Antibiotic resistance and usage: a global problem that all must tackle
Who should take responsibility for ensuring antibiotics are correctlyused, and how can we educate users and prescribers? Nicola Cree reports
Who should take responsibility for ensuring antibiotics are correctly used, and how can we educate users and prescribers? Nicola Cree reports
Antibiotics are life-saving magic bullets but they are also a finite resource that we must conserve, said Brian Duerden, Inspector of Microbiology at the Department of Health, when he spoke at the first annual European Antibiotic Awareness Day, held on 18 November 2008 in London.
The aim of the day was to raise public awareness about inappropriate antibiotics use and how best to use them, said Roger Finch, professor of infectious diseases at the University of Nottingham and consultant to Nottingham University Hospitals NHS Trust, in his opening address.
Alan Johnson, from the Health Protection Agency, told the audience that although the subject of antibiotic resistance is currently high profile, it is actually a problem we have had since antibiotics were first clinically available.
He added that resistance is a problem of global dimensions and that it is important that world-wide surveillance is carried out. A major initiative to help combat the problem of resistance is to optimise the use of antibiotics and decrease their unnecessary use. Doing this, he said, will involve ongoing education of both the public and healthcare professionals.
There has been a decrease in the number of cases of hospital-acquired infection in the past few years but “zero is possible”, as shown in the US, said Martin Kiernan, nurse consultant for prevention and control of infection at Southport and Ormskirk Hospital NHS Trust.
As one of the key speakers, he addressed the way the healthcare industry can move forward in preventing antibiotic resistance and healthcare-associated infections.
She believes that pharmacists are “pretty key” in preventing antibiotic resistance and helping to promote antibiotics awareness.
She would like to see pharmacists working in line with the DoH to educate patients about what is and what is not appropriate for coughs, colds and sore throats.
These views were echoed by Professor Finch, who said that pharmacists are playing a key role in education and auditing of practice as well as advising on the appropriateness of choice and use of antibiotic agents at ward level.
Jonathan Cooke, director of research and development and clinical director for medicines management and pharmacy at the University Hospital of South Manchester NHS Foundation Trust, added that he was pleased to see the role of the antimicrobial pharmacist developing in primary care.
Andrew Pearson, from the HPA, highlighted results from a hospital that found that restricting three types of antibiotic (cephalosporins, co-amoxiclav and ciprofloxacin) led to a decrease in the number of Clostridium difficile cases, suggesting that we should “virtually ban” quinolones and third generation cephalosporins.
GPs often prescribe antibiotics to get patients out of the surgery, rather than spend the time explaining why it is not appropriate to prescribe, commented Dr Johnson. He also disclosed that a small study has shown that doctors have been shifting their diagnosis when recording it to enable them to give antibiotics in situations, such as upper respiratory tract infections, where they are not recommended.
“It’s a social problem in a sense that doctors are trying to keep the patients happy but that can be counter-productive,” he said. There was also a belief that doctors are pushed to use the most powerful antibiotics “blind” rather than risk losing a patient, said David Livermore, of the HPA.
Chris Butler, head of the department of primary care and public health at Cardiff University, said that he believed there was a sense of “it’s not us who have caused the problem” in doctors’ opinions. He added that resistance in primary care does matter to both clinicians and patients, since patients with resistance return more often for treatment.
Dr Butler pointed out that improving communications with patients in order to give them a clear understanding of prescribing, and allowing them to share in the decision-making process would help achieve change. He said that there are massive opportunities for greater standardisation of care and thus decreasing resistance.
Infection prevention control is the future, Mr Kiernan told the audience. He added that the decrease in meticillin-resistant Staphylococcus aureus has been mainly due to infection prevention measures, which nurses have been involved in implementing. Reducing healthcare-associated infection will decrease the use of antibiotics, he added.
“Resistance is coming to dental infections,” said Michael Lewis, professor of oral medicine and head of oral surgery, medicine and pathology at the School of Dentistry, Cardiff University. He pointed out that, in 1989, 5 per cent of abscesses contained resistant strains of bacteria whereas in 1995 this had increased to 55 per cent.
