Dr. Hari Paraton: Drug-resistant bacteria threatens lives of mothers and newborns

2022-05-24

In general, administering stitches to close tears on mothers who have newly delivered a child are a safe and common procedure. However, with the handling of post-delivery sutures and the risk of infection it can be a different story. What are supposed to be happy moments for parents with their new born baby, after going through the delivery process, might sadly end in grief.

This was experienced by Dr Hari Paraton, an obstetrician and gynecologist from Surabaya, Indonesia, who handled a patient, (we will call her “Paramita”) with abnormal post-delivery stitches. Instead of drying out, the wound on the stitches just got worse and wider.

Dr. Hari Paraton, Sp.OG(K) is an obstetrician and gynecologist currently practicing at RSIA Lombok Dua, Surabaya, East Java, Indonesia. He completed his Obstetrics and Gynecology Specialist study at the School of Medicine, Airlangga University, Surabaya.

In addition, he is also a member of the Indonesian Doctors Association (IDI) and the Indonesian Obstetrics and Gynaecology Association. He served as the Chairperson for the National AMR Containment Committee under the Ministry of Health from 2014 to 2019.

After two years of marriage Paramita gave birth to their first child

Paramita, a 35-year-old woman had been married for less than two years and the birth of her first child should have been the most beautiful gift for her and her husband. However, the happiness did not last long when the post-delivery stitches caused a prolonged infection.

During the labour process, the health workers who assisted Paramita gave her antibiotics after administering stitches.

Paramita’s wound did not heal – infection entered the bloodstream

When Paramita’s stitches did not improve she was referred to several doctors. Every time she was referred, she was given a beta-lactam group of antibiotics and the wound was stitched up again. The wound never healed.

Paramita had broad necrosis luas in the perineal area that spread to become systemic infection, sepsis. Her isolate pathogen E.coli was multi-drug resistant and no antibiotics could stop the sepsis infection.

Dr Paraton said that when Paramita was referred to the Dr. Soetomo Hospital, the stitches had widened from the vagina to the anus and infection had entered the bloodstream, causing sepsis. The wound in the area was filled with the bacteria E.coli that are resistant to most antibiotics. No effective antibiotics were available in the country to fight the bacteria.

Paramita did not survive

According to Dr Paraton, even when faced with severe cases of drug-resistant bacteria, doctors could usually control the source of infection. If the source of infection is a suture, then the stitches will be reopened, and the existing suture thread removed. Tragically, this ended in a very sad way for Paramita and her family. When the team of doctors performed a surgery to control the source of the infection, she did not survive.

Crucial to understand proper use of antibiotics

It is important for health workers to understand appropriate use of antibiotics – to help keep antibiotics effective when needed. All use of antibiotics increases pressure on the microbial ecosystem and accelerates selection of bacteria with the genetic mechanism to protect them from the medicine. When this happens, the choices of antibiotics that are effective against bacteria will decrease.

Therefore, clinicians must use antibiotics wisely. Before administering antibiotics to patients, a well-informed health worker will first determine whether the cause of the infection are bacteria or not. If it is a bacterial infection, the doctor will choose the proper antibiotic while also checking whether the patient has received antibiotics before and whether the patient has comorbidities.

Sepsis in neonatal ward

Dr Paraton shared another story about antibiotic resistance that he experienced in one of the hospitals where he worked. The hospital had eleven healthy babies who were born prematurely and kept under special care. Later, the hospital admitted an additional infant patient with sepsis that had been earlier treated in several hospitals with antibiotics. The new baby was placed in the same room as the other babies.

Subsequently the eleven healthy babies also became ill. The test results showed that they were infected with the pan-resistant Acinetobacter baumanii bacteria, the same bacteria that had infected the newborn septic baby.

Transmission of bacteria via stethoscope – changed and provided a stethoscope for each baby

After investigation, it was found that the transmission of bacteria from the septic baby to other babies in the ward occurred through a stethoscope. Responding to the incident, the hospital management issued a regulation preventing unauthorized doctors and nurses from entering the nursery. The hospital also provided a stethoscope for each baby so that one stethoscope is not used on more than one baby. It put out instructions to staff that the stethoscope used should also be cleaned frequently.

Antibiotic stewardship at hospitals saves lives

As a place with a high risk of infection of resistant bacteria, Dr Paraton said, all hospitals are required to have an Antibiotic Resistance Control Committee (KPRA). The Hospital Accreditation Commission will check the presence of KPRAs in hospitals when conducting assessment for hospital accreditation.

The practice of antibiotic stewardship at Dr. Soetomo Hospital in Surabaya, for example, has been carried out through the Integrated Infection Case Study Forum (Forkkit). The purpose is to prevent patients from receiving the wrong antibiotics. Antibiotic evaluation and administration are carried out prospectively, no longer retrospectively. Prescriptions given by doctors will be selected by the pharmacy department and evaluated by referring to the AWaRe grouping.

To date, Forkitt has made a difference at the Dr. Soetomo Hospital. Before antibiotic stewardship was practiced, the use of meropenem could reach 1950 bottles a month. After the stewardship, the monthly use of meropenem was down to 363 bottles. In addition, the number of Carbapenem-Resistant Enterobacteriales (CRE) also fell from 17.19 percent to 3.13 percent.

The existence of KPRA or antibiotic stewardship programs in hospitals can reduce the number of healthcare-associated infection. The infection rate in health facilities is an indicator of its service quality. It was estimated that in the United States, 1 out of every 25 hospitalized patients are affected by an hospital acquired infection (3).

Written by: Adhitya Ramadhan

References

1, Clinical and economic burden of antimicrobial resistance.Maragakis LL, Perencevich EN, Cosgrove SE Expert Rev Anti Infect Ther. 2008 Oct; 6(5):751-63.
2, The challenges of antimicrobial drug resistance in Greece. Miyakis S, Pefanis A, Tsakris A Clin Infect Dis. 2011 Jul 15; 53(2):177-84.
3, Magill SS, Edwards JR, Bamberg W, et al. Multistate Point-Prevalence Survey of Health Care–Associated Infections. New England Journal of Medicine 2014; 370:1198-208.
4, Global burden of bacterial antimicrobial resistance in 2019: a systematic analysis. Murray, Christopher JL et al. The Lancet, Volume 0, Issue 0.