Down with a cold? Forget antibiotics

Dr Hsu Li Yang in an isolation ward of a Singapore hospital.
PHOTO: Down with a cold? Forget antibiotics

Dr Hsu Li Yang, an expert in antibiotic resistance, says that Singapore’s antibiotic-resistant infection rates are higher than in the US, Australia and most European countries, and that most infections are caused by poor hand hygiene.

Dr Hsu Li Yang, 41, is an infectious diseases physician working as a clinician-scientist at the National University of Singapore, where he is assistant professor at the Yong Loo Lin School of Medicine.

His areas of research include the epidemiology of methicillin-resistant Staphylococcus aureus as well as the clinical and socioeconomic impact of antimicrobial resistance.

He has published more than 90 peer-reviewed articles in these areas.

Dr Hsu is concurrently visiting consultant at the Central Tuberculosis Laboratory, Singapore General Hospital, as well as the Singapore Tuberculosis Elimination Programme and Institute of Infectious Disease and Epidemiology, both at Tan Tock Seng Hospital.

He is also an adjunct clinician-scientist at the Institute of Bioengineering and Nanotechnology, which comes under the Agency for Science, Technology and Research.

In addition, he was founding director of the Centre for Infectious Disease Epidemiology and Research at the university's Saw Swee Hock School of Public Health.

This year, he was invited to give the respected Monteiro Lecture. This honour, awarded by the Chapter of Infectious Disease Physicians, College of Physicians, Singapore, was created in 2011 to recognise contributions in the fields of infectious diseases, microbiology and public health.

Dr Hsu, an expert in antibiotic resistance, has come up with a comprehensive range of approaches to control it, which have been put into practice here and abroad.

His initiative to monitor antibiotic resistance trends led to the formation of a taskforce by the Ministry of Health - the National Antimicrobial Taskforce.

And he is a formidable chess player - he is a chess international master, a lifetime title awarded to strong players, and a three-time chess Olympiad.

He is married to oncologist Chin Tan Min; they have a two-year-old son and a six-month-old daughter.

Q: England's chief medical officer has warned that growing resistance to antibiotics should be ranked alongside terrorism in terms of seriousness, and that routine operations could become deadly in just 20 years if we lose the fight against superbugs. Is it really such a ticking time bomb?

Yes, and MRSA (methicillin-resistant Staphylococcus aureus) is just the tip of the iceberg. We're fighting an alphabet soup of bacteria which mutate constantly so they can elude even the strongest drugs. All these bugs can cause serious or fatal infections.

Multidrug-resistant Gram-negative bacteria, for instance, is really worrying because this group is growing more and more resistant and we are running out of ways to treat it. Even the antibiotics we're using are getting more and more toxic, and less effective. Antibiotic resistance is one of the biggest problems in the world - the World Health Organisation recently said it is a major threat to public health across the entire planet.

Q: What's the situation in Singapore?

Singapore has antibiotic-resistant infection rates higher than in the United States, Australia and most European countries. There are instances here where you can't treat the patient at all, it's very scary. There are a few reasons for this.

We're in the tropics, which is a climate bacteria enjoy. Also we're a medical hub. Some of the sickest patients brought their infections here when they came for treatment, and now the bacteria are present in hospitals and making the rounds. I think medical professionals have become blase about isolating such patients and making sure hygiene standards are so stringent that the disease doesn't spread.

Most infections are caused by poor hand hygiene, with health- care workers carrying them from one patient to another. They can also be passed on by visitors and patients themselves. The bugs can survive for several days on surfaces such as beds and cupboards.

But having said that, we are already seeing extremely resistant bacteria infecting patients who weren't in hospital or abroad. This means that some antibiotic-resistant strains are already entrenched in the community.

Q: And such patients also make a dent in a hospital's bottom line?

My work has shown that this problem is not just a serious health risk, but also a big health cost. Patients with such infections will be more ill, and are more likely to die. Someone infected with antibiotic-resistant MRSA, for instance, is 10 times more likely to die than a patient without the infection. And the hospital bill for a patient infected with superbugs is more than $8,600 higher.

Q: The experts say that antibiotic-resistant bacteria represent a huge risk to human health because we're surrounded by bacteria and will never be able to keep up with their ability to mutate. How do we attempt to keep ahead of the curve?

We can certainly be more prudent in the way we use antibiotics, invest in developing new antibiotics, and importantly, prevent transmission of such bacteria by screening for, and isolating infected patients in hospitals.

Over the past few years, in most public-sector hospitals in Singapore, we have set up antibiotic stewardship programmes, funded by the Ministry of Health, to monitor and guide antibiotic prescription by doctors. Right now, we're trying to assemble a big group of researchers here to study the problem of antibiotic resistance in Singapore and the region.

We want to look at how these bacteria spread, whether we can predict outbreaks, what type of resistance is conferred, and what future drugs we can develop. In this line of work, it's always like running to stay in place, because of how fast the bacteria continue to evolve.

Q: By your own admission, antibiotic resistance is not a sexy area of research. What made you go into this field?

Well, it comes from seeing patients suffer from it, most of whom do not even realise they've acquired such bugs. I've seen patients come into hospital for something else entirely, and end up with deep wound infections which call for more and more powerful, and toxic, antibiotics. Sometimes they survive, but one in three of the sicker ones don't make it.

The problem has been invisible in Singapore for so long. I've visited hospitals in Australia and France where the rates are 10 times lower than ours, because they take hygiene so seriously. It's a different attitude.

What I'd like to see is for every hospital to publish rates of say, MRSA or multidrug-resistant Gram-negative bacterial infection, for everyone to see. This would be a great driver for getting hospitals to take responsibility, and has worked very well in the UK, where hospital funding was also tied to MRSA infection rates.

Q: International studies have shown that antibiotic-resistant germs and their genes have been found in meat and other food products. How serious is this?

Last year, I had a patient who had not travelled and hadn't been to hospital. Yet she had contracted a nasty superbug. For a simple urinary tract infection, she had to stay in hospital for two weeks, and get antibiotics on a drip. I believe she contracted the infection through a food source.

International data has shown that one-quarter of meat products from certain big meat-exporting countries are contaminated with bacteria that cause antibiotic resistance. If you don't cook the meat fully, you can get infected.

A study at one hospital's accident and emergency department here showed that 12 per cent of such bacteria can be found in patients' stool despite the majority not having been previously hospitalised. This is another means of transmission.

Q: What advice do you have for the man in the street?

Wash your hands thoroughly with soap and wear a mask if you're sick. Cook your food, particularly your meat, well. Also, if you go to your GP for coughs and colds, almost 100 per cent of the time it's a virus and antibiotics won't work, so don't ask for them - it's not true that yellow or green phlegm is due to bacteria. Also, try to avoid going to the hospital if you don't have a major illness.

Q: Apart from medicine, you won the Singapore Chess Championship in 1992 and 1993, and represented the country three times in the Chess Olympiads. Do you still play?

Only for fun. I stopped competitive chess in 2000. I sometimes joke that my time spent on chess was a misspent youth, but it has taught me some useful skills. It helps me concentrate on the things that matter. I think more strategically rather than just looking at what's in front of me.

This article was published on May 11 in The Straits Times. Get a copy of The Straits Times or go to for more stories.