Microbiology New Zealand Discussion 2022

Running head: MICROBIOLOGY
MICROBIOLOGY
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Introduction
Medications classified as antibiotics are currently used prevalently across the world, due
to their ability to effectively cure infections, illnesses and diseases caused due to microorganisms
like bacteria. Microorganisms which one were responsible to cause global epidemics can now be
safely controlled using these efficient medications (Frieri, Kumar & Boutin, 2017). However, a
key public health concern associated with the practice of antibiotic medication administration is
the emergence of microbial strains which are resistant to these drugs. Illnesses caused due to
microorganisms resistant to antibiotics is a concerning public health problem, which however,
can be prevented using effective stewardship practices related to hygiene and controlled
medication administration (Qiao et al., 2018).
Thus, with respect to the same, the following paper will provide and elaborate and
extensive insight into the emergence and transmission of Tuberculosis (TB) infections caused to
Mycobacterium tuberculosis strains which are resistant to antibiotics as well as the prevalence of
the same, coupled with the adherence to antibiotic intake practices within the New Zealand
context. Additionally, this paper will also provide key insights into the current impacts on society
and the risks in public health associated with infections spread by antibiotic resistant
microorganisms as well as existing or emerging guidelines which may prove to be beneficial in
combating this concerning health issue.
Discussion
Antibiotic Resistant Microorganism and Emergence
TB is an infectious disease caused as a result of droplet transmission, infected by the
bacterial strain Mycobacterium tuberculosis, and inhalation of the same across individuals. The

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main organs affected by TB are the lungs, though in certain cases the spine or the kidneys may
be affected as well. While this infection can be treated and cured, the concern rises when it is
caused by drug resistant bacterial strains (Dheda et al., 2017). Multi-drug resistant TB (MDRTB)
is a form of which demonstrates no response to treatment by two of the most powerful and
prevalent medication, namely rifampicin and isoniazid. Additionally, Extensively Drug Resistant
TB (RXDTB) is another rare form of TB resistant to antibiotics where the infection is not only
resistant to rifampicin and isoniazid but also any of the three second line of injectable
medications like kanamycin, amikacin or capreomycin and also a fluoroquinolone (Knight et al.,
2019). While their exist limited historical detail of the emergence of MDRTB is not known, the
first cases have been reported to have emerged during the years 1943 onwards, possibly due to
genetic mutations. Of this, TB strains classified as the ‘Beijing lineage’ – have been evidenced to
be a causative strain of MDRTB, due to its ability to adapt and mutate (Hargreaves et al., 2017).
Nevertheless, the key behaviors and factors which have been evidence to cause such mutations
and thus, resultant emergence of MDRTB, are associated with mismanaged or misuse or TB
drugs. Such malpractices include: lack of completion of a complete medication course during TB
treatment, administration of incorrect dosage and duration of medication intake by healthcare
professionals, inability of the patient to consume the required drugs due to unavailability and the
intake of anti-TB drugs which are of inadequate quality (Marks, Mase & Morris, 2017).
MDRTB and XDRTB are found prevalently in specific patient groups, such as those
individuals who engage in irregular TB medication consumption, who do not consume all the
required TB drugs, belong to regions with high rates of MDRTB and have been in contact with
patients diagnosed with TB (Trébucq et al., 2018).According to the World Health Organization
(WHO, 2020), there were approximately 4.1% or 8000 new reports and 19% or 600, 000 reports

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of MDRTB of previous cases. During 2017, these figures were reported to rise to an alarming
level in 2017, with new MDRTB cases rising to 558, 000 of which, 161, 000 were newly
detected and reported. Thus, such alarming rises in the prevalence of MDRTB infections can be
associated with a number of faulty medication practices as discussed previously (WHO, 2020).
New Zealand
The prevalence of TB and MDRTB in New Zealand (NZ) has been relatively low, with
the highest prevalence of 88.8% TB reported to occur in 2015. Of these however, approximately
96.2% of individuals in NZ reported with TB were treated on a timely manner and appropriately.
Of these, 34.5% of individuals commenced treatment within a month of symptoms whereas
37.3% reported to have engaged in TB treatment within 1 to 3 months of symptom onset.
However, only two or approximately 0.8% of these cases were reported to be infections of the
MDRTB type. Interestingly, both these incidences were of individuals born overseas of NZ thus
demonstrating the immigration from countries with high TB and MDRTB incidence as key risk
factors for MDRTB prevalence in the nation (New Zealand Government, 2019). Additionally,
since the last decade, approximately 1.2% cases of MDRTB were reported in the nation with an
alarming resistance to all forms of antimicrobials used for MDRTB treatment. Common
antimicrobials which are used for the purpose of TB treatment in NZ include Rifampicin,
Isoniazid, Streptomycin, Pyrazinamide and Ethambutol. Further findings demonstrate the
prevalence of MDRTB in cases with antimicrobials such as: 9% in Isoniazid, 8.7% in
Streptomycin, 4.5% in Pyrazinamide, 1.7% in Ethambutol and 1% in Rifampicin. While there
lies limited research concerning the origins of prevalence of MDRTB in NZ, some of the highest
cases were observed during the year 2003, where total number of MDRTB cases were reported
to be 376 cases respectively (New Zealand Government, 2019).

