Ethics of Infection Control Measures for Carriers of Antimicrobial Drug–Resistant Organisms

Babette Rump; Aura Timen; Marlies Hulscher; Marcel Verweij

Disclosures

Emerging Infectious Diseases. 2018;24(9):1609-1616. 

In This Article

Abstract and Introduction

Abstract

Many countries have implemented infection control measures directed at carriers of multidrug-resistant organisms. To explore the ethical implications of these measures, we analyzed 227 consultations about multidrug resistance and compared them with the literature on communicable disease in general. We found that control measures aimed at carriers have a range of negative implications. Although moral dilemmas seem similar to those encountered while implementing control measures for other infectious diseases, 4 distinct features stand out for carriage of multidrug-resistant organisms: carriage presents itself as a state of being; carriage has limited relevance for the health of the carrier; carriage has little relevance outside healthcare settings; and antimicrobial resistance is a slowly evolving threat on which individual carriers have limited effect. These features are of ethical relevance because they influence the way we traditionally think about infectious disease control and urge us to pay more attention to the personal experience of the individual carrier.

Introduction

Antimicrobial resistance (AMR) is one of the most serious health threats of the 21st century. It challenges effective treatment of infectious diseases, now and in the future. AMR may imply that infections that used to be relatively harmless will pose a severe threat to patients in the future.[1] Many countries have implemented measures to control AMR, including proper use of antimicrobial drugs in humans, minimization of antimicrobial drug use in animals, and prevention of further transmission of resistant microbes within the healthcare system.[1–5] AMR raises a range of ethical questions.[6–12] We explored ethical issues that arise in relation to carriage of antimicrobial drug–resistant organisms (hereafter called carriage).

AMR control measures are directed at carriers. The types of control measures vary by microorganism and depend on resistance pattern, virulence, and mode of transmission. Measures can include control precautions taken during patient care, such as use of personal protective equipment; cleaning and disinfection of the care environment; dedicated single-patient use of rooms and equipment; eradication treatment, if applicable; and, in exceptional cases, exclusion of the carrier from work or joint facilities. The actual control measures recommended by health authorities vary greatly among countries. Countries in northern Europe, for instance, have implemented far-reaching infection control interventions that include preemptive use of contact precautions at the time of admission until the patient is proven culture negative and closure of hospital units to new admissions when applicable. Countries in southern Europe and North America follow a less aggressive approach, emphasizing contact precautions after detection of multidrug-resistant organisms.[1–4]

Control measures may effectively control transmission of multidrug-resistant organisms, but negative effects on the health and well-being of carriers have been reported from countries that follow stringent multidrug-resistant organism policies and from countries that have a less aggressive approach.[13–16] These negative effects make AMR control measures, apart from a technical and medical challenge, also an ethical issue. Our aim with this study was to examine the ethical context of multidrug-resistant organism carriage: what are the negative implications for carriers, and what is the ethical relevance?

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