A situation has evolved that places future patients at serious risk: resistance to antibiotics has risen drastically. ‘Microorganisms such as Escherichia coli and Klebsiella pneumoniae, which are commensals and pathogens for humans and animals, have become increasingly resistant to thirdgeneration cephalosporins,’ according to Jean Carlet and colleagues at the 2011 3rd World Healthcare-Associated Infections (HAI) Forum. ‘Moreover, in certain countries, they are also resistant to carbapenems and therefore susceptible only to tigecycline and colistin,’ they added in their call for action. The causes are numerous; overuse has been identified as a root problem. At the Forum, 70 experts endorsed the Pensières Antibiotic Resistance Call to Action globally. Among them was Professor Dilip Nathwani, who chairs a successful programme in Scotland designed to implement antibiotic stewardship, an approach that he outlined for EH reporter Michael Reiter.
‘Antimicrobial use and consumption in Europe continues to rise, and is a key driver for antimicrobial resistance,’ he explained. ‘In the UK it has been estimated that 80 percent of human antibiotic use takes place in the community, of which up to 50 percent may be inappropriate; 20 percent of use is in hospitals, out of which up to a third may be inappropriate. The consequences of this are antibiotic resistance, Clostridium difficile infection (CDI)-associated diarrhoea, and subsequently an increase in patient morbidity and mortality as well as in healthcare costs.’ The reasons behind this, he explained, are, ‘Misuse – defined as the wrong choice or spectrum of antibiotic, the wrong route, dose, or duration – and increased antibiotics prescribing is driven by a range of factors that include suboptimal clinical and laboratory diagnostics to diagnose bacterial infection, sociocultural and economic influences, defensive medicine, self-medication and poor regulation. Additional factors include poor education both of prescribers and the public, with anti- biotics used to counter common viral infections, and the poor quality of the actual antibiotics also plays a role – particularly in antibiotics available in developing countries.’
Describing the aims of the programme, Prof. Nathwani said, ‘Antimicrobial stewardship is the term used to describe a set of interventions aimed at optimising the quality of antibiotic prescribing and improving the management of infections. In Europe, and globally, a number of initiatives are being implemented to do this. In Scotland, since 2008, there has been a government-funded multi-stakeholder antimicrobial stewardship programme – the Scottish Antimicrobial Prescribing Group* – which I chair. The programme has led to a significant reduction in the number of antibiotics prescribed in the community and hospitals that are associated with CDI, with a substantial reduction in the prevalence of this serious infection at a national level. We implemented it through organisational support and clinical leadership; through the introduction of hospital and community antimicrobial management teams; measures for improvement, and accountability targets for prescribing linked to national targets for disease reduction, such as CDI. Stewardship was also a component of external inspection by the Health Environment Inspectorate. ‘The programme included the development of an integrated framework for surveillance of microbial resistance and measurement of antibiotic consumption and quality and a blended approach to educational support for all prescribers. Presently, the programme has not led to ‘unintended consequences, such as worsening of resistance in key pathogens or evidence of increased mortality due to the change in the types of antibiotics used,’ he pointed out. ‘The measurement of other unintended consequences [e.g. aminoglycoside related toxicity] remains a key component of the programme.’
Summing up the role of the hospital’s activities in this field, he said: ‘The multi-disciplinary stewardship team at Ninewells has been at the forefront of this national work and instrumental in developing & using robust scientific methodology in the evaluation of the impact of the stewardship interventions on core clinical outcomes. We continue to work with other NHS Boards in Scotland, with the Scottish National Patient Safety Programme – the Sepsis Collaborative – as well as European and international collaborations to measure the intended and unintended impact of our stewardship interventions. We remain committed to sharing our experience and learning with other European and international groups.
* http://www.scottishmedicines.org.uk/ SAPG/Scottish_Antimicrobial_Prescribing_ Group__SAPG_
Professor Dilip Nathwani MB FRCP (London, Ed. Glasg.), DTM&H, is a Consultant Physician in Infectious Diseases and Honorary Professor of Infection, Ninewells Hospital and Medical School, Dundee, UK. He chairs the Scottish Government Funded Scottish Antimicrobial Prescribing Group (SAPG), which has been tasked by the Scottish Government to take forward a national clinical antimicrobial stewardship programme. He also chairs the European Study Group on Antibiotic Policies (ESGAP), one of the study groups of the European Society of Clinical Microbiology and Infectious Diseases (ESCMID).