Antimicrobial stewardship is nothing new. Bacteria are living, learning organisms that were around long before humans —they have always been a part of our history. Just as we’ve learned to adapt and survive, so have they. It has often been a fight of the fittest when it came to our ancestors surviving infections, that is, right up until the advent of antibiotics in the 1920s. Since then, we have seen a decline in complications and deaths associated with a variety of infections. We have also gained the ability to perform elective procedures with fewer debilitating infections. Antibiotics have often been referred to as one of the most significant medical achievements in the 20th century for preserving life and function.
What is antimicrobial resistance (AMR)?
Antimicrobial resistance (AMR) is a bacteria’s ability to withstand antibiotic treatment through either inherent (naturally occurring) or acquired (taught/shared) ability. Bacteria can become resistant through:
- Natural occurrence (genetic mutation)
- Previous exposure to antibiotics without eradication (self-learning through exposure to low doses, ineffective antibiotic type, or exposure to a too-short course of antibiotics)
- Transfer of resistance from other bacteria (learning or gaining the trait from others).
As more research was done into bacteria that were surviving antibiotic treatment, we saw the emergence of AMR, multi-resistant organisms (MROs) and the need for newer antibiotics to match those bacterial adaptations. With bacteria’s ability to learn, adapt and share traits, we are ALL at risk of contracting infections that can not be effectively treated by the antibiotics we have. This may lead us back to the pre-antibiotic era of high morbidity and mortality rates.
What’s the real cost?
There is broad consensus that AMR-related costs and effects on patients in our health services are likely to be significant in the coming years. This is because of longer recovery times, increased adjunct medication use, longer treatments, the inability to perform elective procedures without high infection risk and generally higher levels of disability.
A 2014 UK review on the global economic cost of AMR suggested that if the current trends remain the same, that, by 2050, approximately 10 million people may die annually from factors directly related to AMR. Also, the gross domestic product (GDP) could decrease by 2%–3.5%, which could cost the world’s economy over US$100 trillion. This is likely an underestimation as it does not take into account the social costs or the costs for institutions to manage MRO outbreaks.
Why developing new antibiotics isn’t the golden ticket.
The main contributing factors to AMR in the healthcare setting are the inappropriate prescription and overuse of antibiotics across tertiary and primary healthcare facilities. Antibiotics are commonly used in residential care facilities for the treatment of urinary tract infections, respiratory infections and wound infections. Overuse of antibiotics is said to be one of the causative factors for the development of resistant organisms, which includes but is not limited to MRSA, VRE, CRE and Clostridium difficile.
- In New Zealand, community-based consumption of antibiotics is estimated to have increased by up to 49% between 2006 and 2014.
- The antibiotic consumption level in New Zealand is high compared with many other countries — up to 95% of antibiotics are dispensed in the community.
- A 2015 Australian report on antimicrobial use and resistance in human health shows a general increase in community dispensing of antibiotics, with 60% of those aged 65 years or over, and 76% of those aged 85 years and over, being supplied at least one antimicrobial.
Designing and disseminating new antibiotics is unfortunately not a sustainable answer to this issue, as we cannot keep up with the concerning rates of AMR seen around the world, especially in the context of MROs (e.g. MRSA, ESBL). It has been noted by Dr Sally Roberts, clinical lead to HQSC’s IPC programme, that new antibiotics could take 10–15 years to develop and that there is low incentive for drug companies to do so as antibiotics are usually prescribed for only short periods of time.
A race of one-upmanship with antibiotics is not sustainable when it comes to matching the spread and adaptation of bacterial infections.
Antimicrobial Stewardship: A HQSC and World Health priority
With the knowledge that antibiotic development cannot match the alarming rates of bacteria developing resistance worldwide, the focus has shifted to prevention and monitoring. Over the last year, the Health Quality and Safety Commission (HQSC) has announced that the main focuses for our healthcare communities are active infection surveillance, appropriate antibiotic prescription and effective infection prevention programmes.
Recommendations to show that antimicrobial stewardship is a quality initiative:
- Avoiding infections in the first place is key to lower antibiotic prescription
- Effective and consistent use of Standard Precautions
- Yearly IPC education and updates for all levels of staff (from management to cleaning staff)
- Implementing an AMS programme/policy
- Establishing a multidisciplinary AMS team to implement and review the AMS programme quality initiatives
- Correct sample collection and identification of the culprit bacteria. This guides correct antibiotic choice and reduces the learning opportunities of bacteria
- