The Flu in Time of Antibiotic Resistance

Rosario Bottone1, Stefania Milione1, Barbara Guerrera2, Mauro Giordano1

1. Department of Medical, Surgical, Neurological, Metabolic and Geriatric Sciences, University of Campania “Luigi Vanvitelli”, Naples, Italy
2. Internal Medicine, Clinical Hospital of Marcianise, ASL Caserta, Caserta, Italy

This first issue of the Italian Journal of Emergency Medicine comes out during a period in which Italian Emergency Systems are severely strained by flu epidemic.
“The peak of Influence has been reached (even if the severity still remains quite high)” – we read in the health policy newspapers released in January – especially children within 15 years are affected”.
It would therefore appear a common flu to be treated at home with common medications and, when necessary, with a properly and responsibly use of antibiotics in that case of a bacterial complications.
However, while in children flu could start out as a trivial form, in the elderly, in the immunocompromised subjects or in other people “at risk” (i.e chronically debilitated patients or even neoplastic), pulmonary and cardiac complications may come out and be life-threatening.
The Emergency Physician experienced that very well, seeing the overcrowding in the Emergency Department, noting the increased need of hospital beds. Repercussions afflict not only the Hospital System, but also the Territorial Emergency System, in fact Ambulances are most likely to not be ready to promptly ride after transportation of a patient to the ED.

In this scene, known for years to the emergency physicians, two peculiarities are now available: H1N1 Influenza A virus and antibiotic resistance phenomenon.

1) Against the flu we should be vaccinated (covering for H1N1 and H3N2 type A and B virus); every year, however, many deaths are attributable to the flu, among elderly and chronically debilitated patients. The H3N2 virus (“the Australian virus”) leads to a widespread and severe form that, as reported in many health policy newspapers, has undermined the Health Systems of many countries because of important requests for hospital treatments. The H1N1 virus (“the Mexican virus”) had pioneering merits in 2009, because the fear of a high-gravity pandemic, led to a worldwide “influence path” inside the hospitals. In fact, virological tests of nasopharyngeal secretions, use of personal protective equipment, hospitalization criteria, antimicrobial therapies were straight systematized and pinpointed the Emergency Department as the first link in the chain, the primary front door. Yamagata B Virus, initially understated, is now affecting a huge number of people, also because a very large portion of vaccination do not provide the adequate cover.

2) Antibiotic resistance already causes hundreds of thousands of deaths worldwide.
It is a phenomenon we are going to have to deal with, more and more, if we do not introduce new antimicrobial molecules.
Antibiotic resistance results in the ineffectiveness of antibiotic therapy, with longer duration of both therapy and hospitalization, moreover could even lead to a poor prognosis of the patients.
Albeit, considering that some hospital care practices (i.e. major surgery), high-intensity care environments (such as intensive care units) or even cancer and post-transplant therapies, have certainly improved patient survival, unfortunately we must be aware that all these conditions could promote the onset of infections, even by opportunistic germs.
However, a hospital response designed to fight back this phenomenon, which is becoming increasingly evident, must be given.
Otherwise the lengthening of hospitalizations, also in wards such as Emergency Medicine, the isolation of patients affected by Staphylococcus aureus, Escherichia coli, Klebsiella pneumoniae, Pseudomonas aeruginosa, Acinetobacter Baumannii, Clostridium difficilis infections (with the possible subsequent reduction in beds capacity), are all elements that will contribute to hinder the work of the emergency physicians, called to treat increasingly complex patients, in more critical environmental conditions, with lack of therapeutic weapons.
Italy is already the country where antibiotic resistance remains among the highest in Europe. Our emergency services more and more admit patients with severe infections, acute lung failures and sepsis.
One can only hope, this is not the season in which initial spreading of antibiotic resistance will give us the chance to take a look into the future…