By Dr Enrique Castro Sanchez and Dr Bryony Dean Franklin, Centre for Patient Safety and Translational Research (PSTRC), Imperial College London
In the last few months we have seen increased attention and alliances around the world to develop interventions to address the challenge presented by drug-resistant infections. For example, a landmark declaration at the United Nations General Assembly on the matter of Antimicrobial Resistance was signed by 193 countries, providing a historic opportunity for experts, governments and citizens to collaborate on a global response to this worldwide threat to patient safety. Only the fourth time in history that a health topic had been at the centre of attention at the UN, the meeting supported commitment of adequate resources to guarantee a much needed sustained and robust response.
However, despite the impetus given and the clear progress already achieved, there are still areas for concern. Although increased consideration has been given to drug-resistant infections, citizens worldwide are yet to completely understand how antibiotics work and how drug resistance develops. While work at Imperial has concluded that, generally, experts and citizens agree on antibiotic misuse or overuse as being the most common driver of antimicrobial resistance, the public seems to attribute much less importance to other factors such as suboptimal rapid diagnostics or inappropriate dosing driving up rates of antimicrobial resistance, a finding with important implications for the design of public health messages related to antibiotics.
What are the factors contributing to antimicrobial resistance? Perceptions from experts and citizens
Castro Sanchez et al, 2016, DOI: 10.1186/s12879-016-1810-x. Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/). No changes made.
It also seems that when people are admitted to hospital and receive antibiotics, they would like to be much more involved in the decisions surrounding their use. However, doctors and pharmacists often relegate patients to a passive and unsatisfying role, hampered by unclear language and a suboptimal experience in terms of communication [http://bmjopen.bmj.com/content/6/10/e011040.short]. At a more general level, such inactive participation may be reinforced by the narrow focus of current antibiotic–related educational messages, mostly focused on encouraging people to ‘take antibiotics as directed’.
While taking antibiotics as prescribed is certainly essential, an initial investigation conducted on the role and responsibilities assigned to citizens by European antimicrobial policies suggests that policies could be much more progressive in terms of their public health perspective, and could encourage citizens to engage in self-care activities such as vaccination uptake and optimal hand hygiene that may ultimately reduce the need for antibiotics. Drug-resistant infections demand that a careful balance is maintained between reducing unnecessary use of antibiotics to arrest the loss of effective drugs, and guaranteeing that those patients who urgently require them have immediate access to them. In essence, we must ensure that ‘cautious’ use of antibiotics does not result in tardy use.
The consequences of drug-resistant infections can be disastrous not just for patients but also for healthcare organisations. A recent investigation vividly described the impact of an outbreak on the activity and finances of a hospital. The organisation was required to allocate precious capital and human resources to resolve the outbreak, and ended up incurring costs approaching a million pounds. The opportunity costs would have also been significant, detracting attention and energy to other clinical and patient safety programmes.
Outbreaks are a poignant reminder of the need to carefully plan and combine antimicrobial stewardship and infection prevention control activities in synergy, if maximum benefit and efficiency are to be achieved. An example of such collaboration between different fields is the recent appointment of two nurse research fellows in antimicrobial research at the Imperial Academic Health Sciences Centre, with funding from the Biomedical Research Centre. These positions reflect the increasing contribution of nurses and other healthcare professionals to antimicrobial stewardship interventions, and the need to intensify research capacity in this area. These research fellows will design and conduct studies about ideal screening practices for drug-resistant infections such as Carbapenemase-producing Enterobacteriaceae, and investigate the influence of optimal safety culture on effective antimicrobial use and patient safety. Additionally, the fellows will collaborate in the organisation of a Nursing Summit on Antimicrobial Stewardship in January 2017, where key stakeholders from the Department of Health, Public Health England, the World Health Organisation, the Royal College of Nursing as well as nurses implementing antimicrobial stewardship interventions in Scotland, England, South Africa and China will discuss existing frameworks of practice and learn about opportunities for nursing contribution.
The continued emergence of drug-resistant infections demands that healthcare workers, researchers, service commissioners and citizens embrace any available opportunity to improve clinical and public health practice and work together to achieve a future free from drug-resistant infections.