The Face of Resilience: Vanessa Carter's Journey Fighting Antimicrobial Resistance (AMR)

By Hamu Madzedze

Online Health Editor-Zimbabwe

Vanessa Carter is one of the patients who experienced Antimicrobial Resistance (AMR), and her story will continue to capture the hearts and minds of many people across the globe.

Waking up disfigured in intensive care after a car accident is not easy. Having said that, surviving infections that are resistant to the antimicrobial medicines you are being prescribed is even worse.

Her accident took place in 2004, when she was only 25 years old.

"I was out for dinner with friends that evening. On our way home, a car overtook us on the wrong side of the road and sent us into a violent spin on Republic Road in Johannesburg,” said Vanessa.

She said their car went headfirst into a concrete wall and from there she cannot recount the events that followed, except for hearing a voice from one of the paramedics asking her if she was on any medical aid scheme.

"I was unable to respond due to excessive bleeding internally as well as on my face due to multiple fractures. I had also suffered from severe injuries to my neck, back, and pelvis", said Carter.

She added that she was resuscitated on the scene with a defribillator. The driver of their car informed the emergency services that she was not registered with any medical insurance and therefore she was transported to a public health facility.

“After laying in high care, unconscious for three days, I woke up in Charlotte Maxeke Johannesburg Academic Hospital.”

She described the team of doctors and nurses assigned to her as an incredible medical team.

She pointed out that after a period between one and two years, she gained the ability to perform everyday tasks such as driving a car and returning to work as her body had gradually recovered its physical capabilities.

However, Vanessa highlighted that she had come to terms with the disfigurement of her face and the visual impairments which came with this accident. This was because she had also lost her right eye.

According to Vanessa, to attain a sense of physical and functional normalcy, she required the insertion of various types of facial prosthetics. Given the complexity of the facial area, a sizable medical team was necessary This meant she needed to consult various specialists including plastic surgeon, maxillofacial surgeon, Ear Nose and Throat (ENT) surgeon, ophthalmologist, and prosthetist (ocularist), among others.

"It took me two years, but eventually, I was able to apply for medical aid and seek out doctors in private practice", she pointed out.

She highlighted that her initial implant was an ocular floor implant because the bone under her eye socket had been “smashed to pieces”.

"The second step was to create an artificial eye which we couldn’t quite perfect because the facial bone was asymmetrical, and this led to another implant to bridge a wide gap of missing bone between my nose and cheek which couldn’t be restored at the time of my accident" she highlighted.

The surgeon performing the cheek implant was a maxillofacial surgeon. He inserted the implant slightly too high and made incisions (cut) under the lower eyelid.

The cut caused scarred tissue to attach itself onto the cheek prosthetic and pull the lower eyelid down and outwards. In medical terms, this is called an ectropion, and to Vanessa it was bad news because it exposed her to bacterial infections which put her other prosthetics at risk.

To fix the ectropion, Vanessa said she needed a plastic surgeon to release the scarred tissue and perform minor reconstructive surgery to restore her drooping eyelid (skin flap).

Two weeks following that flap she was out shopping about two weeks after being discharged and felt moisture on her face.

"When I reached my car, I pulled down the rear-view mirror only to seeping out of the surgical wound. l called the plastic surgeon’s office in a panic and in no time l was readmitted into a hospital and an emergency surgery was performed to repair the damaged tissue and clean the prosthetic.

According to Vanessa, two weeks later, the infection came back a second time, but this time it was worse, so the procedure was performed again.

After multiple surgeries Vanessa sought answers from several specialists who gave differing opinions and there was minimum communication among them.

"In between these consultations and surgeries, I was repeatedly prescribed antibiotics, sometimes 14-day courses, while I waited to see the next specialist" she said

Vanessa pointed out that eleven months down the line of repeated surgeries and antibiotics, her plastic surgeon insisted that the cheek prosthetic needed to be removed.

She argued with the plastic surgeon because the other doctors weren’t echoing that sentiment.

"I was due for my second sinus drainage surgery, and my plastic surgeon was working in the same hospital as the ENT surgeon. The plastic surgeon said he was going to visit the operating theatre and remove my implant if he saw the infection was still aggressively present on the prosthetic”.

“I took him with a pinch of salt because I had not signed any indemnity form to approve this but lo-and-behold, when I woke up the prosthetic was out”.

According to Vanessa this was the moment that alarm bells rang. “I was told the prosthetic had been sent for testing and so decided to call Lancet Laboratories to ask for a copy. I couldn’t understand why my plastic surgeon had taken a risk like this”.

"Lancet emailed me the test results which made no sense to me with a group of “R’s” and “S’s” running down the page. Later, I learned that meant I was either “Resistant” or “Susceptible” to a certain type of antibiotic. A suspicious term at the top of the test also read, “MRSA”. Resistance meant those antibiotic medicines listed on the test were no longer working, susceptible meant I was responding to some of them.

Vanessa Carter

Information about my antibiotic-resistant infection meant I could take a more active role as a patient

As most patients would, Vanessa searched online to learn more about her antibiotic-resistant infection, which was called “MRSA” Methicillin-resistant Staphylococcus aureus.

