Yes. Thank you.
Evidence of meeting #77 for Health in the 42nd Parliament, 1st Session. (The original version is on Parliament’s site, as are the minutes.) The winning word was antibiotics.
A recording is available from Parliament.
Evidence of meeting #77 for Health in the 42nd Parliament, 1st Session. (The original version is on Parliament’s site, as are the minutes.) The winning word was antibiotics.
A recording is available from Parliament.
November 7th, 2017 / 4:45 p.m.
Conservative
Marilyn Gladu Conservative Sarnia—Lambton, ON
Thank you, Chair, and I'd like to thank our witnesses as well for taking the time to be with us today.
I'm going to start with a question for Dr. Rau.
I was very interested when you detailed where we are seeing this kind of resistance in Canada: in ICU burn units, in cystic fibrosis, in oncology. It's mainly in hospital environments.
You also outlined a concern about foreign travel and new Canadians and that maybe there's a risk there. The reason that's interesting to me is that I've heard a lot of criticism that says that the reason we're having antimicrobial resistance has to do with agriculture and farming in Canada. Some farms are organic and aren't giving antibiotics. Other farmers give antibiotics when the animals are sick, and sometimes they give them preventatively.
Can you comment? Is there any truth to the link between farms and agriculture and the AMR that we see now?
4:45 p.m.
Infectious Diseases Specialist and Medical Microbiologist, Halton Healthcare
There is truth to the link between farm use of antibiotics for animal husbandry purposes and drug resistance, but I don't think it applies so much to Canada. In Europe it was definitely observed, especially with the emergence of vancomycin-resistant enterococci, which, as it turns out, is not as important a bug right now in terms of having a drug discovery void, where we don't have anything left to treat people with. Although I think it's very important for us to clean up those practices where they are occurring here and I wouldn't ignore them, I don't think that's where the biggest problem is in this environment.
Again, it goes to that triangle I spoke to. Our environment is not the same as the environment in a developing country, where you have antibiotics ending up in sewage water and contaminating tap water, such as in India, for example.
4:45 p.m.
Conservative
Marilyn Gladu Conservative Sarnia—Lambton, ON
To focus on foreign travel, I used to travel around the world myself. I was in charge of over 254 plants, and eventually I became germ resilient. However, every time I came home, everyone in my family got sick.
With that in mind, and thinking about people who are coming from Europe and the Middle East and Asia, there is no testing for people visiting. You can fly in on a plane, and there's no testing in place. Do you think the screening for new Canadians is adequate, and would you suggest, for countries of concern, that those screening tests be applied to travellers?
4:45 p.m.
Infectious Diseases Specialist and Medical Microbiologist, Halton Healthcare
I don't want this to turn into airport screening. That's for sure, and I will say that at the outset, but there is a form of screening we are doing for hospital-admitted patients who fit certain risk factors. It is not simply visitors. It's true that visitors who come into the hospital, who walk in, might have a drug-resistant bug on them, but they're not necessarily transmitting infections. Many people are carrying these infections. If they become ill and then have an intravenous put in or end up on dialysis or on a breathing machine, that very bug that's living on them as a commensal now becomes a pathogen.
Finding those people who are carriers of those bugs, if they fit certain criteria, is becoming a subject of great interest. That's actually a lab resource issue. For example, we, in my hospital, have implemented a selective screening protocol, as per our province's guidelines, to look for carriage. Again, it can be very resource-intensive to chase something that's not common. It's sort of like chasing, at airport security, the killer maple syrup that's out there that someone's bringing onto the airplane. It is the same idea. We have to be careful that we don't turn this into airport screening. It has to be selective and targeted. The technology has to be there, and the support and resources for a hospital to add that to its budget have to be there, which speaks to a point I made earlier.
4:45 p.m.
Conservative
Marilyn Gladu Conservative Sarnia—Lambton, ON
This question is for the Canadian Patient Safety Institute.
I was astounded to hear that in terms of patient safety, these infections are actually the third-leading cause of death. It's that severe. I had no idea. What do you think the government could do to address that problem?
4:45 p.m.
Senior Director, Strategic Partnerships and Priorities, Canadian Patient Safety Institute
Certainly even having these discussions is important. That again is why we are here: to provide that lens to raise awareness around patient safety, even with our political leaders across the country. Antimicrobial resistance is a patient safety concern. There are many different types of patient safety incidents, and these conversations around how patient safety is a public health crisis are really important conversations.
