FOR more than half a century, scientists have been signalling the dangers of human-induced climate change, and nobody listened. It’s here.

For decades, scientists have been highlighting the serious threat posed by pandemics, and nobody listened. We were caught napping despite the increase in their frequency over time. It cost us big time and we have yet to recover.

Scientists have also been warning about AntiMicrobial Resistance (AMR) for decades, and again few have listened.

In fact, the inventor of penicillin, Alexander Fleming, warned about AMR in his Nobel lecture of 1954:

“I would like to sound one note of warning. Penicillin is to all intents and purposes non-poisonous, so there is no need to worry about giving an overdose and poisoning the patient. There may be a bigger danger, though, in under-dosage. It is not difficult to make microbes resistant to penicillin in the laboratory by exposing them to concentrations not sufficient to kill them, and the same thing has occasionally happened in the body.

“The time may come when penicillin can be bought by anyone in the shops. Then there is the danger that the ignorant man may easily under-dose himself and by exposing his microbes to non-lethal quantities of the drug make them resistant.”

The resistance of bacteria to penicillin is essentially evolution in action.

A good example of evolution in action is provided by the peppered moth, which in a short period of time turned black when soot and smoke from coal burning blackened trees in industrial England in the late 1800s. It is a mutation in the gene cortex that is responsible for darkening the wings of some peppered moths.

Recently, Christopher Murray and a very large group of collaborators have published in the prestigious medical journal, The Lancet, a paper entitled, Global burden of bacterial antimicrobial resistance in 2019: a systematic analysis.

In their analysis, the authors estimated 4.95 million deaths to be associated with bacterial Antimicrobial Resistance (AMR) in 2019, including 1.27 million deaths attributable to bacterial AMR. This should constitute yet another wake-up call.

If you look at the timeline of antibiotic development, you will see that the time between antibiotic development and resistance by the microbes has become practically zero and that we have not developed a new antibiotic since 2011.

In fact, the latest discovery of a new antibiotic class reached the market back in 1987. It would seem that we are losing the battle against ubiquitous microbes.

That has some serious implications and poses some big questions. For instance, how will we conduct surgeries once we run out of antibiotics that work?

The World Economic Forum has recently described AMR as a “silent epidemic,” and one of the most dangerous threats to global health. They make the following important points:

• Antimicrobial resistance, rendering antibiotics ineffective, is incredibly harmful, associated with 4.95 million deaths in 2019.
• A significant cause of antimicrobial resistance is over-prescribing antibiotics and inadequate diagnostics for the right therapeutic solution.
• Adequate data collection along the health value chain is important for valuable insights to inform prescriptions properly.

The fact that AMR kills millions is hard to dispute and it is also clear that resistance to antibiotics causes resistance.

The second point, and one we don’t seem to take seriously, is that to combat AMR we need to prescribe the right antibiotic for the right pathogen and do it quickly. There is no time to lose in bringing an infection under control.

Unfortunately, this is where we fall down. Centralised laboratory facilities mean that in order for an accurate diagnosis to be handed down and treatment started requires a sample to reach a laboratory quickly.

Despite the best efforts of those involved, collecting samples from around the Eastern Bay and delivering them to a centralised facility in Tauranga can take up to 72 hours and that is 72 hours too slow.

Nowadays, the identification of bacterial and fungal isolates (bugs) is no longer performed using microscopes and staining techniques; it is done using a technique called Matrix Assisted Laser Desorption-Ionisation-Time of Flight Mass Spectrometry (MALDI-TOF MS) which is fast, accurate and inexpensive. But wasting time getting a sample to a lab decreases the chances of a good clinical outcome for patients.

In the words of Calderaro & Chezzi “MALDI-TOF MS represents the most relevant revolution introduced in the last few years that is able to make a contribution to the clinical microbiology setting for the identification of pathogenic bacteria and fungi and the detection of resistance to antimicrobial drugs”.

The cost of these instruments is dropping quickly. A new instrument would cost in the $300,000-$400,000 range while refurbished instruments can be purchased for $75,000-$100,000.

In the scheme of scientific instruments, this is not expensive. Aside from faster and more accurate identification of pathogens compared to traditional techniques, the MALDI-TOF MS technique has been shown to significantly reduce costs.

If a sample that is taken from a patient has to travel from one location to another, this speed advantage is lost. The sample needs to get from the person to the instrument ASAP.

That is not happening with our current set-up in which samples are collected from, in some cases, relatively remote communities and then have to make their way to a centralised laboratory.

In our region, the reason that microbiology testing is centralised in Tauranga rather than being performed in Whakatāne is because it is supposedly cheaper that way.

However, in the long run, a delay in diagnosing can result in patient hospitalisation, which will end up being much more costly, especially when correct diagnosis can cost only a dollar or two.

My experiences with the Ministry of Health suggests that it is quite likely that in this country no one has done the numbers properly.

Having microbiological facilities for diagnosing infectious diseases centralised in Tauranga is probably great for Tauranga residents, but not so flash for folk living in ours and neighboring districts.

Since MALDI-TOF MS instruments are not so expensive I have to ask, why we can’t have one located here in Whakatāne?

If we can spend millions of dollars on road safety management, which I’m told adds 30-40 percent to the cost of building roads, then why can’t we do better to combat the serious and potentially catastrophic problem of AMR?

In New Zealand in 2019, there were 330 deaths attributable to AMR and 1500 deaths associated with AMR.

Whakatāne Hospital has become something of a regional facility. It is one of the biggest employers in our district with about 800 staff.

Recently, a new Magnetic Resonance Imaging (MRI) scanner has been installed in our hospital by Bay Radiology, which will offer state-of-the-art imaging of soft tissue to complement the X-ray CT scanner that has been in operation in the hospital for years. Installation of the MRI should be completed by year’s end.

The Pathology Laboratory at Whakatāne Hospital is run by a private outfit, Pathlab, and does a great job of hematology. However, it is the microbiology samples that need to be transported to their centralised laboratory in Tauranga.

I look forward sometime in the future to the introduction of routine Point-of-Care Testing (POCT).

POCT is clinical laboratory testing conducted close to the site of patient care where care or treatment can be provided. Technologies such as lab-on-a-chip devices that integrate laboratory functions on nano-chip are still a way off but they are coming.

Clinical practice and the delivery of patient care are also areas where Artificial Intelligence (AI) is likely to play a significant role in the coming decade.

Imagine talking to Doctor AI, telling it your symptoms and providing it whatever diagnostics you have at hand (e.g. blood pressure, pathology tests, or diagnostic images).

Doctor AI has read the entire medical literature and would use your test results to come up with an accurate diagnosis within seconds. I suspect we are not far off.

AI is already being used in healthcare and in drug design.

-Victor Luca