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According to the Ministry of Health (2017), some of the most important causative factors
associated with the incidence of MDRTB in NZ, include: having a previous case of TB, being
exposed to an individual having TB and travelling to or emigrating from a country with high TB
incidence. In NZ, MDRTB cases individuals being both overseas have been attributed to
countries located in South Asia and Pacific Island regions such as India and the Philippines.
Additionally, for MDR cases which were identified within native NZ populations, the highest
prevalence was reported to be across Maori’s (50.3%). Thus, indigenous or Aboriginal ethnicity
may be a key factor of MDRTB in NZ due to the remote nature of these areas resulting in poor
sanitation, inadequate accessibility and availability to appropriate drugs, resources and treatment
as well as economically underprivileged conditions of these populations (Basu et al., 2018).
With respect to the consumption and use of antibiotics for TB across NZ, the most
prevalently used drugs include Rifampicin, Isoniazid, Streptomycin, Pyrazinamide and
Ethambutol as mentioned previously. In NZ, citizens can consume antibiotics only under an
authorized prescription of a certified healthcare professional or general practitioner. The
prevalence of antibiotic resistance, as compared to other Asian regions, have been evidenced to
be significantly low. However, to tackle the menace of antibiotic resistant infections like
MDRTB as well as associated misuse or malpractices associated with antibiotics, the
government of New Zealand developed the ‘Antibiotic Resistance Action Plan’ in the year 2017
(Ministry of Health, 2017; New Zealand Government, 2019). This public health plan concerning
antibiotic use in NZ has been associated with a number of key objectives and principles such as:
initiating improvements in awareness and knowledge of antibiotic resistance, the implications as
well as possible strategies for mitigation; strengthening knowledge concerning this issue across
healthcare professionals via increased public health evidence based research’ enhancing

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improvements in current infection control practices across healthcare settings; optimizing and
strictly regulating the prescription and usage of antibiotics by healthcare professionals and
patients alike and establishing high quality governance and collaborative clinical practice for the
mitigation and prevention of antimicrobial resistance (Ministry of Health, 2017).
Societal Impacts
Lack of prompt and immediate mitigation of infections caused by antibiotic resistant
strains can pave the way for key risks in public health. Antibiotics are used prevalently for the
treatment of a number of infections. Antibiotic resistance is thus likely to render these treatments
as ineffective and pave the way for reduced tolerance to disease, increased prevalence of
preventable infectious disease as well as high rates in morbidity and mortality (Kendall et al.,
2017). Additionally, antibiotic resistance is likely to increase the risk of intolerance towards
interventions requiring invasive procedures like surgeries, organ transplantation and even
caesarean deliveries. The high rates of mortality is directly associated with reduced economic
growth in a nation. Additionally, the ineffectiveness of invasive interventions as well as
resistance towards common medications will call for greater duration of hospital stay resulting in
economic impacts of rising costs in healthcare and overall poor economic growth of a nation
(van den Hof et al., 2016).
Stewardship Guidelines
According to Auckland Regional Public Health Service (2018), some of the key
preventive guidelines which individuals can adhere to for the prevention of MDRTB is to strictly
ensure consumption of TB medications as per the prescribed medications and dosage, throughout
the complete medication course, without any form of prematurely stopping before or during the
treatment. Additionally, the WHO (2018), for the prevention of MDRTB recommends