“I had never heard of MRSA or antibiotic resistance in my life " she said. The term resistance did start to make more sense to me though, because I started to realise that was why the infection wasn’t responding to the antibiotic medicines.

Vanessa highlighted that antibiotic resistance clearly was something she needed to be paying more attention to since she was taking so many courses of antibiotics and in some instances stopping them halfway because they seemed to not be working.

"One if the things I questioned, was why I didn’t think to ask for a test sooner. Why was it not common knowledge to realise the reason my infection wasn’t clearing was because it was resistant. Understanding antibiotic resistance earlier may have helped her make better decisions.

She had to wait for a year before doctors could attempt any more surgeries and she was put onto a course of vancomycin for seven days.

This is a type of “last-resort” antibiotic used to treat resistant MRSA infections.

Vanessa pointed out that methicillin and penicillin were the types of antibiotics the MRSA bacteria were resistant to, which meant she had to be prescribed something different.

While I was recovering, I managed to find a craniofacial surgeon in the US called Dr Edward J. Caterson who had written an article in a medical journal about face transplants and infection management. His secretary wrote to me and to my surprise, said that Dr Caterson was willing to speak to me because he saw cases like mine often. I had compiled my medical history into a few pages which I emailed him. He explained that I needed as few foreign objects as possible and I that should have a zygomatic osteotomy (cut the cheek bone and move it forward) and then simple touch-up plastic surgery with the soft tissue. The point of this was to ensure that I had as few surgeries as possible.

"I visited numerous renowned doctors in Johannesburg until finding Professor Johan P. Reyneke who was a maxillofacial surgeon. His advice mimicked Dr Caterson’s. "

We performed the zygomatic osteotomy, but regrettably the infection did reappear. I suspect it could have been worse if we used more foreign prosthetics.

She said the test results showed I had both an infection and allergy. I was using an antibacterial ointment, chloramphenicol on my surgical wound at the time and it was stopped then of the Professor rotated different types of oral antibiotics for three months.

Reyneke’ s fear was that I had developed a bone infection (osteomyelitis) so we didn’t want to take any chances. What that meant, was that the infection was not only destroying the soft tissue and skin, but also the bone. One of the most important things that he did was to spend a few minutes explaining how to take my antibiotics more precisely. Timing was of the essence. His words were,

“If your antibiotic is due at 5am, I want you to wake up and take it at 5am. Don’t give the bacteria a 20-minute window to mutate. Make sure you take the antibiotic at equal intervals.” said Prof Reyneke

She also highlighted the most important aspect she adopted which was the frequency of washing her hands and sanitising them every few minutes, especially when shewas out and about.

"Clean hands were critical, especially since it was a natural habit to touch my face like most other people do, and that was where the deadly infection was, Dirty hands meant more germs on my face.” said Vanessa

She added that clean hands also meant she reduced the risk of spreading the MRSA bacteria to her family, friends, and community. This was equally important in hospital for other patients and medical staff when she was admitted with an infection.After a while, the infection began to diminish, allowing her to reveal her face. “I have grown cautious of undergoing surgery unless absolutely necessary and am equally wary of relying on antibiotics unless absolutely essential”.

After her full recovery in 2013, almost ten years after the accident, Vanessa has not only advocated for improved communication regarding antibiotic resistance but also emphasised the importance of patient and public involvement and engagement in addressing this issue.

Antibiotic resistance poses a serious threat to human and animal health. This is not a recently emerging problem it has been neglected for years, even since the first discovery of antibiotics in 1928. Alexander Fleming, the discoverer of penicillin, foresaw the issue of antibiotic resistance as early as his Nobel Prize lecture in 1945. During his address, Fleming warned about the dangers of improper use of antibiotics. He stated:

"It is not difficult to make microbes resistant to penicillin in the laboratory by exposing them to concentrations not sufficient to kill them, and the same thing has occasionally happened in the body. The time may come when penicillin can be bought by anyone in the shops. Then there is the danger that the ignorant man may easily underdose himself and by exposing his microbes to non-lethal quantities of the drug make them resistant."

AMR must be treated with the seriousness it deserves as it represents a crisis that demands personal engagement from all stakeholders. Having said that, these precious medicines has saved millions of lives and continue to do so. What we ultimately need to learn is how to use them responsibly.

Vanessa’s work continues do focus on exactly that through not only her advocacy work, but also through a charity she founded called The AMR Narrative which aims to develop advocacy capacity and awareness among patients and the public, health professionals, policymakers and others. She also currently serves as Chair of the World Health Organisation Task Force of AMR Survivors.

Vanessa closed by saying, “Living in a world without these precious medicines would mean a simple infection could result in death. We must figure out more proactive and innovative ways to make sure they continue to work for us all. Patients in low-and-middle income regions (LMICs), including sub-Saharan Africa, are at the highest risk of AMR, therefore policymakers and others should be focusing their efforts more strategically in these regions”.