At an INTEGRATE AMR networking meeting, Warwick Medical School's Dr Esther Robinson brought home just how serious a problem antimicrobial resistance poses from a clinician's perspective.

1. On the edge of the abyss
Dr Esther Robinson 1st March 2016

2. View from the clinical frontline
Postcard from the
edge
Into the Void
Bridging the Gap

3. It all starts with a patient…
Mr S, DOB xx.xx.xx
Specimen type: nephrostomy urine
Result: E.coli isolated
CPE isolated
Positive for OXA-48, sent to
reference laboratory for confirmation

4. Clinical questions
• Antibiotic treatment?
• Where did Mr S catch it from?
• Where will it go?

5. Alphabet soup
CRO
CPE
CRE
MDRO
MDRE
MDREc
ESBL
OXA
KPC
NDM
VIM
IMP
CTX-M
TEM
ROB
SHV
AMPC

6. Ward screening
• Rectal swab PCR:
• Index case: CPE OXA-48
– 2 OXA-48 (not in same bay), 1 KPC
• None of them are E.coli
• What does that mean?

7. Into the void

8. Rise of the resistance
0
10
20
30
40
50
60
70
MRSA bacteraemia rates per 100k population
E coli bacteraemia rate per 100k population
MRSA and E. coli bacteraemia rates E. coli antibiotic resistance
0
10
20
30
40
50
60
70
80
2002 2004 2006 2008 2010 2012 2013
coamox
amox
cipro
ctx
tzp
mero

9. Selection pressure
www.openprescribing.net

10. Wider perspective

12. Nightmare bugs

13. Holding back the tide
• CPE screening: national policy, local
variety in implementing (money)
• Infection control measures: failing?
• Stewardship: balancing on the edge of
surviving sepsis and reducing
antimicrobial use

14. Bridging the gap 1: teetering on
the brink
• How do we use existing antibiotics optimally
to retard resistance?
• Can new/ rapid diagnostics improve control of
spread/ inform better antimicrobial use?

15. Bridging the gap 2: beyond the
abyss
• New drugs: prevent spread of resistance
– Can we cure plasmid in vivo or out-compete it?
– Target drugs to site of infection: limit collateral
damage, selection pressure
• New drugs: conventional antibacterials and
alternatives