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individuals to never share their TB medications with others or use leftover antibiotics, engage in
regular practices of hand hygiene, engage in food preparation using strict standards of hygiene
and sanitation and to never coerce healthcare professionals for antibiotics if unpermitted by
them.
However, considering the severity of the issue as well as the fact that patients may lack
adequate awareness and knowledge, healthcare professionals must engage in a variety of
stewardship or supervisory guidelines for the purpose of MDRTB prevention. Firstly, healthcare
professionals must strictly adhere to regular and effective hand sanitizing, disinfection and
hygiene practices, before, during as well as after patient observation and treatment (Fox et al.,
2017). In addition to prescribing only those antibiotics which are needed, there is also a need for
healthcare professionals to educate patients on the importance of maintaining correct dosages as
well as the effects of malpractices and MDRTB. Healthcare professionals must also educate and
supervise individuals on correct infection prevention practices to be followed at home, during
social interactions as well as precautions in case of contacting infected individuals (Suryavanshi
et al., 2020).
A collaborative, multidisciplinary approach can be effective in encouraging prevention
and supervision of MDRTB prevention. Thus, healthcare professionals must immediately report
any incidences of MDRTB to public health surveillance bodies as well as governmental
organizations for immediate action and mitigation (WHO, 2018). Additionally, public health
professionals like policy makers can play a key role in stewarding both citizens as well as public
health professionals on MDRTB prevention (Parmar et al., 2018). Policy makers must
collaborate with the government as well as healthcare organizations on the development of a
more robust and comprehensive national action plan for MDRTB prevention. Additionally,

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governments and public health organizations must establish improved systems of surveillance
and reporting as well develop improved strategies of infection control (WHO, 2018).
Additionally, these organizations must engage in the development of public educational
resources on antibiotic resistance, correct usage and disposal of medications as well as
preventive strategies of MDRTB which can be accessed and comprehended by the public. There
is lastly a need for research organizations to engage in greater evidence based research on
MDRTB (Weyer et al., 2017).
According to Auckland Regional Public Health Service (2018), a key treatment
intervention for MDRTB is directly observed therapy (DOT). This comprises of continuous
observation by a nurse of health worker to ensure that a patient strictly takes correct dosages of
medications and regularly as per the prescribed time duration.
Conclusion
This paper thus provides a comprehensive and detailed insight into the current prevalence
and possible causative factors associated with the incidence of MDRTB globally as well as
across NZ. While the incidence of MDRTB is relatively low and there exists strict regulations
concerning the prescription and usage of antibiotics, there is still a need to adhere to
comprehensive preventive guidelines for the mitigation of this global prevalence. Additionally,
some of the key causative predictors associated with the prevalence of MDRTB in NZ is the
immigration of individuals from countries with high incidence of the same as well as due to poor
socio-demographic and economic conditions, particularly with respect to Aboriginal populations.
The emergence of antibiotic resistant infections like MDRTB is particularly a matter of concern
since it poses key public risks such as increased disease prevalence, reduced tolerance to
invasive procedures and infections and subsequent economic impacts to name a few. There is

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thus a need to practice comprehensive, robust and effective stewardship guidelines and practices
with regards to prevention of infections caused to antibiotic resistant microbial strains. To
conclude, the prevention of antibiotic resistance infections is the not the responsibility of a single
body, but rather requires collaborative practice across public health organizations, the
government, policy makers as well as the citizens.

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References
Auckland Regional Public Health Service. (2018). Multi-drug Resistant Tuberculosis (MDR-
TB). Retrieved 19 April 2020, from
https://www.arphs.health.nz/assets/Uploads/Resources/Disease-and-illness/Multi-drug-
Resistant-Tuberculosis-v0.2-20181116.pdf.
Basu, I., Bower, J. E., Roberts, S. A., Henderson, G., Aung, H. L., Cook, G., ... & Newton, S.
(2018). Utility of whole genome sequencing for multidrug resistant Mycobacterium
tuberculosis isolates in a reference TB laboratory in New Zealand. The New Zealand
Medical Journal (Online), 131(1487), 15.
Dheda, K., Gumbo, T., Maartens, G., Dooley, K. E., McNerney, R., Murray, M., ... & Theron, G.
(2017). The epidemiology, pathogenesis, transmission, diagnosis, and management of
multidrug-resistant, extensively drug-resistant, and incurable tuberculosis. The lancet
Respiratory medicine, 5(4), 291-360.
Fox, G. J., Schaaf, H. S., Mandalakas, A., Chiappini, E., Zumla, A., & Marais, B. J. (2017).
Preventing the spread of multidrug-resistant tuberculosis and protecting contacts of
infectious cases. Clinical Microbiology and Infection, 23(3), 147-153.
Frieri, M., Kumar, K., & Boutin, A. (2017). Antibiotic resistance. Journal of infection and public
health, 10(4), 369-378.
Hargreaves, S., Lönnroth, K., Nellums, L. B., Olaru, I. D., Nathavitharana, R. R., Norredam, M.,
& Friedland, J. S. (2017). Multidrug-resistant tuberculosis and migration to
Europe. Clinical Microbiology and Infection, 23(3), 141-146.

