Dr. Fidelma Fitzpatrick is Consultant Microbiologist at the Beaumont Hospital and Health Protection Surveillance Centre, Dublin, Ireland. She sent this article in exclusivity for EurActiv.
"Antibiotics are wasted on colds and flu. Last year (2011) the European Commission issued an action plan against the rising threat of antimicrobial resistance (AMR). The plan highlights the gap between the increasing problems related to antibiotic-resistant bacteria in the EU and the need for the development of new antimicrobials to meet medical needs. Indeed, AMR is a key health priority for the Danish Presidency of the EU in first half 2012.
Antibiotics are a precious resource. They have transformed medical practice over the last 60 years. Infections that used to kill people are now treatable. Antibiotics have also facilitated many of the advances in medical practice that we now take for granted, such as orthopaedic surgery, cancer chemotherapy and organ transplantation.
These procedures would simply not be possible without the use of antibiotics. The germs that antibiotics kill – bacteria – have existed for billions of years and are very adept at survival.
Bacteria can rapidly develop defence mechanisms that stop antibiotics from killing them (AMR), particularly in situations where they are overused. AMR is a fact of life. It is a natural survival mechanism for an organism to develop defence mechanisms and become resistant to antimicrobials.
Examples of antibiotic resistant bacteria include meticillin-resistant Staphylococcus aureus (MRSA), penicillin-resistant pneumococcus and carbapenem-resistant enterobacteriaceae (CRE). Other consequences of the over use of antibiotic include potential drug side effects/toxicity and Clostridium difficile infection (CDI).
In addition, very few new antibiotics are being developed. This means that we must endeavour to protect those that we have to ensure that they remain effective for the sake of future generations. We cannot return to the pre-antibiotic era so it beholds us all, healthcare professionals, patients and members of the public to use the ones we have appropriately.
AMR bacteria contribute significantly to the burden of healthcare-associated infection (HAI). An HAI is an infection that someone acquires after coming into contact with the healthcare services. This includes hospitals, long term care facilities, primary care and indeed when someone receives healthcare in their home. HAI and infection with AMR bacteria cause suffering, pain, disability, loss of income and mortality.
AMR infections are potentially more difficult to treat because of limited antimicrobial choices. They are more costly to the healthcare system because of the need to use more expensive antimicrobials, extended healthcare facility stay with risk of further HAI, antimicrobial side effects and potential litigation as a result of complications resulting from HAI. HAI is now recognised as a major patient safety issue and AMR is recognised as a threat to public health.
It is also important to note that antibiotic use in the non-human sectors (agriculture, veterinary and food) can potentially result in AMR in humans. This is why national and international AMR control strategies need to address prevention and control in all sectors.
From a national/international policy context it is also important that AMR control strategies are linked with surveillance and the prevention and control of HAI. The latter has traditionally been addressed under the patient safety umbrella. While not all HAI are due to AMR bacteria, a significant proportion are. There is a need to integrate patient safety and our knowledge of HAI and public health and AMR strategies. A strategic approach to HAI and AMR prevention is fundamental to the delivery of a healthcare system’s objectives in relation to patient safety, quality care, clinical governance and performance. Effective prevention and control systems and an ongoing commitment to education and learning are essential for safe patient care.
The communication from the commission to the European parliament and the council regarding the AMR action plan is timely. It summarises the need to prevent AMR in a holistic inter-disciplinary fashion in both humans and animals. While not specifically addressing HAI control, many of the elements outlined in the communication are essential components of a HAI preventative strategy. Key elements include using antimicrobials appropriately, preventing infections spreading with appropriate infection prevention and control, developing new antimicrobials, focusing on research and innovation and working together as a global community.
Good surveillance underpins much of this communication – Surveillance of healthcare-associated infection (HAI) is a key requirement under European Commission decision 2119/98/ and must be a key component of a national/international HAI and AMR strategy. Without HAI and AMR surveillance, the true burden of HAI and AMR is unknown, emerging threats will remain undetected and policymakers would have no mechanism to track the effect of preventative strategies and interventions.
Developing high quality health intelligence is essential for the development, implementation and evaluation of policy and practice to prevent and control HAI and AMR at local, national and international levels. The consistent collection, analysis and reporting of valid surveillance data is essential to inform the future development, implementation and evaluation of HAI and AMR preventative policies and practices. The old adage of ‘you can’t manage what you can’t measure’ underpins much of our surveillance efforts.
Of course, HAI and AMR surveillance is not simply a data collecting exercise – it must be linked to action to improve patient care. At a European level there are a number of well established international surveillance programmes, many now coordinated by the European Centre of Disease Prevention and Control (ECDC). The Healthcare-Associated Infections Surveillance Network (HAI-Net) has coordinated two recent prevalence (snapshot) studies of HAI and antimicrobial use in acute care hospitals and in long term care facilities and oversees ongoing surveillance of surgical site infections and HAI in intensive care units.
The ESAC database facilitates international comparison of antibiotic use between countries in relation to antibiotic resistance patterns, socio-economic determinants and general health indicators. One of the aims of the newly established ECDIS-network is to establish standardised C. difficile surveillance at a European level. Monitoring C. difficile infection is a good way of assessing infection control and antibiotic prescribing practices (antibiotic stewardship). C. difficile infection is no longer a hospital infection; there are increasing reports in Europe of cases in long term care facilities and indeed in the wider community. EARS-Net collates information on AMR from patients with bloodstream infection and has enabled trends in AMR to be monitored over time. However, much of our surveillance remains hospital based, while most of our antibiotic prescriptions occur outside hospitals. In addition, global networks, such as the Transatlantic Taskforce on Antimicrobial Resistance (TATFAR), are being developed.
While it is essential to maintain hospital surveillance as our sickest most vulnerable patients are in hospital, there is increasing evidence that the source of AMR and HAI may also have community reservoirs which need to be monitored. Increasing reports of AMR in common community infections such as urinary tract infections (where bacteria such as E. coli have developed resistance) means that in some cases there are no oral antibiotics available for treatment. This necessitates the use of intravenous antibiotics and often hospital admission.
As outlined above, the AMR action plan from the EU outlines several areas for action including the importance of public education. Patients and members of the public have an important role in efforts to control AMR and HAI. There is considerable disinformation provided to the public on the role of antibiotics.
Half of EU citizens falsely believe that antibiotics can work on viral infection such as colds and flu’s. Well-informed patients and the public are an essential component of an AMR/HAI control strategy. The European Antibiotic Awareness Day is an important focus for public education, however this is not supported consistently in all EU countries, and education on antibiotics and AMR has to go beyond one day. Much of the literature on AMR and HAI is also written for a specialist (usually scientific) audience and is not necessarily accessible to non-specialists.
The public needs accurate information written in an accessible form without jargon. In the current economic climate, public information and preventative messages may become a low priority; however, as outlined in the EU AMR document, these play an essential part in controlling resistance.
In summary, antibiotics are a precious resource. Bacteria are natural survivors so AMR is always going to be a fact of life. However, there are many things we can do to prevent and control AMR to preserve the efficacy of antibiotics. It beholds us all, healthcare professionals, patients and members of the public to use the ones we have appropriately."
Note: The author wishes to acknowledge editorial support from Astellas Pharma Europe Ltd in the development of this article. The author did not receive any payment.