The ‘Crucible Prize’ at the 2019 BSH Annual Scientific Meeting in Glasgow was won by Dr Jennifer Darlow and her presentation; Antimicrobial resistance: Biting the hand that feeds'.
The aim of the session was to encourage reflection amongst haematologists on their practices with a theme of ‘How can haematologists change the world?’ The five best abstracts were selected for presentation, with the trainees then being questioned by a panel of experts.
We spoke with Jennifer about her journey in haematology, as well as her Crucible Prize success.
What is your education/career background in haematology?
I am about a year and a half into my haematology specialist training. I actually started training in general paediatrics, before switching to haematology with a plan to specialise in paediatric haematology.
What was your Crucible session presentation about?
My presentation was titled "Antimicrobial Resistance: Biting the Hand that Feeds."
Antimicrobial resistance, in particular carbapenem resistant enterobacteriaceae (CPE), is becoming an increasingly worrying problem, and is already leading to the death of thousands of people internationally every year, particularly in low to middle income countries. It has been shown that the biggest factor contributing to antimicrobial resistance is human and animal antimicrobial overuse and misuse. Haematology in particular is a culprit in driving antimicrobial resistance through the intense use of broad spectrum antibiotics for our immunocompromised patients. Haematology has a role to play in reducing antimicrobial resistance. This can be achieved through several ways including close collaboration with infection specialists; use of newer diagnostics; having the confidence to narrow therapy in patients who are not neutropenic or in whom a causative organism has been identified; and through research into questions we have little evidence for such as optimal time for a course of antibiotics.
What inspired the content of your presentation?
I have seen many examples in our clinical practice of poor antimicrobial stewardship. There is sometimes a feeling among haematologists that because a patient has an underlying haematological malignancy, even if a patient is not neutropenic, there is an unnecessarily low threshold for treating with carbapenems. Haematologists use a disproportionately larger amount of carbapenems than other specialities, and hence are big drivers in antimicrobial resistance.
Already across the world we are seeing not only epidemic but also endemic CPE infections. This means that we are increasingly seeing infections which are harder or sometimes impossible to treat, and there are very few new antibiotics coming through to help fight these infections. In the future, it is possible that simple infections such as urinary tract infections and pneumonias for the first time in decades will be untreatable. It will also cast doubt as to whether will be able to treat leukaemia patients with induction chemotherapy or transplant as we will no longer be able to treat their inevitable neutropenic sepsis.
I strongly believe that we should consider this crisis as an ethical position. Can we justify non-diligent use of broad spectrum antibiotics when continued use will lead to untreatable infections and therefore the death of potentially millions internationally? We as haematologists are morally responsible for looking after not only our own patients in the here and now, but also our patients in the future not only here but across the world.
What does winning this award mean to you?
Participating in the Crucible session was a fantastic experience, and winning meant a lot. The other presentations from Jessica, Megan, Edmund and Amelia were all excellent and thought provoking and it was wonderful to be part of a very exciting session at BSH. I would like to thank BSH for this opportunity.
While winning the award in itself was brilliant, if I can convince even some people to consider more carefully their antimicrobial use in daily practice, it will have been worthwhile.
What would your advice be for someone wanting to choose haematology as their specialism?
Do it! It's great.
One thing which attracted me to haematology is the diversity. You can choose to work in many different areas of haematology. You can work as a generalist or a subspecialist; work more clinically or in a laboratory and the research opportunities are endless.
What do you plan to do next in your haematology career?
Apart from the usual goals of passing exams, I hope to pursue my career in paediatric haematology and incorporate research into my training. I am still undecided where I might sub specialise, but I am lucky that I enjoy many different aspects of haematology and would probably enjoy many different interests.
Haematology, more than many specialities, manages patients with compromised immune systems (e.g. neutropenic, bone marrow transplant patients). These patients regularly contract infections and consequently receive broad spectrum antibiotics. This includes carbapenems, particularly in the context of rising antimicrobial resistance and recent piperacillin-tazobactam shortages.
In the last decade the emergence and spread of carbapenem resistance presents antimicrobial dependent medicine with an unprecedented crisis. Globally, carbapenem resistance is rising – in parts of India, resistance rates are above 50%. Even in the developed world, carbapenem resistance is a growing problem, costing millions and leading to patient mortality. This is compounded by the fact that the new antimicrobial pipeline is sparse.
Widespread use of carbapenems contribute to this problem, by providing selection pressure that allows resistant organisms to flourish. Although haematology uses a relatively small quantity of antibiotics, its intensive use of carbapenems drives resistance disproportionately. Haematologists are therefore contributing to the aforementioned antimicrobial resistance situation. This is self-defeating in the medium-to-long term. If carbapenem resistance continues to be encouraged, immunosuppressive therapeutic interventions for haematological conditions, such as bone marrow transplant, will be unviable. Haematology is changing the world by driving a global crisis from which it will be difficult to return.
There are strategies that we can adopt to help avoid this nightmare scenario:
- With close collaboration with infection specialist colleagues, we can alter our prescribing habits to reduce antimicrobial resistance selection pressure whilst still treat patients appropriately.
- Wider and more consistent use of diagnostics, along with development and adoption of new diagnostics, can allow targeting of patients who require antibiotics and reduce unnecessary prescriptions for those that don’t.
- We can encourage investigation into the use of broad-spectrum antibiotic in haematological patients, to determine where it is necessary and where narrow therapy can be safely used instead.