Within that same study I cited and that we recently released, we know that if nothing changes over about the next 30 years, 12.1 million Canadians will be harmed by the health care they receive, and 1.2 million of them will die because of health care safety issues. While the human cost of this is certainly significant—and that's just the human toll—it's estimated the financial cost of our poor performance as a country, in both patient safety and acute care and home care, which is where the data was drawn from, over that same 30-year period will be $82 billion.
I would challenge us that as a country, as political leaders, we're not doing enough around patient safety to really draw the attention to the things that aren't going well. There are many different competing demands and priorities within health care. Harm reduction around the opioid crisis is certainly a patient safety concern. We are doing many different activities in support of the joint statement of action, and certainly at local levels as well, and working with the health systems and patients to address some of these issues.
As a precedent as well, antimicrobial resistance is also a medication safety issue. We've been talking about appropriate use of antimicrobials and appropriate antimicrobial stewardship, and our colleagues have certainly spoken to the significant need. Political leaders around the world, through the World Health Organization, as well as health ministers around the world, are starting to talk about how patient safety should be an issue for political leaders. The World Health Organization has also announced a third global patient safety challenge on medication safety, called Medications without Harm. It has a really ambitious aim of reducing severe, avoidable harm related to medication by 50% in five years. Canada can achieve this goal, and our efforts and our support around antimicrobial resistance can go a long way toward Canada's achieving that aim.
4:50 p.m.
Conservative
Marilyn Gladu Conservative Sarnia—Lambton, ON
Excellent.
I have a final question, then, for Dr. Shevchuk.
As a pharmacist, are there things that can be done at that end? Once people have been given a prescription and you're filling it, is there something that can be done there that would address this issue?
4:50 p.m.
Associate Dean Academic and Professor, College of Pharmacy and Nutrition, University of Saskatchewan, As an Individual
With respect to resistance, certainly we want pharmacists to know what the indication for the antibiotic is so that they can also make a decision about whether it is the best choice for that particular patient in that situation. There's always the option of having a conversation with the prescriber about that.
One thing that can potentially reduce resistance is making sure that antibiotic courses don't go too long. The other thing to look at is the length of the course of therapy. There's data out there that tells us that for very simple, uncomplicated urinary tract infections, three days are enough. You don't need a week. Just by shortening the course....
There are a number of strategies that people can use. People with viruses feel unwell. They feel sick. They need treatment too. It's simply that an antibiotic is not the treatment. There are other things. There are fever reducers and analgesics and things that can help a cough and a sore throat that could go a long way to making patients feel better. There are lots of strategies that pharmacists can use.
4:50 p.m.
NDP
Don Davies NDP Vancouver Kingsway, BC
Thank you, Chair. Thank you to all the witnesses for being here.
Dr. Rau, I have a few questions for you. In a 2007 article published in the Toronto Star, you're quoted as saying that the implementation of a provincial tracking system would help family physicians diagnose drug resistance and identify strains of bacteria early so that they could be treated properly. Can you update us on the status of those kinds of tracking systems in Canada?
4:50 p.m.
Infectious Diseases Specialist and Medical Microbiologist, Halton Healthcare
In that case I was referring to community-associated MRSA. It really hasn't changed much, now that you raise it. People know it's out there. They'll have their own experience as physicians in obtaining a culture and seeing there's a bit of drug resistance out there. What they don't know is, a priori, if I have a patient in front of me, what's the probability that they have a drug-resistant infection? If they think it's very high, they're going to use the big-gun antibiotic and blow it away with that antibiotic. Over a period of time, if everybody keeps doing that.... If they know the rate is only 5%, they might take a chance and stay with the more conservative antibiotic, knowing the probability is low.
They might obtain a culture, but not everyone has that luxury when they're in an ambulatory community setting. It's easy sometimes for us who are hospital-based to criticize how people are behaving out in the community as prescribers, but they also have limited resources, so they have to go based on symptoms. They don't have diagnostic tests to tell them if it is a virus or not, which we might have in a hospital.
Still, the tracking thing, giving that pre-test chance of it being resistant, is missing, and that's what we need. It's the same thing even for these ominous, critical priority pathogens: if we think in hospital that someone has one of these real superbugs and we don't know yet, and we don't have the rates, we have a problem. We're going to start using the big-gun new antibiotic that comes out and blow it away.
4:55 p.m.
NDP
Don Davies NDP Vancouver Kingsway, BC
It's 10 years since you wrote that article. It sounds as though we haven't made a lot of progress in the provincial tracking system you recommended.
4:55 p.m.
Infectious Diseases Specialist and Medical Microbiologist, Halton Healthcare
We haven't progressed much in the federal system either. We have good labs that collect good data. We have some community labs, private labs, that publish resistance rates, like LifeLabs in Ontario, but we don't have a national clearing house, which should also have local data, because we can't use just national data. You need local data, because there are differences. Brampton, for example, has way more drug-resistant pathogens in hospital patients than Brandon does.
4:55 p.m.
NDP
Don Davies NDP Vancouver Kingsway, BC
Conventional advice to patients was that if you stopped your antibiotics course too soon, you would help breed resistance. Others say that resistance primarily emerges when bacteria are exposed to antibiotics, so the longer bacteria are exposed to antibiotics, the greater the risk of resistance developing. What is your view?
4:55 p.m.
Infectious Diseases Specialist and Medical Microbiologist, Halton Healthcare
This old wives' tale, if I can call it that, has been somewhat demystified in the last year—the idea that when you get an antibiotic course, you have to finish it. You have to take the whole course. We now know there is no evidence for that, and people are encouraging shorter-course regimens, as Dr. Shevchuk was saying. If it is not an infection due to bacteria, we are encouraging patients to stop the antibiotic, because so many antibiotics are given for viral infections. Patients get the antibiotic when they have a virus; then they get better and they think the antibiotic made them better. In fact, there is no causal link between the antibiotic and the fact that they got better, in the case of a virus. Aborting a course of antibiotics is appropriate. There is no need to finish it off.
I still think the whole issue of prescribing antibiotics at the outset is the big question. How do we cut that down? I think we need new diagnostic strategies or clinical scores. We can't get this to zero. This is not the opioid crisis, where we're aiming for zero. We're trying to get it lower and lower, but it's not like a marketing exercise in which next year we're going to drop it by another 10% and ultimately get to zero. The floor is the ceiling at some point.
4:55 p.m.
NDP
Don Davies NDP Vancouver Kingsway, BC
Thank you.
Dr. Shevchuk, I was quite taken by your shocking statistic that 30% to 50% of prescriptions are inappropriate. I take it that's not just for antibiotics, so first, are you referring to 30% to 50% of prescriptions for antibiotics or 30% to 50% of prescriptions generally? Second, to the extent that these are inappropriate prescriptions for antibiotics, I think I'm getting a bit of an idea of why that's the case. It sounds as though it's the difficulty of determining a virus infection versus a bacterial inflection. Are there any other reasons we're prescribing so inappropriately?
4:55 p.m.
Associate Dean Academic and Professor, College of Pharmacy and Nutrition, University of Saskatchewan, As an Individual
I will clarify that those numbers are for antibiotic prescriptions.
A lot of that comes, as you say, as a result of using antibiotics for viral infections. They are not going to respond. Those statistics come from different studies, and studies study slightly different things. The definition of “inappropriate” might be that it's just not the right kind of antibiotic for that particular infection. That would be one case. In some of the studies, it was that the duration of therapy was not right for that particular infection.
There are other definitions of “inappropriate”, but mostly it's about the mismatch between bacterial and viral, and using antibiotics for viral infections.
4:55 p.m.
NDP
Don Davies NDP Vancouver Kingsway, BC
Do you have any suggestions as to how we might reduce those numbers? As a pharmacist, can you tell us whether pharmacists can play a role in helping to catch some of those inappropriately prescribed antibiotics? Could pharmacists act as a buffer for doctors writing these prescriptions?
4:55 p.m.
Associate Dean Academic and Professor, College of Pharmacy and Nutrition, University of Saskatchewan, As an Individual
Pharmacists certainly have a role. We tell pharmacists when they are students that it's part of their job to look at whether this is the best drug for this particular patient. If they feel it's not, then it's their responsibility to have a conversation with the prescriber. One of the pieces of information that pharmacists are often missing is the indication, the actual reason. When patients come to me with a prescription for amoxicillin, I don't know if they have a wound on their leg or a urine infection or a lung infection, and it's very difficult for me to figure out whether it's the right choice, so one of the things we ask for, as pharmacists, is to make the diagnosis a requirement on the prescription. That's a reasonable starting place for us.
5 p.m.
Associate Dean Academic and Professor, College of Pharmacy and Nutrition, University of Saskatchewan, As an Individual
No, it's not, and that's one of the challenges. When we say “monitoring antibiotic use” in this country, we might know how many prescriptions are prescribed or how many units are bought by a pharmacy, but we don't know what those antibiotics are used for, to be honest. It's a bit of a black hole.
