By Grace Lineo Nyenye, Head pharmacist at Maluti Adventist Hospital in Lesotho.
A 69 years old woman, a known hypertensive patient with well-controlled blood pressure taking only hydrochlorothiazide was last admitted to the Maluti Hospital in the year 2007 when she had laparatomy. She had good hydration and nutrition as well as good physical and mental state with no history of drug allergy of food allergy.
The patient developed a rash on the right leg in November 2018, which was treated with an antihistamine. The same year in the following month the patient came back with a mild septic rash which was treated with oral cloxacillin as an outpatient. In January 2019, the patient came back again with no improvement, cloxacillin was prescribed and metronidazole was also added while still treated as an outpatient. The following month, February 2019 the patient came back again still with no improvement and was seen by another doctor who diagnosed her with septic rash with fungal infection and treated with oral erythromycin and griseofulvin as outpatient again.
In March 2019, the patient came back again still with no improvement, but this time complained of painful leg and wound oozing. The pus swab for culture and sensitivity test was taken to a laboratory for investigations and the patient was prescribed painkillers but antibiotic was not given this time around while waiting for the laboratory test result. After three days, the laboratory test results came out with Gram-positive cocci, a Non-Haemolytic Streptococcus identified from the culture. The microorganism was resistant to penicillin G, amoxicillin, augmentin, erythromycin, ciprofloxacin, Gentamycin, meropenem, ampicillin, cefotaxime, oxacillin, cotrimoxazole, colistin, and Nalidixic acid.
It was intermediate sensitive to clindamycin with a very little zone of inhibition. The microorganism was only sensitive to vancomycin which is expensive, more toxic and not readily available in Lesotho and only available as an injectable in the country.
Therefore the patient had to be admitted to the hospital for vancomycin administration because it was given intravenously several times a day and also it was not possible for the patient to come to the hospital for daily injections from home since she was staying several kilometers away from the hospital. More health care costs were incurred in treating this AMR case because first, the patient had to be admitted. Also, kidney function tests had to be done prior to vancomycin administration since it is toxic to the kidneys and the patient already had vulnerable risk factors to kidney injury since she is an elderly patient with hypertension. After completing vancomycin treatment at the hospital, the wound was clean, no longer septic and oozing.
Lessons learnt from this case were that resistant microorganisms are not only found in health care facilities only but can also be found from communities as well. Also delaying doing relevant investigations to find a definitive cause of infection leads to high waste of resources such as money and drugs as well loss of income due to high absenteeism from work that could have been avoided.
In conclusion, when treating infections, let us always think of antimicrobial resistance. Antimicrobial resistance definitely has a huge impact on health care cost and economic growth.