A generation in microbiology A generation in microbiology and infection controland infection control

- eclipse and regeneration- eclipse and regeneration

Professor Brian Duerden CBEProfessor Brian Duerden CBEInspector of Microbiology and Infection Inspector of Microbiology and Infection

Control,Control,Department of Health, LondonDepartment of Health, London

……a personal journeya personal journey

1968 – first microbiology (bacteriology) class1968 – first microbiology (bacteriology) class1970 BSc Med Sci Bacteriology1970 BSc Med Sci Bacteriology1972 MBChB1972 MBChB1979 MD,MRCPath; Sen. Lecturer/Cons.1979 MD,MRCPath; Sen. Lecturer/Cons.1983 Professor of MM, Sheffield1983 Professor of MM, Sheffield1990 Professor of MM, Cardiff & PHL Dir1990 Professor of MM, Cardiff & PHL Dir1995 Dep Dir/Med Dir PHLS; 2002 Dir of PHLS1995 Dep Dir/Med Dir PHLS; 2002 Dir of PHLS2003 HPA Dir for Clinical Quality2003 HPA Dir for Clinical Quality2004 Inspector of MM & IC, DH2004 Inspector of MM & IC, DH

Infection is different…….Infection is different…….

…….it spreads!…….it spreads!

BiologyBiology

Microbial populationsMicrobial populations

Human populationsHuman populations

Human behaviourHuman behaviour

Human population - worldHuman population - world

6.5 ‘billion’6.5 ‘billion’

6.5 x 106.5 x 1099

6,500,000,0006,500,000,000

Bacterial population - manBacterial population - man

500 million million500 million million

(500 true billions)(500 true billions)

5 x 105 x 101414

500,000,000,000,000500,000,000,000,000

per person!per person!

Ignac Semmelweis 1818-1865Ignac Semmelweis 1818-1865

1844 – MD Vienna1844 – MD Vienna

1846 July – Lecturer 1846 July – Lecturer in Obstetricsin Obstetrics

1846 October – 1846 October – removed from postremoved from post

1847 March – 1847 March – returned to Viennareturned to Vienna

Kolletschka dies from Kolletschka dies from autopsy woundautopsy wound

The first 100 yearsThe first 100 years

Microbes cause disease!!Microbes cause disease!!– Pasteur, Koch Pasteur, Koch et alet al

Antisepsis and asepsisAntisepsis and asepsis– ListerLister

VaccinesVaccines

Antibiotics and chemotherapy Antibiotics and chemotherapy – Ehrlich, Fleming Ehrlich, Fleming et alet al

1945-19701945-1970

Antibiotic eraAntibiotic era

–SUCCESS!!SUCCESS!!

19681968

“Infectious diseases have been “Infectious diseases have been conquered”conquered”

William StewartWilliam Stewart

Surgeon General, USASurgeon General, USA

New infections - since 1975New infections - since 1975

HIVHIV

vCJDvCJD

Hepatitis C, EHepatitis C, E

HTLV; HHV6, 7, 8 HTLV; HHV6, 7, 8

Lassa, EbolaLassa, Ebola

Nipah; HendraNipah; Hendra

Hantavirus (Hantavirus (SNSN))

Avian fluAvian flu

SARSSARS

LegionellaLegionella

CampylobacterCampylobacter

C. difficileC. difficile

Helicobacter pyloriHelicobacter pylori

E. coli E. coli O157O157

Vibrio cholerae Vibrio cholerae O139O139

CryptosporidiumCryptosporidium

ChlamydiaChlamydia

Re-emerging and resurgentRe-emerging and resurgent

TuberculosisTuberculosis

DengueDengue

MalariaMalaria

CholeraCholera

West Nile virusWest Nile virus

Yellow feverYellow fever

PolioPolio

1985 – the slippery slope1985 – the slippery slope

Clinical microbiology developingClinical microbiology developingVirology diagnostics starting to emergeVirology diagnostics starting to emerge

BUTBUTThe antibiotic heyday – a drug for every bug!The antibiotic heyday – a drug for every bug!Cancer and heart disease top the pollsCancer and heart disease top the pollsOutbreaks – low priorityOutbreaks – low priorityEXCEPT HIV/AIDS – but a different specialty!EXCEPT HIV/AIDS – but a different specialty!Moves to disband the PHLSMoves to disband the PHLSMedical education – break with traditional sciences; the Medical education – break with traditional sciences; the rise of social study and “communication”rise of social study and “communication”

1990 – 20001990 – 2000

The nadir – training numbers cut!The nadir – training numbers cut!

