested improvements, and taken steps to assuming ownership of the content.

Good design effecting positive change – excellent.

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Formed stool received. Test cancelled.

ME1SD

This specimen has not been processed as a specimen collected on the same day has already been processed

MEMS

Multiple specimens received. Only the most recently collected specimen has been processed.

ME3D – Enteric 3 days or> in hospital

Patient has been hospitalized for 3 days or more.

Because infectious diarrhea caused by normal bacterial and protozoal pathogens is extremely unlikely to be acquired in hospital, ova and parasite and culture examination will not be performed.

If the sample is diarrheal a C. difficile cytotoxin assay will be performed. If you feel a nosocomial outbreak is occurring please contact the Infection Control Officer. If there are unusual circumstances warranting a culture or ova and parasite exam please contact the microbiology laboratory.”

MFSCDT – Enteric formed CDT not done

Specimen consisted of FORMED STOOL which indicates that C. difficile testing is not warranted. If examination seems clinically indicated, please contact the microbiology laboratory.

Back to Stool Culture

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Fluoroquinolones have only been in existence since the 1980s and first licensed for sale in Canada in 1988. They were the first new class of antibiotic introduced for many years and were received with extreme expectations. They were widely touted as the solution to antibiotic resistance to penicillins, tetracyclines, sulfa antibiotics and others. Ciprofloxacin, the most successful of the class was brilliantly marketed to community-based physicians as having “IV power in an oral formulation”.

In 20 short years one might say “the arse has well and truly fallen out of ‘er”. Fluoroquinolones are all but useless for many clinical indications. 20 years! All over the world!

Another good reason to increase attention to antibiotic misuse and develop the regulatory structures needed to tackle this urgent and relentless problem.

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