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Death certificates should record antimicrobial resistance as cause of deaths, says CMO

BMJ 2018; 362 doi: https://doi.org/10.1136/bmj.k3832 (Published 06 September 2018) Cite this as: BMJ 2018;362:k3832

How would clinicians prove antimicrobial resistance after patients' death?

I agree that the problem of antimicrobial resistance needs to be tackled.<1> However, it may be difficult for clinicians to prove antimicrobial resistance after patients' death and document that in the death certificates. To confirm antimicrobial resistance, one may need to compare the culture susceptibility results before and after the use of antimicrobials. Molecular testing may follow to support that the antimicrobial resistance is acquired but not intrinsic<2>. Nevertheless, in general, not every patient requires post-mortem investigations; not every microbiology culture requires susceptibility testing. A literature review published in the Journal of Clinical Microbiology concluded that post-mortem cultures are of value in only a limited number of preselected cases.<3> Even in live patients, repeat blood cultures are not recommended in gram-negative and streptococcal bacteraemias, as per the conclusion of a retrospective cohort study on 1801 index bacteraemias from 2010 to 2014.<4> The same study reported that 1031 inappropriate repeat cultures costed their hospital $22,433–$58,250. The Choosing Wisely campaign is strongly discouraging costly medical overuse.<5> Furthermore, microbiology culture and susceptibility testing can take days to complete that would delay completion of death certificates.

I appreciate the initiative to tackle antimicrobial resistance and make the problem more transparent to the public.<1> However, clinicians need better guidance to determine what investigations are required to confirm antimicrobial resistance in patients' death certificates.

References
1. O’Dowd A. Death certificates should record antimicrobial resistance as cause of deaths, says CMO. BMJ. 2018;362:k3832.
2. Fluit AC, Visser MR, Schmitz F. Molecular Detection of Antimicrobial Resistance. Clin Microbiol Rev. 2001;14(4):836-871.
3. Riedel S. The Value of Postmortem Microbiology Cultures. J Clin Microbiol. 2014;52(4):1028-1033.
4. Wiggers JB, Xiong W, Daneman N. Sending repeat cultures: is there a role in the management of bacteremic episodes? (SCRIBE study). BMC Infectious Diseases. 2016;16:286.
5. Wise J. Choosing Wisely: how the UK intends to reduce harmful medical overuse. BMJ. 2017;356:j370.

Competing interests: I have been paid for working as a physician, but not for writing this letter.

11 October 2018
Eugene Y.H. Yeung
Physician
Lancaster, UK, LA1 4RP