Eclipse – microbiology in the backroomEclipse – microbiology in the backroom

Antibiotic use imprudentAntibiotic use imprudent

EMRSA soar out of controlEMRSA soar out of control

C. difficile C. difficile affects ever more patientsaffects ever more patients– But does anyone notice?But does anyone notice?

Microbiology fights for self preservationMicrobiology fights for self preservation– But does not use its main asset – patients!But does not use its main asset – patients!

Medical Education and AcademiaMedical Education and Academia

1983 – a professorial head in every medical 1983 – a professorial head in every medical school – what now?school – what now?1980-90 Drug company research funding1980-90 Drug company research funding1990 – 2000 loss of identifiable courses1990 – 2000 loss of identifiable courses2003 GMC Tomorrow’s Doctors2003 GMC Tomorrow’s Doctors– No mention of infectionsNo mention of infections

2010 GMC Tomorrow’s Doctors2010 GMC Tomorrow’s Doctors– Recognises infection (HCAI mainly)Recognises infection (HCAI mainly)

Research Assessment ExercisesResearch Assessment Exercises– Bias against applied clinical research Bias against applied clinical research

1980s-90s : the backroom days1980s-90s : the backroom days

IncreasingIncreasing– HCAIHCAI

MRSAMRSAClostridium difficileClostridium difficileAcinetobacterAcinetobacterNorovirusNorovirus

– Antimicrobial Antimicrobial resistanceresistance

ESBLESBL

– Pandemic threatsPandemic threats– Need for Need for

microbiology!!microbiology!!

DecreasingDecreasing– Training numbersTraining numbers– Academic inputAcademic input

Reduced medical Reduced medical student impactstudent impactEffect of RAEEffect of RAEDislocation of Dislocation of academic/service academic/service interface interface

– Training in asepsisTraining in asepsis– Supply of Supply of

microbiologists!!microbiologists!!

World Disaster Report 2000World Disaster Report 2000

International Federation ofInternational Federation of Red Cross/Red Crescent Red Cross/Red Crescent

INFECTIOUS DISEASE IS INFECTIOUS DISEASE IS BIGGEST KILLERBIGGEST KILLER

13 million deaths in 199913 million deaths in 1999100,000 deaths from natural disasters100,000 deaths from natural disasters

Getting Ahead of the Curve - 2002Getting Ahead of the Curve - 2002

Emphasis on Health ProtectionEmphasis on Health Protection

Emerging threatsEmerging threats– Infections, chemicals, radiologicalInfections, chemicals, radiological– Natural eventsNatural events– Deliberate release and bioterrorismDeliberate release and bioterrorism

Priorities identifiedPriorities identified

Health Protection Agency to be createdHealth Protection Agency to be created

NHS responsibilities to contribute to HPNHS responsibilities to contribute to HP

Microbiology standards - Inspector Microbiology standards - Inspector

Priorities fromPriorities from GAC GAC

HCAIHCAI– bacteraemia (MRSA, GRE)bacteraemia (MRSA, GRE)– C. difficile C. difficile associated diarrhoeaassociated diarrhoea– surgical site infectionsurgical site infection

TuberculosisTuberculosis

Blood-borne & sexually transmitted viruses Blood-borne & sexually transmitted viruses (and others!)(and others!)

