Following on from World Antibiotic Awareness Week, which took place from 18-22 November, there has been much discussion around how to prevent the further emergence and spread of antimicrobial resistance. In fact, this year's campaign marks the first in a new 5-year National Action Plan in the UK for tackling antimicrobial resistance, which will aim to reduce inappropriate prescribing, and control and prevent infection (NHS England, 2019).
Developing resistance
The development of antibiotics has been revolutionary for medicine and public health. However, given the resistance that is now building up against them, we are facing one of the most significant and urgent threats to global health and, as former Prime Minister David Cameron put it: ‘If we fail to act, we are looking at an almost unthinkable scenario where antibiotics no longer work and we are cast back into the dark ages of medicine’.
Entering an era where antibiotics are no longer effective is beginning to pose a threat to the medical community. Antibacterial therapy has the sixth largest pipeline of any therapy area across the entire pharmaceutical industry, driven by society's need for new antibacterial products capable of tackling rising antibiotic resistance (Pharmaceutical Technology, 2018). While many antibiotics are still currently effective and available, for some infections therapeutic options are limited and at crisis point (Appelbaum, 2012). Examples of this looming threat have been seen in recent history: in 2016, a woman in her 70s checked into a hospital in Reno, Nevada, with a bacterial infection in her hip of carpabenem-resistant Enterobacteriaceae. However, in addition to carpabenem, this strain was also resistant to tetracycline, colistin, and all of the 26 other antimicrobials available on the market. A few weeks later, she developed septic shock and died (Molteni, 2017) – the medical community must all do what it can to ensure we're not catapulted back to an era where this becomes the norm.
Antimicrobial stewardship
Prescribers can contribute to preventing the spread of antibiotic resistance in various ways. For example, the Centers for Disease Control and Prevention (2017) in the United States recommend the following:
- Prescribe antibiotics only when they are likely to benefit the patient
- When an antibiotic is likely to provide benefit to a patient, prescribe an antibiotic that specifically targets the bacteria that is most likely causing the patient's illness
- Encourage patients to use the antibiotic as instructed
- Collaborate with one another, as well as with office staff and, importantly, patients, to promote appropriate antibiotic use.
While these points may sound obvious to some, the World Health Organization (WHO) estimated that half of all antibiotic prescriptions in 2015 were for viral conditions, for which they could provide no benefit (Sprenger, 2015). The WHO also emphasises that more can be done to prevent infections in the first instance as well, such as ensuring hands, instruments and the environment are clean, and employing vaccines where appropriate (Sprenger, 2015). Hygiene of hands, kitchen utensils and the home environment is something that may be underestimated by some members of the general public. It is easy to assume that people know to wash their hands, teach their children to do the same, and to keep their environment clean and free of bacteria to the best of their ability. However, this is not always taken seriously, and health professionals should stress the importance of this to their patients.
Another approach that can be used with patients to reduce inappropriate prescribing is known as the six ‘R's (Ashiru-Oredope, 2019):
- Reassurance: reassure the patient about the infection
- Reasons: explain why antibiotics are not normally necessary
- Relief: suggest suitable over-the-counter preparations for symptom relief – for example, paracetamol for pain
- Realistic: give a realistic timeframe in which the patient can expect to start feeling better
- Reinforce: provide written information to support the advice that has been given
- Rescue: explain when to seek further help.
Role of the patient
In the age of the informed and empowered patient, health professionals are no longer in the paternalistic position of treating their patients without their involvement. The problem of antimicrobial resistance belongs to every member of society, from prescribers and other health professionals, to governments and pharmaceutical companies, and every individual in the general population (Ashiru-Oredope, 2019). However, most of your patients likely don't know how they might contribute to such a mammoth global threat.
Health professionals can help to increase patient awareness of antimicrobial resistance and how they may become stewards for this cause. For example, the Centers for Disease Control and Prevention (2017) provide the following advice for the general public, which can aid health professionals in supporting and educating patients:
- Express any concern about antibiotic resistance to your health professional
- Ask your health professional if there are steps you can take to feel better and get symptomatic relief without using antibiotics
- Take the prescribed antibiotic exactly as your health professional tells you
- Safely throw away leftover medication
- Ask your health professional about vaccines recommended for you and your family to prevent infections that may require an antibiotic
- Never skip doses
- Never take an antibiotic for a viral infection like a cold or the flu
- Never pressure your health professional to prescribe an antibiotic
- Never save antibiotics for the next time you get sick
- Never take antibiotics prescribed for someone else.
A (lack of) progress report
In 2014, a review was commissioned by the then UK Prime Minister, to analyse the global issue of rising drug resistance and drug-resistant infections, and to propose concrete action steps that could be taken in an effort to tackle the problem internationally (Review on Antimicrobial Resistance, 2016).
However, a recently published progress report notes that while there has been progress in raising awareness, there is less evidence about any impact being made on behaviour (The Pharmaceutical Journal, 2019). In fact, it is suggested that ‘multinational pharmaceutical companies actually have fewer projects to develop antibiotics than they did when the report was launched three years ago (The Pharmaceutical Journal, 2019).
However, according to Raymond and Powell (2019), simply reducing the use of antibiotics and developing new ones isn't enough – they suggest several rules for preventing a crisis of antimicrobial resistance beginning with the most obvious: prevention of infection in the first place.
Conclusions
While antibiotic use is necessary in certain situations, it must be remembered that the use of antibiotics, whether appropriate or not, contributes to the problem of antibiotic resistance. Therefore, not only do prescribers need to be prudent in their decision-making regarding when to prescribe an antibiotic, but patients also need to take the responsibility of taking them appropriately and in appropriate doses, ensuring never to pressure a health professional into prescribing an antibiotic, and remaining open to other available solutions, which prescribers can make them aware of.
While drugs will inevitably lose their ability to kill the bacteria that cause diseases over time as a result of natural selection and genetic adaptation, there is much that can be done to slow down this process, such as more generous and rapid investment in new drug development; more effective use of infection prevention strategies; safe, informed and sparing use of antibiotics by patients; and a push towards appropriate prescribing in what has become our overmedicalised society.
‘Half of all antibiotic prescriptions were for viral conditions, for which they cannot provide benefit’