The ASID test

The Australasian Society for Infectious Diseases view on infectious diseases challenges in 2016 and beyond

This year, 2016, is a historic year for the Australasian Society for Infectious Diseases (ASID), being the 40th anniversary of the formation of the society. It is an opportunity not only to celebrate our achievements in infectious diseases and microbiology over the past 4 decades but also to anticipate future challenges. Principal among these are antimicrobial resistance (AMR) and the emergence or re-emergence of previously controlled or unrecognised diseases.

Although infectious diseases were thought to have been conquered as public health problems 40 years ago, our complacency has been repeatedly challenged by new and re-emerging threats. In this issue of the MJA, we read about re-emergence of Ebola virus,1 preparedness for Zika virus2 and local transmission for hepatitis E3 as salient examples. Williams and colleagues also describe the diagnosis of subacute sclerosing panencephalitis in a 23-year-old man,4 a timely reminder that high levels of herd immunity are required to prevent measles outbreaks, which still occur in parts of Australia with suboptimal immunisation rates.5 But emerging infections are not only viral. In this issue, Mandrawa et al discuss carbapenem-resistant Klebsiella,6 which highlights the serious impact of AMR on clinical practice.

AMR remains a global challenge. It results in about 2000 attributable deaths per year in Australia and a projected 10 million globally by 2050.7 As antibiotics become less effective, old diseases re-emerge, many in Australia’s near neighbours. Tuberculosis (TB) remains one of the most lethal infectious diseases with a third of the world’s population being infected, and over 1.5 million annual TB-related deaths worldwide.8 In this issue, Cheng and Trauer report on the increase in multidrug-resistant TB in Australia and the region.9 Another disease from times past, gonorrhoea, is also re-emerging as increases in AMR result in treatment failures. In 2015, the National Neisseria Network reported a marked increase in rates of gonococcal disease, with the highest ever proportion of strains on record with reduced susceptibility to ceftriaxone, and high-level resistance to azithromycin recorded for the first time.10 These patterns reflect trends around the world, and as noted by Lahra and colleagues, suggest that Neisseria gonorrhoeae is emerging as a global public health threat.10 Both TB and N. gonorrhoeae emphasise our need for national, coordinated AMR surveillance in humans and animals so we can monitor and respond to these trends.

Surveillance alone will be ineffective if there is not a clear plan to reduce the AMR threat, as well as a coordinated mechanism to implement this plan across jurisdictions (which is currently lacking). The federal government released its national AMR strategy in late 2015.11 A key element is the need to develop a “one health” approach to antimicrobial stewardship, including capture of prescription data in both humans and animals, and regulation of antimicrobial use and national antimicrobial guidelines for veterinary practice and agriculture. Guideline development in animals and humans needs to be supported by implementation science to improve uptake and adherence. We also need to reduce the unnecessary use of antibiotics, which is estimated to occur in up to 75% of antibiotic prescriptions in Australia,12 the bulk of which are dispensed in primary care. There needs to be coordination of strategies to address this problem across stakeholders including professional colleges and societies. ASID, led by Professor Denis Spelman, and the Royal College of Pathologists Australasia have collaborated with the Royal Australasian College of Physicians’ EVOLVE campaign to list the top five low value interventions in infectious diseases and microbiology practice.13 These include the use of antibiotics for asymptomatic bacteriuria, leg ulcers without clinical infection, uncomplicated upper respiratory tract infections, and faecal pathogens in the absence of gastrointestinal symptoms (with some exceptions). Avoiding inappropriate diagnostic tests is one important aspect of reducing antibiotic prescribing for these conditions. For example, as Bowen et al report in this issue,14 faecal multiplex polymerase chain reaction testing results in high rates of reporting of the non-pathogenic parasites Dientamoeba fragilis and Blastocystis spp., which could lead to unnecessary antibiotic use in patients who test positive.

Another benefit of reducing unnecessary antibiotic use is reduction of adverse events. In their study of medical inpatients at a Melbourne hospital, Trubiano and colleagues found that almost one in four had a serious antibiotic allergy, most commonly associated with overuse of broad spectrum agents.15 Of particular concern was poor documentation of allergies in patient records and charts.

Over the past 40 years, members and affiliates of ASID have contributed to paradigm-shifting approaches to infectious diseases and microbiology — including the elimination of smallpox and the link between Helicobacter pylori infection and duodenal ulcers. Who knows what challenges lie ahead. We are on the cusp of personalised medicine that will predict our risk of disease, inform our likely response and guide our therapy. We must, however, remain mindful of key lessons from the past, so that history does not repeat itself. As Kurt Vonnegut, Jr wrote: “History is merely a list of surprises. It can only prepare us to be surprised yet again.”