WAAW 2024: As an infection specialist, doctors dial me up for advice, some calls make me wonder — is next pandemic already knocking on our doors?

"How can this be happening!" – was the angry greeting from my neonatologist (specialist with neonatal healthcare) on a Tuesday morning a couple of years ago. 

I then heard him talk about how he was struggling to save the life of a prematurely born boy, who was born six days back and had been in the neonatal ICU ever since. 

Somewhere within these six days in the hospital, he had contracted a bacteria called carbapenem resistant Enterobacteriaceae (CRE) that was now causing sepsis (bloodstream poisoning). 

The chances of a patient surviving this infection are as low as 60 per cent let alone a prematurely born infant with an undeveloped immune system. 

Almost miraculously, after a month-long fierce struggle in the hospital, this boy went home alive. 

A month later, a couple of twin infants, who were two weeks old, were admitted into this same neonatal ICU, both of whom had contracted another pathogenic bacteria called multi-resistant Acinetobacter baumannii (MRAB) sepsis.

Tragically, only one of the two infants survived.

In my 26 years as a physician in which 22 years have been spent as an infectious diseases physician in a busy tertiary public hospital in Malaysia’s Klang valley, I am used to receiving many requests for consultation when it comes to pathogenic infections. 

Most are routine calls from colleagues seeking advice or reassurances on recognising or managing endemic infections like HIV, TB, dengue, COVID-19, syphilis or other common bacteria or viruses. 

Sometimes rare and interesting (to the extent of being exotic) germs or long forgotten infections like whooping cough, leprosy, tetanus, diphtheria rear their malicious heads. 

I am grateful for the great minds of the past who had figured out these bugs and by whose training I am able to guide others on how to manage and often cure these infections. 

‘Gut-wrenching calls’

However, the trouble begins when gut-wrenching calls like the ones above are received.  I call them gut-wrenching because CRE and MRAB are two bacteria specifically mentioned in the World Health Organization’s list of ‘critically prioritised bacteria’ due to their ability to resist treatment and spread resistance to other bacteria – a phenomenon widely referred to as antimicrobial resistance (AMR).

In other words, these two germs occupy the top spots for being the nastiest bacteria on the planet. 

I also find them gut-wrenching because it is usually the infants or the vulnerable people they infect.  While every human life is precious, we would all agree that there is something intrinsically tragic when one of the weakest, most vulnerable people among us battle these nasty germs — and often lose.

What is even more alarming is that these bugs are no longer uncommon in our hospitals.

Just 10-15 years ago, CRE and MRAB would belong in the rare category I mentioned earlier. Today, they have found their way into many patients in our wards and ICUs.

Even then, there are still hallowed areas in our hospitals like the neonatal ICU and the operation theatres, that have remained largely protected from the scourge of these bugs. 

Witnessing these nasty germs now cross these thresholds makes me shudder — which explains the outburst from my neonatologist colleague. 

For some patients who contract these germs, even if they survive, they would be permanently scarred by the obligatory use of aggressive curative means which even includes surgeries or amputations or be left with permanently damaged internal organs. 

Not to mention, a prolonged and highly expensive hospital stay.  

How did we get to this state and what are the implications if this threat is left unchecked? From the earliest days of the discovery of antibiotics, it had already been recognised that bacteria are capable of evolving in the presence of antibiotics, where stronger or more ‘fortunate’ strains among their species are able to resist the antibiotic and propagate through selection pressure. 

Antibiotics — when less is more

Thus, while antibiotics can be life and limb saving when used appropriately, doctors need to avoid injudicious and wanton use to minimise the threat posed by AMR. 

Once a resistant bacterium emerges, given the right circumstances and environment, it will spread especially to those more vulnerable. 

This occurs especially so in crowded hospitals and in areas where infection prevention practices are less than perfect. Just like other infections (COVID-19, influenza, Mpox, leptospirosis), AMR also exists in animals, often being selected out in animal farming environments and from there, spreading to the human sphere, often through the food chain. 

This is why today we address AMR through the lenses of ‘One Health’, which combines human, animal, plant and environment concerns.

One only needs a casual Google search to realise how totally life changing antibiotics have been in these last 100 years, providing the essential building blocks of modern health and allowing for the possibility and advances in surgery, chemotherapy, transplants and critical care.

The emergence and continued march of AMR threatens this very fabric of modern medicine. 

Globally and locally, from governments and the United Nations down to the average human or animal health care practitioner,  AMR is now being recognised for the looming disaster it threatens to be, and all of us are charged to be responsible stewards of antibiotics and prevent spread of AMR. 

This battle requires the average man on the street to be thoughtful of AMR and learn necessary precautions to avoid its spread (e.g. seek advice from qualified health professionals before taking antibiotics). 

We all share this responsibility to ensure antibiotics are properly stewarded and judiciously prescribed both in human as well as animal health. We owe it to our forefathers to ensure the generations to come continue to reap the benefits of these miraculous and wonderful but easily abused precious resource. 

Views expressed are author's own and don't necessarily reflect that of Down To Earth

The author is an Infectious Disease Consultant at Sungai Buloh Hospital, Ministry of Health, Malaysia