Australian travellers who have been hospitalised in countries where there’s a high risk of acquiring highly drug-resistant bacteria will be kept in isolation after returning home if they are found to be infected.
The decision to segregate sick returned travellers is part of a nationwide health strategy designed to prevent the deadly superbugs from spreading here.
The draft guidelines are expected to be finalised by September and in place across Australia by the end of this year. They were unveiled at the Australasian Society of Infectious Diseases conference on the Gold Coast last week.
Delegates also heard that travellers visiting Asia who engage in unprotected casual sex are also at a much higher risk of contracting drug resistant strains of sexually transmitted diseases, especially gonorrhoea, and infecting a partner in Australia before they’re diagnosed.
In his presentation, Associate Professor David Whiley, of the Queensland Children's Medical Research Institute (QCMRI) at the University of Queensland, said strains of extensively-drug resistant (XDR) gonorrhoea had been detected in several countries and sexual health experts believe their arrival in Australia is ‘only be a matter of time’.
Air travel fuelling spread of superbugs
Rapid international air travel is providing an unprecedented opportunity for the transfer of antibiotic-resistant bacteria, according to a leading Australian infectious diseases specialist, Associate Professor John Ferguson. Assoc Prof Ferguson, the director of the Infection Prevention and Control at Hunter New England Health in NSW, presented the guidelines at the conference.
Of particular concern are carbapenem-resistant Enterobacteriaceae (CRE) bacteria.
“The emergence of CRE and their spread across the world create special risks for patients and potential challenges for healthcare infection control,” Assoc Prof Ferguson said.
“When carbapenem antibiotics are no longer effective, we have to turn to a handful of ‘last-line’ antibiotics that are expensive and often less effective.
“As such, infections due to CRE are much harder to treat and have higher mortality rates.
“In some cases, no antibiotics are effective. In such cases, mortality is very high.”
Australia needs a national approach
The guidelines will recommend testing for CRE in the following travellers admitted to hospital on their return to Australia:
- those directly transferred from any overseas hospital.
- those who were admitted overnight to an overseas hospital or who resided in a residential care facility overseas in the previous 12 months.
- those who had contact with a CRE patient during previous hospitalisation and have not had tests that prove they are not infected.
Patients will be systematically questioned about their travel history during the hospital admission process as part of a national implementation.
Under the guidelines a sick returned traveller might spend at least 2 days awaiting the results of tests to detect CRE.
If CRE is found, strict infection control measures will include isolation in a single room and a requirement that hospital staff caring for the patient wear protective clothing to minimise the risk to themselves and other patients.
CRE spreads rapidly among patients, staff
CRE typically ‘colonise’ the gastrointestinal systems of humans and spread easily from person to person through contaminated water sources, on the hands of healthcare personnel, or on virtually any item of equipment used in hospitals, nursing homes and other healthcare facilities.
“Most people are unaware of this as they have no symptoms of infection,” Dr Ferguson said.
“Some may remain colonised with CRE for 6 months or longer.
“People at highest risk from infection are those with compromised immune systems and those undergoing treatment in hospitals, especially those using temporary medical devices like catheters or ventilators.
“Typically, there is a high mortality rate among patients who develop septicaemia or other serious infection due to CRE.”
Strict hygiene the key to prevention
Strict hand hygiene by healthcare staff is the key to preventing the spread of multidrug-resistant microorganisms. Attention to cleaning and disinfection of all healthcare environments is also critical.
“The unnecessary use of antibiotics in hospitals and the wider community also drives the spread of multidrug-resistant microorganisms and it’s important to reduce their use,” Professor Ferguson said.
“We need to ensure that antibiotics are used only in situations where they are really needed, but that is a great challenge.”
Control of an outbreak hinges on screening to identify patients or hospital staff who are colonised or infected by a superbug, then isolating and treating them to effectively eliminate the risk of the infection spreading.
CRE spread will see more local deaths
Most types of CRE have been introduced into Australia by travellers, including New Delhi metallo-beta-lactamase-1 (NDM-1), although secondary spread has been limited.
However, increasing numbers of CRE cases due to a local type of CRE known by its gene name, IMP-4, are being detected in Australia. It was first detected in 2004 and has affected patients along the Eastern seaboard with outbreaks and clusters recorded in several locations.
‘‘Numbers are still very low numbers, but they are slowly rising,’’ Assoc Prof Ferguson said.
“If CRE is allowed to spread unchecked, then the number of patients with serious, at times fatal infection will increase.
“Subsequent control measures will become much more difficult than at present when CRE detection is still a relatively rare event.”
Early implementation of consistent national measures is critical for controlling CRE in Australia. A taskforce of specialists in infection control, infectious diseases and microbiology was formed by the Australian Commission on Safety and Quality in Healthcare to develop the new guidelines.
Logistical challenges for hospitals
New Zealand conference delegate, Dr Joshua Freeman, of the Auckland District Health Board, warned of potential logistical challenges in implementing the new guidelines.
As superbugs become more commonplace, isolating patients in single rooms could tax the resources of hospitals, and result in delayed treatment, more adverse events, and anxiety for patients, he said.
Similar procedures will also be put in place for a returned traveller arriving home with symptoms of illness, especially if their travel history put them at risk of other infectious diseases.
These could include China’s deadly H7N9 bird flu, which has killed 43 of the 130 people infected, or the Middle East Respiratory Syndrome coronavirus (MERS-CoV), which has now claimed 46 of the 94 people infected to date.
Fortunately, apart from MERS in hospital settings, neither disease spreads easily and to date are seen as a low risk for travellers.