Antimicrobial resistance Antimicrobial resistance

House of Lords - 2003House of Lords - 2003

Fighting Infection Fighting Infection – England has not experienced major England has not experienced major

epidemics in recent yearsepidemics in recent years

– this is due more to good fortune than this is due more to good fortune than good managementgood management

– improvements are neededimprovements are needed

Public HealthPublic Health

1974 Medical Officers of Health abolished1974 Medical Officers of Health abolished1984 Health Act1984 Health Act– Retained notifications from 1860sRetained notifications from 1860s

1980s – major outbreaks1980s – major outbreaks– Legionella – StaffordLegionella – Stafford– Salmonella – Stanley Royd, WakefieldSalmonella – Stanley Royd, Wakefield

1989 CCDC created1989 CCDC created2002 Getting Ahead of the Curve2002 Getting Ahead of the Curve2008 Health and Social Care Act2008 Health and Social Care Act– Notification overhauledNotification overhauled– Laboratory notification from October 2010Laboratory notification from October 2010

Bacterial meningitisBacterial meningitis

Meningococcal meningitis - facinatingMeningococcal meningitis - facinating– 1980 – lowest numbers; c. 1000 reports1980 – lowest numbers; c. 1000 reports– 1980-90 steady rise – mostly Group B1980-90 steady rise – mostly Group B– 1990s continued rise; B & C; >20001990s continued rise; B & C; >2000– 1999 MenC vaccine – dramatic effect!1999 MenC vaccine – dramatic effect!– 2000s – some fall in B; vaccine needed!!!2000s – some fall in B; vaccine needed!!!

Haemophilus influenzaeHaemophilus influenzae b b– 1980s – as many as meningococcal <5y1980s – as many as meningococcal <5y– 1992 Hib vaccine – dramatic effect!1992 Hib vaccine – dramatic effect!

1996-8 small increase; booster vaccine1996-8 small increase; booster vaccine

Influenza AInfluenza A

A century of pandemicsA century of pandemics1918 – H1N11918 – H1N1– Devastating; killed young peopleDevastating; killed young people

1957 – Asian flu1957 – Asian flu– Spread in children & young peopleSpread in children & young people– Severe illness in elderlySevere illness in elderly

1968 – Hong Kong flu1968 – Hong Kong flu– Variants became seasonal fluVariants became seasonal flu

[2005-10 Planning for the next pandemic][2005-10 Planning for the next pandemic]

2009 – Swine flu – H1N1v2009 – Swine flu – H1N1v

Influenza pandemic strainInfluenza pandemic strain

New strainNew strain– Very different from recently circulating strainsVery different from recently circulating strains

Able to infect humansAble to infect humans

Readily transmissible , person to personReadily transmissible , person to person

Causes illness in high proportion of those Causes illness in high proportion of those infectedinfected

Spreads widely because few have any Spreads widely because few have any immunityimmunity

Weekly GP consultations for fluWeekly GP consultations for flu

Food-borne infectionsFood-borne infections

The rise (to 1990) and fall of The rise (to 1990) and fall of SalmonellaSalmonella– SalmonellaSalmonella in eggs “scandal” in eggs “scandal”

The rise and rise ofThe rise and rise of Campylobacter Campylobacter

Mid-1980s onward – BSE/vCJD/prionsMid-1980s onward – BSE/vCJD/prions– Food chain; 1000s of cases predicted Food chain; 1000s of cases predicted – Surgical instruments; decontamination issuesSurgical instruments; decontamination issues– Blood safetyBlood safety

AND AND E. coli E. coli O157 (VTEC)O157 (VTEC)

VTEC infectionsVTEC infections

Very small infectious doseVery small infectious dose– Highly infectiousHighly infectious

1990s – undercooked hamburgers1990s – undercooked hamburgers– ““barbecue infection”barbecue infection”– Cooking standards for commercial burgersCooking standards for commercial burgers

Person-to-person (child-to-child)Person-to-person (child-to-child)– Nursery schools; need for personal hygieneNursery schools; need for personal hygiene

Open farms (petting farms)Open farms (petting farms)

Burgers – why not rare steak?Burgers – why not rare steak?

