In general, administering stitches to close tears on mothers who have newly delivered a child are a safe and common procedure. However, the handling of post-delivery sutures by health workers without sufficient understanding about the use of antibiotics and the risk of infection 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 was a 35-year-old private employee who had been married for less than two years. The birth of the first child should have been the most beautiful gift for her and 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. According to Dr Paraton, post-delivery stitches do not require antibiotics. “This is overuse,” he says. Dr Paraton adds, the World Health Organization (WHO) does not recommend the use of antibiotics after childbirth. Billions of bacteria in the vagina will secrete certain enzymes that can heal wounds. Lactobacillus spp in the vagina, for example, will help heal surface wounds.
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 or sepsis. Her isolate pathogen E.coli had become multidrug resistant organism 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 that are super resistant to all 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.
Colistin might have helped – but the drug is not avaliable in Indonesia
Colistin, an antibiotic of last-resort in cases of bacterial resistance, might have been able to treat the infection. However, the drug was not available in Indonesia as colistin is not listed in the national formulary in Indonesia. Hospitals must import them from Singapore through a special scheme. During the COVID-19 pandemic, where flights were restricted and national borders were closed, it became extremely difficult to import drugs.
The worse news was that some bacteria were already resistant to colistin. Apart from being used in health facilities, colistin is also often used in the livestock sector. Antibiotic resistance does not occur only in the human health sector and the use of antibiotics as feed additives or for disease prevention in the livestock sector also triggers antibiotic-resistant bacteria.
Use of antibiotics or antiseptics can kill our normal flora
In addition, the use of antiseptics, which are intended to clean wounds, can also be counterproductive.
Dr. Paraton says:
“Sometimes the midwives reasoned that the mothers in the village couldn’t maintain their hygiene, so they gave antibiotics to patients after giving birth. Excessive use of antiseptics is not good. We should not let the use of antibiotics or antiseptics kill our normal flora.”
Overuse or inappropriate use of antibiotics can lead to bacterial resistance to antibiotics. As a result, patients might have to be treated longer, with an increase in the risk of being admitted to the emergency unit, the frequency of surgeries required, the use of health equipment, costs and the risk of death.
Patients with infections due to antimicrobial-resistant organisms have greater hospital costs (US$ 6000-30,000) than to patients with infections due to antimicrobial-susceptible organisms (1,2).
Crucial to understand proper use of antibiotics
What happened to Paramita shows how crucial it is for health workers to understand the proper use of antibiotics. 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 right antibiotic while also checking whether the patient has received antibiotics before and whether the patient has comorbidities.
Unfortunately, Dr Paraton said, in 2017 about 80 percent of antibiotic use by health workers was inappropriate. Dr. Paraton says:
“In developed countries, doctors who are careless in administering antibiotics could have their license revoked. In Indonesia and many Asian countries, this is not the case. With good antibiotic stewardship, doctors who use antibiotics will be called in for discussion, and directed to be more prudent in prescribing antibiotics,”
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 too 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.
According to Dr Paraton, Acinetobacter is one of the most resistant bacteria to antibiotics in Indonesia besides Escherichia coli, Klebsiella pneumoniae, Pseudomonas aeruginosa, as well as Methicillin-Resistant Staphylococcus Aureus (MRSA).
Among the types of bacteria mentioned above, E coli and Klebsiella pneumoniae are included in the category of extended-spectrum beta lactamase (ESBL) producing bacteria, which are indicators of extent of antibiotic resistance in a country.
According to Dr Paraton ESBL bacterial resistance in Indonesia continues to increase every year. The prevalence of resistant E coli bacteria in 2005 was 9 percent. That figure increased to 40 percent in 2013, rising to 60 percent in 2017, and 62.7 percent in 2020.
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)
The World Health Organization (WHO) has declared antimicrobial resistance (AMR) as one of the biggest public health threats of the 21st century. The true magnitude of antimicrobial resistance in humans is not fully known. However, a new study published in The Lancet estimated that resistant infections directly caused around 1·27 million deaths in 2019 (4).
In 2019, WHO classified antibiotics under the term AWaRe, which stands for Access, Watch, and Reserve. The AWaRe database is used to maximize the benefits while monitoring potential resistance.
Antibiotics part of the Access group are those used to fight various types of pathogens that have a lower resistance potential than other types of antibiotics. This group includes 48 antibiotics of which 19 are included in the WHO list of essential drugs. The Watch group has a greater potential for resistance. This group includes 110 antibiotics, which deserve more attention.
The Reserve group includes antibiotics used to fight resistant bacteria and their use must be reserved for s when all alternative therapies have failed. The Reserve group includes 22 antibiotics.
Dr Paraton says:
“This group must be protected. For example, antibiotics such as meropenem, linezolid, and vancomycin,”
Written by: Adhitya Ramadhan
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.
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