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Kendall, E. A., Azman, A. S., Cobelens, F. G., & Dowdy, D. W. (2017). MDR-TB treatment as
prevention: The projected population-level impact of expanded treatment for multidrug-
resistant tuberculosis. PloS one, 12(3).
Knight, G. M., McQuaid, C. F., Dodd, P. J., & Houben, R. M. (2019). Global burden of latent
multidrug-resistant tuberculosis: trends and estimates based on mathematical
modelling. The Lancet Infectious Diseases, 19(8), 903-912.
Marks, S. M., Mase, S. R., & Morris, S. B. (2017). Systematic review, meta-analysis, and cost-
effectiveness of treatment of latent tuberculosis to reduce progression to multidrug-
resistant tuberculosis. Clinical Infectious Diseases, 64(12), 1670-1677.
Ministry of Health. (2017). Antimicrobial Resistance: New Zealand’s current situation and
identified areas for action. Retrieved 19 April 2020, from
https://www.health.govt.nz/system/files/documents/publications/antimicrobial-resistance-
nz-situation-areas-for-action-mar17.pdf.
New Zealand Government. (2019). Guidelines for Tuberculosis Control in New Zealand.
Retrieved 19 April 2020, from
https://www.health.govt.nz/system/files/documents/publications/guidelines-tuberculosis-
control-new-zealand-2019-august2019-final.pdf.
Parmar, M. M., Sachdeva, K. S., Dewan, P. K., Rade, K., Nair, S. A., Pant, R., & Khaparde, S.
D. (2018). Unacceptable treatment outcomes and associated factors among India's initial
cohorts of multidrug-resistant tuberculosis (MDR-TB) patients under the revised national
TB control programme (2007–2011): evidence leading to policy enhancement. PloS
one, 13(4).

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Qiao, M., Ying, G. G., Singer, A. C., & Zhu, Y. G. (2018). Review of antibiotic resistance in
China and its environment. Environment international, 110, 160-172.
Suryavanshi, N., Murrill, M., Gupta, A., Hughes, M., Hesseling, A., Kim, S., ... & Dawson, R.
(2020). Willingness to Take Multidrug-resistant Tuberculosis (MDR-TB) Preventive
Therapy Among Adult and Adolescent Household Contacts of MDR-TB Index Cases: An
International Multisite Cross-sectional Study. Clinical Infectious Diseases, 70(3), 436-
445.
Trébucq, A., Schwoebel, V., Kashongwe, Z., Bakayoko, A., Kuaban, C., Noeske, J., ... &
Fikouma, V. (2018). Treatment outcome with a short multidrug-resistant tuberculosis
regimen in nine African countries. The International Journal of Tuberculosis and Lung
Disease, 22(1), 17-25.
van den Hof, S., Collins, D., Hafidz, F., Beyene, D., Tursynbayeva, A., & Tiemersma, E. (2016).
The socioeconomic impact of multidrug resistant tuberculosis on patients: results from
Ethiopia, Indonesia and Kazakhstan. BMC infectious diseases, 16(1), 470.
Weyer, K., Dennis Falzon, D., Jaramillo, E., Zignol, M., Mirzayev, F., & Raviglione, M. (2017).
Drug-resistant tuberculosis: what is the situation, what are the needs to roll it back. AMR
control, 20, 60-67.
WHO. (2018). Antimicrobial resistance. Retrieved 19 April 2020, from
https://www.who.int/news-room/fact-sheets/detail/antimicrobial-resistance.
WHO. (2020). Drug-resistant tuberculosis. Retrieved 19 April 2020, from
https://www.who.int/tb/areas-of-work/drug-resistant-tb/en/.

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