Evidence of meeting #16 for Health in the 45th Parliament, 1st session. (The original version is on Parliament’s site, as are the minutes.) The winning word was resistance.
A recording is available from Parliament.
Chair, Canadian Antimicrobial Innovation Coalition, Chief Scientific Officer, Fedora Pharmaceuticals Inc.
I'm not an epidemiologist, so maybe this question should be directed to an epidemiologist as you conduct your studies. I can't really answer that question with accuracy.
Conservative
Helena Konanz Conservative Similkameen—South Okanagan—West Kootenay, BC
Is there another person on our panel who would have some insight into that question?
I can repeat it: In Canada, what kind of demographic or regional differences are we seeing in antimicrobial resistance—for example, differences between young versus old or rural versus urban?
Liberal
Conservative
Helena Konanz Conservative Similkameen—South Okanagan—West Kootenay, BC
That's okay. Thank you.
Dr. Fafard, a pharmacist I spoke with noted to me that many newcomers to Canada are surprised at the lack of over-the-counter access to the antibiotic or antiviral drugs that we consider to be prescription medications here. In their countries, they're able to just walk in and get these drugs. Are you seeing a higher rate of antimicrobial resistance among newcomers to Canada?
Medical Doctor, As an Individual
Yes, I can answer that question.
In fact, we are seeing resistant microbes being imported by people who travel, not necessarily migrants. We are seeing these microbes moving between populations through tourism, whether medical tourism or leisure tourism. Sometimes there are unexpected hospitalizations during a trip.
We are seeing patients returning to our country with resistant microorganisms. Candida auris, a fungus that is resistant to almost all first-line antifungals, is a very good example. South of the border, in the United States, this fungus colonizes hospital intensive care units. We are seeing more and more diagnoses related to this fungus in people who have travelled. The proportion remains very low for now, but we expect an increase in the future. Most of the time, it is associated with travel.
Conservative
Helena Konanz Conservative Similkameen—South Okanagan—West Kootenay, BC
Thank you for that answer: You're not seeing that among newcomers.
Have you heard that they are having trouble finding antibiotic or antiviral drugs and that they're concerned that they can get them at home but not here?
Medical Doctor, As an Individual
In Canada, you normally need a prescription from a doctor, pharmacist or front line professional to access antibiotics.
In some countries, regulations surrounding access to antibiotics are much less stringent. Individuals can access antibiotics in their country without a prescription and without consulting a health professional. This is not an advantage for people outside Canada. In fact, it is a disadvantage, because easy access to antimicrobials abroad will promote increased antimicrobial resistance.
Conservative
Helena Konanz Conservative Similkameen—South Okanagan—West Kootenay, BC
Thank you.
Dr. Fafard, in Canada, is there an over-prescription of any antibiotic, antifungal or antiviral drug for infections that you can name in particular?
Medical Doctor, As an Individual
There is currently little research on prescribing patterns for antimicrobials. However, several countries are making efforts to publish guidelines for clinicians to reduce the number of unnecessary prescriptions for antimicrobials. More guidelines should be developed. They should be produced for other common infections and shared with clinicians. However, we do not really have any statistics on prescribing patterns.
Conservative
Helena Konanz Conservative Similkameen—South Okanagan—West Kootenay, BC
Dr. Fafard, can you name a condition or ailment for which the treatment is most publicly over-prescribed at this time? What are the front-runners?
Medical Doctor, As an Individual
As I explained, we do not have statistics on prescriptions. However, the optimal-use guidelines produced in my field cover certain common infections, such as community-acquired pneumonia, which can sometimes be confused with viral respiratory infections, for which antibiotics are not necessary. The same applies to ear infections in children; the recommendation is to wait before prescribing antibiotics.
These are the types of infections targeted by optimal-use guidelines to improve prescribing practices.
Liberal
The Chair Liberal Hedy Fry
Thank you, Dr. Fafard.
I now go to Mr. Eyolfson, the next questioner for the Liberals.
Liberal
Doug Eyolfson Liberal Winnipeg West, MB
Thank you, Chair.
Thank you, all witnesses, for coming.
I should just clarify. I think we all knew this, but in colloquial French, “fungus” translates to exactly the same word as “mushroom” in French. For the English speakers, when she was talking about the “infectious mushroom”, it was an infectious fungus. It's the classic case of being lost in translation.
Dr. Fafard, thank you so much for coming.
I was quite shocked to hear of the increased resistance to azithromycin for chlamydia. I know that for years, when someone came in with an STI, the standard treatment was to automatically give one gram of azithromycin and 400 milligrams of cefixime, and then we would wait for serology on syphilis.