He highlighted that 7 to 8 per cent of all UK oral antibiotics are for dentistry, but these are only figures from the NHS since private prescriptions are not accounted for. There is a general acceptance that most dental prescribing is unnecessary or inappropriate, he added. He believes that educational outreach improves prescribing habits.
Veterinary surgeons should use antibiotics wisely and only when required, said Susan Dawson, senior lecturer in companion animal infectious diseases at the University of Liverpool. She told the audience that 87 per cent of veterinary antimicrobials are sold for use in food-producing animals.
She highlighted that the use in food-producing animals could have an impact on humans because of the potential that resistance can spread from food to humans. She also pointed out that resistance can spread to humans from contact with animals and, with 50 per cent of households in the UK having a pet, there is also a risk with the use of antibiotics in companion animals.
Dr Dawson also highlighted how MRSA been found to be transmitted from humans to dogs and cats, which then harbour the resistant bacteria. She also said that in the Netherlands it has been found that MRSA has been transmitted from pigs to humans.
However, although there is a surveillance system for antibiotics use in food-producing animals, there is not one for companion animals. Dr Dawson said that animal owners could help in the veterinary antibiotic situation by only giving antibiotics prescribed by a vet, using the course correctly, and maximising disease control by good husbandry.
Professor Finch told the audience that it is hard to make a list of people who are not at risk of antibiotic resistance and patients need to be aware of how to avoid infection. There was a general feeling from the audience that patients have the wrong perception about how antibiotics work.
Dr Livermore commented that he believed this was not helped by the national media’s definitions of viruses and bacteria. Roger Goss, co-director of Patient Concern, told The Journal that it was not the role of the patient to educate the healthcare professional about antibiotic awareness.
He believed that it was the role of the regulatory bodies to ensure that their members are fit to practise. He also said that practitioners should ensure that patients are aware of why or why not they feel it appropriate to prescribe.
Cliodna McNulty, of the HPA (left), Ann Keen, Parliamentary under-secretary for health services, and Dominic Wood, children’s television presenter, test the “snot gun”, a learning tool designed for the “e-Bug” scheme (www.helenjonesphotography.co.uk)
Cliodna McNulty, of the HPA, said that the idea of e-Bug was to teach in an exciting, fun way that the overuse of antibiotics may have an adverse effect.
The e-Bug scheme has been trialled in schools across England and Scotland. One of the children involved in the trial, James Fawcett, was the winner of the DoH’s campaign to design a poster promoting antibiotic awareness.
James told The Journal that what he had learnt in his e-Bug training had inspired him to design the poster. Children’s television presenter Dominic Wood was there to present James with an award for his winning poster.
Mr Wood told The Journal that he believed the campaign was very important for highlighting to children when they should and should not be taking antibiotics. He said that children need to seek advice from their pharmacist if they are prescribed antibiotics for a cough or cold and to think before taking them.
The pharmaceutical industry
There is a big falsehood in the belief that there are no new antibiotics, said Dr Livermore. However, pharmaceutical companies are moving away from developing them because it is less profitable and less interesting than developing drugs for long-term conditions.
Dr Johnson added that there has been a dramatic drop in the number of new antibiotics developed since the 1970s and that this is an increasing cause for concern. The antibiotic development industry needs reinvigorating and made more economically viable in order to encourage the development of new antibiotics, Dr Livermore believes.
The first annual European Antibiotic Awareness Day took place in London on 18 November 2008. It was organised by the Advisory Committee on Antimicrobial Resistance and Healthcare Associated Infections, the British Society for Antimicrobial Chemotherapy and the Department of Health
Teaching tools such as the “snot gun” (see above) are designed to teach about respiratory hygiene in a fun way while showing to children how far respiratory excretions can travel when they do not cover their mouths.
Another original teaching method is teaching secondary school children about sexual transmission via a water trick which demonstrates how infections can be spread by bodily fluids.
A website is available to support the learning packages, www.e-bug.eu
Citation: The Pharmaceutical Journal URI: 10040679
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