A massive threat is emerging in South Africa from a family of superbugs known as CRE, described as "nightmare bacteria" in the US where cases are increasing.
"The exponential rise of CRE in South Africa has the potential to become a national crisis," warned clinical microbiologist Dr Adrian Brink, co-chair of the South African Antibiotic Stewardship Programme.
In 2012, 64 patients in South Africa tested by just one of the leading laboratories - Ampath - had CRE, or carbapenem-resistant Enterobacteriaceae. Only three years later the lab found that 587 patients were positive.
The germs live in the gut and can kill up to half the patients who get bloodstream infections.
"The big problem at the moment is CRE," said Professor Guy Richards, director of critical care at Charlotte Maxeke Johannesburg Academic Hospital.
MRSA, the methicillin-resistant Staphylococcus aureus, "was the big bug that the public was aware of 10 years ago," the professor said.
CRE are among the three most common resistant bacteria found in Mediclinic hospitals, said Briëtte du Toit, manager of infection prevention and control for Mediclinic Southern Africa.
Dr Tom Frieden, director of the Centers for Disease Control and Prevention in the US, said in a report: "CRE are nightmare bacteria. Our strongest antibiotics don't work and patients are left with potentially untreatable infections."
Carbapenems are one of the last classes of antibiotics that reliably work against resistant infections.
The menace of superbugs has grown worse since 2004 when the Sunday Times reported that about one in seven patients were at risk of deadly infections in major state and private hospitals in South Africa.
Roughly one in every five patients admitted to selected state hospitals are at risk of contracting a hospital-acquired infection, often caused by superbugs that are hard to treat.
The statistic was arrived at by a recent survey involving close to 3000 beds in 13 hospitals across four provinces and conducted under the direction of Professor Adriano Duse, chairman of the South African national working group for the Global Antibiotic Resistance Partnership.
"As this study does not include all state hospitals and did not include private sector hospitals where, in selected facilities infection rates may be as high, if not higher, the results are not generalisable to the South African public or private hospital services," Duse said.
Duse, a top infection control expert at the University of the Witwatersrand, said these were preliminary data which still had to be verified.
Gauteng health MEC Qedani Mahlangu said about 1500 people contracted hospital-acquired infections in Gauteng provincial hospitals from 2012 to 2014. Twenty of these patients died.
Dr Roshini Moodley Naidoo, head of clinical quality management at Discovery Health, said hospitals were not obliged to report healthcare-associated infections.
"Infections are in general significantly under-reported," she said. "We have anecdotal and other evidence [such as the use of certain antibiotics] of infection outbreaks in some hospitals."
Private hospital groups Mediclinic and Netcare said their rate of healthcare-associated infections was well within the internationally accepted norm.
Immune-compromised patients are the most at risk but any patient can be exposed to superbugs.
Richards said even patients going in for elective surgeries were increasingly exposed to resistant infections. "It is quite common for patients to go in for a procedure like a knee or hip replacement and develop an infection," he said.
Common healthcare-associated infections are, for example, urinary tract infections, surgical site infections, bloodstream infections from intravenous catheters and pneumonia associated with ventilators.
The good news is that academic, public and private hospitals at the forefront of infection control in South Africa are taking steps like early detection and surveillance to try to ensure superbugs are under control.
Medical aid schemes including Discovery, Bonitas and GEMS monitor the quality of hospitals through indicators like infection rates, mortality rates and readmission rates.
Public and private hospitals are among those supporting the "Best Care Always" campaign launched in 2009 to reduce healthcare-associated infections and promote antibiotic stewardship.
"Hundreds of lives have been saved and much harm averted," Naidoo said, citing estimates from campaign data.
Department of Health spokesman Joe Maila said South Africa had developed an antimicrobial strategy and implementation plan in line with the antimicrobial global action plan of the World Health Organisation.
"A strength of the current strategy is the department's strong working relationship with infectious disease clinicians and microbiologists," he said.
"Antimicrobial resistance has not reached crisis stage yet. However, if the current trend continues, then it is likely that we will have a crisis."