BurgersBurgers– Chopped meatChopped meat– Contamination all Contamination all

throughthrough– Must be fully cookedMust be fully cooked

SteakSteak– Contamination on Contamination on

outsideoutside– Killed by direct heatKilled by direct heat– Inside not Inside not

contaminatedcontaminated

VTEC – why farms?VTEC – why farms?

E.coli E.coli O157 common in animalsO157 common in animals– Cattle, sheep, goats, pigs etcCattle, sheep, goats, pigs etc– No illness in animals – normal commensalNo illness in animals – normal commensal

Animal faeces contaminate pens, grassland, Animal faeces contaminate pens, grassland, footpathsfootpaths

Children’s hands contaminated from touchingChildren’s hands contaminated from touching– Animals, gates, fences – animal environmentAnimals, gates, fences – animal environment– Own shoes!Own shoes!

…………what do we do about it?what do we do about it?

AnaerobesAnaerobesC. difficile C. difficile is not the only one!is not the only one!1975-85 the Anaerobe Renaissance1975-85 the Anaerobe Renaissance– 1977-8 1977-8 Bacteroides fragilisBacteroides fragilis in abdominal wounds in abdominal wounds

Metronidazole prophylaxis – dramatic reductionMetronidazole prophylaxis – dramatic reduction

1985 Anaerobe Discussion Group agenda1985 Anaerobe Discussion Group agenda– C. difficile;C. difficile; molecular taxonomy; oral infections; GU infections molecular taxonomy; oral infections; GU infections

(vaginosis); anaerobic cabinets; routine diagnostic tests(vaginosis); anaerobic cabinets; routine diagnostic tests

BUT BUT “Anaerobes isolated, metS” the norm“Anaerobes isolated, metS” the norm1990s – eclipse; except 1990s – eclipse; except C. difficileC. difficileLate 1990s – 2010 Lemierre’s diseaseLate 1990s – 2010 Lemierre’s disease– Fusobacterium necrophorum Fusobacterium necrophorum resurgence – why?resurgence – why?

2000 2000 C. novyi C. novyi in IVDUs (then in IVDUs (then C. tetani, C. botulinumC. tetani, C. botulinum))BUT BUT “Anaerobes isolated, metS” still the norm“Anaerobes isolated, metS” still the norm

AntibioticsAntibiotics

1980s major Pharma activity and spending1980s major Pharma activity and spending– Anti-gram-negative agentsAnti-gram-negative agents– Cephalosporins +++, fluoroquinolones ++Cephalosporins +++, fluoroquinolones ++

1990s Profligate (imprudent) use1990s Profligate (imprudent) use– BUT no new agentsBUT no new agents– Funding decreasesFunding decreases– Resistance increasesResistance increases

2000s Stewardship and prudence2000s Stewardship and prudence– An uphill struggleAn uphill struggle

Strategy - 40 years of reports Strategy - 40 years of reports Swann Report – animals & vet. med. 1969Swann Report – animals & vet. med. 1969House of Lords House of Lords – Antibiotic resistance 1998Antibiotic resistance 1998– ………… …………. Revisit 2001. Revisit 2001– Fighting infection 2003Fighting infection 2003

Standing Medical Advisory Committee Standing Medical Advisory Committee – Path of Least Resistance Path of Least Resistance 19981998

Chief Medical OfficerChief Medical Officer– Getting Ahead of the CurveGetting Ahead of the Curve 2002 2002– Winning Ways Winning Ways 20032003

Infection prevention & controlInfection prevention & control

1980s Infection Control Officers (doctors) 1980s Infection Control Officers (doctors) and Nursesand Nurses– No specific trainingNo specific training– HIS createdHIS created– Cooke Report 1Cooke Report 1

1990s Cooke Report 2; 1990s Cooke Report 2; C difficileC difficile guidance; MRSA guidanceguidance; MRSA guidance

Did anyone read or listen!!Did anyone read or listen!!

