In April of this year the World Health Organisation released a sobering report on the state of antibiotic resistance internationally. This is the latest in a long line of reports since the Department of Health published “The Path of Least Resistance” in 1998, which made the following key points:
• Antibiotics have enabled huge advances in medicine
• Antibiotic use selects for resistant bacteria
• Resistant bacteria accumulate and spread
• Resistance increases clinical complications, lengthens
hospital stay and adds cost
• Development of new antibiotics is slow, expensive and
cannot be guaranteed
• With more resistance and few new antimicrobial agents,
modern medicine is threatened
• Antibiotics have enabled huge advances in medicine
• Antibiotic use selects for resistant bacteria
• Resistant bacteria accumulate and spread
• Resistance increases clinical complications, lengthens
hospital stay and adds cost
• Development of new antibiotics is slow, expensive and
cannot be guaranteed
• With more resistance and few new antimicrobial agents,
modern medicine is threatened
Click for larger image
Reading this WHO report, it doesn’t appear that much has changed in the last 16 years, except that we are using antibiotics more and more, micro-organisms are "getting ahead" and therapeutic options are reducing. It is possible
that antibiotics will have been discovered and become obsolete within living memory unless something is done to prevent it.
Antibiotics are unique compared to other medicinal drugs, as resistance to them can develop. This occurs by selective pressure from the antibiotic which promotes evolution of the bacteria by “survival of the fittest”, or more specifically survival of those bacteria resistant to the antibiotic. It has been shown time and again that the number and duration of
antibiotic courses, particularly in the preceding 12 months, is strongly associated with the likelihood of isolating resistant bacteria from a patient.
If you consider the 50,000 episodes of Gram-negative bacteraemia per year in the UK for which the mortality is double (30%) if the bacteria are resistant (resistance rates 15%) you can calculate that antibiotic resistance results in over 1250 excess deaths per year from these specific infections alone. Most patients currently survive because their treatment is changed to an antibiotic which still works. Imagine what would happen if there were no antibiotics left to change to. Fact: There are no new classes of antibiotic in Phase II or III clinical trials to treat these infections. We are
rapidly running out of time to address this worrying trend.
So what has been done to try and tackle this
problem?
In 2003 the Department of Health invested £12M over 3 years to support clinical pharmacy activities aimed at promoting prudent antimicrobial prescribing in the NHS. The initiative was called Antimicrobial Stewardship.
Antimicrobial stewardship promotes the use of the right
antibiotic, at the right dose, route and duration, for the right infection at the right time in order to improve patient care whilst reducing antibiotic resistance. At the forefront of this fight are Antimicrobial Pharmacists; specialist clinical pharmacists who help optimise antibiotic use within hospitals and the community.
that antibiotics will have been discovered and become obsolete within living memory unless something is done to prevent it.
Antibiotics are unique compared to other medicinal drugs, as resistance to them can develop. This occurs by selective pressure from the antibiotic which promotes evolution of the bacteria by “survival of the fittest”, or more specifically survival of those bacteria resistant to the antibiotic. It has been shown time and again that the number and duration of
antibiotic courses, particularly in the preceding 12 months, is strongly associated with the likelihood of isolating resistant bacteria from a patient.
If you consider the 50,000 episodes of Gram-negative bacteraemia per year in the UK for which the mortality is double (30%) if the bacteria are resistant (resistance rates 15%) you can calculate that antibiotic resistance results in over 1250 excess deaths per year from these specific infections alone. Most patients currently survive because their treatment is changed to an antibiotic which still works. Imagine what would happen if there were no antibiotics left to change to. Fact: There are no new classes of antibiotic in Phase II or III clinical trials to treat these infections. We are
rapidly running out of time to address this worrying trend.
So what has been done to try and tackle this
problem?
In 2003 the Department of Health invested £12M over 3 years to support clinical pharmacy activities aimed at promoting prudent antimicrobial prescribing in the NHS. The initiative was called Antimicrobial Stewardship.
Antimicrobial stewardship promotes the use of the right
antibiotic, at the right dose, route and duration, for the right infection at the right time in order to improve patient care whilst reducing antibiotic resistance. At the forefront of this fight are Antimicrobial Pharmacists; specialist clinical pharmacists who help optimise antibiotic use within hospitals and the community.
The Role of the Antimicrobial Pharmacist involves:
• Expert advice regarding antibiotic usage in specific individual patients in conjunction with Microbiologists or Infectious Diseases Physicians
• Participation in Route Cause Analysis (RCA) of cases of Clostridium difficile associated disease and MRSA bacteraemias
• Educating healthcare staff about prudent antibiotic usage
• Developing evidence-based guidelines for:
- Empirical antibiotics for treatment and surgical prophylaxis
- Restricted antibiotics which specifically require the approval of a Microbiologist or Infectious Diseases Physician before their use
- Intravenous to oral switching to reduce the unnecessary use of IV antibiotics
- Stop and review to reduce unnecessarily long courses of
antibiotics
• Providing clinical tools such as antibiotic drug charts to
facilitate compliance with guidelines
• Surveillance and audit of antibiotic usage to ensure compliance with guidelines
• Antibiotic formulary decision-making and horizon-scanning for information about new antibiotics
• Representation at Infection Prevention and Control
Committees and Antibiotic Steering Groups (sub-committees of Hospital Drug and Therapeutic Committees)
• Expert advice regarding antibiotic usage in specific individual patients in conjunction with Microbiologists or Infectious Diseases Physicians
• Participation in Route Cause Analysis (RCA) of cases of Clostridium difficile associated disease and MRSA bacteraemias
• Educating healthcare staff about prudent antibiotic usage
• Developing evidence-based guidelines for:
- Empirical antibiotics for treatment and surgical prophylaxis
- Restricted antibiotics which specifically require the approval of a Microbiologist or Infectious Diseases Physician before their use
- Intravenous to oral switching to reduce the unnecessary use of IV antibiotics
- Stop and review to reduce unnecessarily long courses of
antibiotics
• Providing clinical tools such as antibiotic drug charts to
facilitate compliance with guidelines
• Surveillance and audit of antibiotic usage to ensure compliance with guidelines
• Antibiotic formulary decision-making and horizon-scanning for information about new antibiotics
• Representation at Infection Prevention and Control
Committees and Antibiotic Steering Groups (sub-committees of Hospital Drug and Therapeutic Committees)
Does Antimicrobial Stewardship Work?
