In 2003, the UK Department of Health's announcement of a £12 million funding package for the Hospital Pharmacy Initiative marked a major step in the development of antimicrobial stewardship (AMS), resulting in updated local antimicrobial guidelines, improved relationships between microbiology/infectious diseases and pharmacy, and greater education and training for healthcare professionals in prudent antimicrobial use (Gilchrist et al, 2015).
Vergnano et al (2020) recently described the characteristics of paediatric AMS programmes in 17 UK regional children's hospitals with paediatric intensive care and paediatric infectious diseases (PID) departments. They found that microbiology/pharmacy-led services were more likely than PID-led services – 75% vs 33% – to implement antimicrobial restriction, to focus on broad spectrum antibiotics and to review patients with positiveblood cultures.
The apparent reluctance to address the challenges of antimicrobial resistance (AMR) and AMS can hardly be attributed to lack of advance warning. For example, as Lobanovska and Pilla (2017) note, in 1940, it was shown that an E. coli strain could inactivate penicillin by producing penicillinase, by 1942, penicillin resistance was documented in four S. aureus strains recovered from hospitalised patients and by the late 1960s, more than 80% of community- and hospital-acquired strains of S. aureus were penicillin-resistant. Further, by December 2014, the O'Neill Review on Antimicrobial Resistance (2014) was predicting a global death toll of 10 million people by 2050, making AMR the biggest cause of death above cancer.
Yet despite such warnings, Pan et al (2016) state: ‘it is known that doctors are influenced by many factors when deciding to prescribe, and that many of these factors are neither clinically nor ethically relevant’ but driven by a wish to please the patient. Citing a UK primary care study, which reported that antibiotic prescribing volume predicts satisfaction in a doctor/practice, according to the General Practice Patient Survey, they make the gloomy observation that ‘this does not bode well for antibiotic stewardship, given the impact of those satisfaction scores on GPs' pay-for-performance Quality and Outcomes framework’ (Pan et al, 2016). Similarly, Machowska and Lundborg (2019) adduce data from the UK showing that doctors overestimated patients' expectations for antibiotics and prescribed antibiotics to maintain a good patient–doctor relationship.
On the strength of such evidence, it could be argued that those who knowingly prescribe antibiotics merely to please their patients are acting unethically; as Singer (1979) observes: ‘an ethical judgment that is no good in practice must suffer from a theoretical defect as well, for the whole point of ethical judgments is to guide practice.’ Johnstone (2016) is clear that addressing AMR includes acknowledgement of a distinct ethical dimension. This includes concerns such as the promotion and protection of people's wellbeing and welfare interests, and sharing responsibility for, and responding justly to, the competing needs and moral interests of future generations. Published before the COVID-19 pandemic, but freighted with contemporary relevance, Johnstone (2016) speculates that in the context of AMR, new standards of optimal care may evolve, ‘but in all likelihood will probably contravene many of the normative standards of care that, prior to an era of apocalyptic superbugs, were very much taken for granted.’
‘Objective evidence-based medical science cannot be wholly separated from the more subjective demands of morality and ethics’
And there is an ominous element in the warning of Littmann and Viens (2015) that medical science's role in the emergence of AMR entails a responsibility to consider the question of accountability. For example, if we are ethically obliged to preserve effective antimicrobials for current and future generations, ‘then we should also hold people blameworthy or sanctionable for the ignorant, unnecessary or wrongful use of antibiotics, or any other practice that is likely to hasten the emergence of AMR.’
In the context of AMS in PIDs, as considered by Vergnano et al (2020), the observations of Littmann and Viens (2015) are relevant. For example, they ask whether a good antimicrobial steward should ‘provide everyone equal access to antimicrobials or can preference be given to some over others?’. Thus, might antimicrobial agent X be reasonably withheld from elderly adults if the subsequent development of resistance makes it less effective in children?
It is perhaps time to recognise that objective evidence-based medical science cannot be wholly separated from the more subjective demands of morality and ethics, which, arguably, are at the heart of a healthcare professional's calling.