Staphylococcus aureusStaphylococcus aureus

Courtesy of Centers for Disease Prevention and Control, Atlanta, GA, USA

Staphylococcus aureus bacteraemia and methicillin susceptibility (voluntary reporting scheme):

England and Wales, 1990 - 2004

0

2000

4000

6000

8000

10000

12000

14000

16000

18000

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004

year

nu

mb

er

of

rep

ort

s

Sensitive

No Information

Resistant

C. difficile C. difficile voluntary reporting 1991 – 2005: voluntary reporting 1991 – 2005: England, Wales and Northern IrelandEngland, Wales and Northern Ireland

0

5000

10000

15000

20000

25000

30000

35000

40000

45000

50000

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

year

nu

mb

er

of

rep

ort

s

Clostridium difficile Clostridium difficile diseasedisease

Late 1970sLate 1970s– Antibiotic-associated diarrhoeaAntibiotic-associated diarrhoea– Pseudomembranous colitisPseudomembranous colitis– Toxic megacolonToxic megacolon

Linked toLinked to– Clindamycin (including surgical prophylaxis)Clindamycin (including surgical prophylaxis)– Broad spectrum antibioticsBroad spectrum antibiotics

1991 - 19941991 - 1994

1991 - 92 : large outbreak in Manchester1991 - 92 : large outbreak in Manchester– 170+ cases; 17 deaths (at least)170+ cases; 17 deaths (at least)– Elderly patients; winterElderly patients; winter– High antibiotic useHigh antibiotic use

Reference Lab PyMS typing confirmed Reference Lab PyMS typing confirmed cross-infectioncross-infection

Parliamentary questions!Parliamentary questions!

Smaller outbreaks widespreadSmaller outbreaks widespread

C. difficile C. difficile reports (voluntary scheme)reports (voluntary scheme)

0

5000

10000

15000

20000

25000

30000

35000

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

Nu

mb

er

of

rep

ort

s

75+ years

65-74 years

45-64 years

15-44 years

The political responseThe political response

Do something!!

[…..to reduce the numbers]

0

100

200

300

400

500

600

700

Oct-Dec07

Jan-Mar08

Apr-Jun08

Jul-Sep08

Oct-Dec08

Jan-Mar09

Apr-Jun09

Jul-Sep09

Oct-Dec09

Episodes of MRSA

bacteraemia

Trust-apportioned All other episodes

The future?????The future?????MRSA – maintain controlMRSA – maintain control– Bacteraemias AND other infectionsBacteraemias AND other infections– What about MSSA? And PVL-SA??What about MSSA? And PVL-SA??

C. difficile – C. difficile – stop the outbreaksstop the outbreaks– What is the impact of the wider health and social care What is the impact of the wider health and social care

community?community?– Improved treatment?Improved treatment?

Other organisms – ESBL-producersOther organisms – ESBL-producers– Carbapenemase-producers etcCarbapenemase-producers etc

Antibiotic resistance and prescribingAntibiotic resistance and prescribing………….there is still much to be done!.there is still much to be done! ………… …………but who will do it?but who will do it?

Roles in Medical MicrobiologyRoles in Medical Microbiology

Teamwork and specialisationTeamwork and specialisation– Laboratory expertiseLaboratory expertise

Diagnostic specialisationDiagnostic specialisation

Reference laboratoriesReference laboratories

– Clinical - laboratory interfaceClinical - laboratory interface– Clinical advice…….and management?Clinical advice…….and management?– Control of infectionControl of infection– Health protectionHealth protection

Epidemiology, surveillance, preventionEpidemiology, surveillance, prevention

Evolution……Evolution……

From Medical Microbiologists From Medical Microbiologists and ID Physicians to and ID Physicians to Infection DoctorsInfection Doctors

- - a spectrum of skills in a spectrum of skills in one specialtyone specialty

2010 and beyond……2010 and beyond……

Infection –Infection –

there’s still a lot of it aboutthere’s still a lot of it about

(and we neglect it at our patients’ peril)(and we neglect it at our patients’ peril)

Man and MicrobeMan and Microbe

War and peaceWar and peace–Pathogenicity and symbiosisPathogenicity and symbiosis

……..to be continued (for ever!)..to be continued (for ever!)