From 2005 to 2009 the antimicrobial stewardship programs in hospitals have lead to a 40% reduction in the use of fluoroquinolones, such as Ciprofloxacin, and a 50% reduction in the use of cephalosporins, both high-risk
antibiotics for Clostridium difficile associated diarrhoea. However, over the same time period the overall use of antibiotics in hospitals increased by approximately 12%. This was largely due to a rise in the use of beta-lactamase inhibitor combinations, such as Co-amoxiclav and Piptazobactam, as well as the carbapenems. Worryingly, during the same time period, the over reliance on these antibiotics has already lead to the development of resistance to them (AmpC, Extended-spectrum beta-lactamases and carbapenemases).
At present we still have the ability to treat the vast majority
of infections, even those resistant to our 1st and 2nd line
antibiotics. However, the options are reducing and recent trends in resistance such as the rapid spread of carbapenem-resistant Enterobacteriaceae make the possibility of a post-antibiotic era a real probability.
It is not necessarily that antimicrobial stewardship doesn’t
work; the problem is in persuading healthcare staff to prescribe appropriately and patients to accept that antibiotics are not required for every illness. These changes in behaviour are not easy to achieve and may even prove impossible.
In 2008, the Chief Medical Officer’s report stated: “Every
antibiotic expected by a patient, every unnecessary prescription written by a doctor, every uncompleted course of antibiotics, and every inappropriate or unnecessary use in animals and agriculture is potentially signing a death warrant for a future patient”.
Currently it is estimated that 50% of antibiotic prescriptions are inappropriate. We need to change prescribing. No doctor can afford to be resistant to change. Every specialty needs to develop the expertise and accept the responsibility for managing their own infections: Orthopaedic surgeons need
to know how to manage osteomyelitis and septic arthritis, Cardiologists need to know how to manage infective endocarditis, Surgeons need to know how to manage
post-operative wound infections, and Urologists need to know how to manage UTIs. The list goes on and on. All too frequently I am asked by Specialists how to manage the common infections of their speciality.
From 2005 to 2009 the antimicrobial stewardship programs in hospitals have lead to a 40% reduction in the use of fluoroquinolones, such as Ciprofloxacin, and a 50% reduction in the use of cephalosporins, both high-risk
antibiotics for Clostridium difficile associated diarrhoea. However, over the same time period the overall use of antibiotics in hospitals increased by approximately 12%. This was largely due to a rise in the use of beta-lactamase inhibitor combinations, such as Co-amoxiclav and Piptazobactam, as well as the carbapenems. Worryingly, during the same time period, the over reliance on these antibiotics has already lead to the development of resistance to them (AmpC, Extended-spectrum beta-lactamases and carbapenemases).
At present we still have the ability to treat the vast majority
of infections, even those resistant to our 1st and 2nd line
antibiotics. However, the options are reducing and recent trends in resistance such as the rapid spread of carbapenem-resistant Enterobacteriaceae make the possibility of a post-antibiotic era a real probability.
It is not necessarily that antimicrobial stewardship doesn’t
work; the problem is in persuading healthcare staff to prescribe appropriately and patients to accept that antibiotics are not required for every illness. These changes in behaviour are not easy to achieve and may even prove impossible.
In 2008, the Chief Medical Officer’s report stated: “Every
antibiotic expected by a patient, every unnecessary prescription written by a doctor, every uncompleted course of antibiotics, and every inappropriate or unnecessary use in animals and agriculture is potentially signing a death warrant for a future patient”.
Currently it is estimated that 50% of antibiotic prescriptions are inappropriate. We need to change prescribing. No doctor can afford to be resistant to change. Every specialty needs to develop the expertise and accept the responsibility for managing their own infections: Orthopaedic surgeons need
to know how to manage osteomyelitis and septic arthritis, Cardiologists need to know how to manage infective endocarditis, Surgeons need to know how to manage
post-operative wound infections, and Urologists need to know how to manage UTIs. The list goes on and on. All too frequently I am asked by Specialists how to manage the common infections of their speciality.
Click for larger image
Microbiologists and Antimicrobial Pharmacists cannot single-handedly solve the wide-spread problems of inappropriate prescribing. Despite popular medical opinion we are not the “antibiotic police”. The responsibility for appropriate
prescribing needs to lie with the prescriber. We should however be accountable for providing better education to prescribers to ensure the profession has the knowledge to fight against antibiotic resistance in order to try and prevent the post-antibiotic era occurring.
prescribing needs to lie with the prescriber. We should however be accountable for providing better education to prescribers to ensure the profession has the knowledge to fight against antibiotic resistance in order to try and prevent the post-antibiotic era occurring.
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