Are resistance patterns emerging for cefixime or to the first-line drugs as treatment for gonorrhea, or to ceftriaxone, or are there any resistance patterns for syphilis?
Medical Doctor, As an Individual
For syphilis, there is none. In fact, when azithromycin was still recommended as first-line treatment, there were cases of failure and resistance in the United States. Currently, good old penicillin is recommended as treatment for syphilis. There is no resistance.
However, we have identified strains of the Neisseria gonorrhoeae bacterium in Canada that are resistant to ceftriaxone. This antibiotic is administered by intramuscular injection, which means that patients with resistant infections must receive intravenous antibiotics to treat their infection. These cases are still rare, but we are seeing more and more of them.
Liberal
Doug Eyolfson Liberal Winnipeg West, MB
All right. Thank you.
As you know, physicians use different resources to keep up with what is latest. A lot of physicians subscribe to a peer-reviewed service called UpToDate, where you can find out in real time the latest scientific consensus on a disorder that you haven't seen in a while. One of the things that has been a frustration for a lot of physicians, particularly in emergency and other primary care settings, is getting the latest evidence-based recommendations for a given infection, particularly when you have to treat empirically and you don't have time to wait for cultures.
UpToDate will give recommendations, but it will then say to be aware of local resistance patterns. That's not always easy to keep up with. In an emergency department, it's hard enough, but at least we're always regularly seeing our specialists in internal medicine and infectious diseases. It's even harder in a family doctor's office.
What would be the solution for disseminating, in real time, the latest local antibiotic resistance patterns to physicians so that they can make better prescribing choices for infections?
Medical Doctor, As an Individual
I'm sorry, I think the interpreter may have missed some parts of your question, but from what I understand, you were talking about local resistance.
You are right when you say that we have guidelines for clinicians, but the ideal situation would be to have a picture of local resistance in one's own environment, hospital or community. This is because resistance profiles can vary greatly between a community hospital and a university hospital.
In an ideal world, we would need to be able to extract data from each hospital, based on the pathogens found and the antibiotics for which these pathogens have been analyzed, in order to create a database.
National data on antimicrobial resistance would also need to be provided. However, we would also need to be able to refine the picture of resistance locally in a given setting, to enable the use of the antibiotic with the narrowest possible spectrum to curb the emergence of resistance.
Liberal
Doug Eyolfson Liberal Winnipeg West, MB
Okay. Thank you.
Is there a method in Quebec of getting this latest local information out to primary care providers in offices? In hospitals—
Liberal
Doug Eyolfson Liberal Winnipeg West, MB
Thank you.
Again, my practice has been almost exclusively hospital-based, in an emergency department. We get the interdepartmental memos that there's now resistance to whatever and, therefore, we need to switch to another antibiotic.
Is there a means in Quebec for keeping rapid dissemination of this information on the local resistance patterns to primary care providers who are not in a hospital setting?
Medical Doctor, As an Individual
In Quebec, at this time, this type of system does not exist at the provincial level. These are local initiatives. Each hospital has its own antibiotic stewardship committee, which is responsible for compiling a local picture of resistance and sharing this picture within their hospital. I work for a provincial organization, and from a central perspective, we do not have access to this local data at this time.
Liberal
The Chair Liberal Hedy Fry
Thank you. The time is up.
I now go to the Bloc Québécois.
Madame Larouche, you have six minutes, please.
Bloc
Andréanne Larouche Bloc Shefford, QC
Thank you very much, Madam Chair.
I would like to thank the witnesses for being here with us today for this important study.
Personally, what strikes me is how we are realizing that antimicrobial resistance knows no borders. That is something we must keep in mind.
Ms. Fafard, at the very end of your presentation, you spoke about the importance of metagenomic research on waste water.
Could you tell us a little more about the importance of this type of research?
Can you tell us what we can learn from waste water?
Medical Doctor, As an Individual
This is research and development. It's a work in progress. What you have to understand is that the data we're currently receiving comes from hospital systems or culture prescriptions by clinicians. This requires the patient to come in for an emergency room visit, be admitted to hospital, or see their doctor.
Obtaining a picture of resistance using genomic methods in an environmental sample, such as waste water, bypasses patient behaviour. It therefore makes it possible to identify patterns of resistance that could be found in people who do not consult the health system for all sorts of reasons.
Bloc
Andréanne Larouche Bloc Shefford, QC
Thank you very much.
Clearly, waste water can reveal more than we think.
Mr. Salama, in your opening remarks, you mentioned the European Union. You spoke about it briefly, but what useful experience could we draw on for this study and here in our country?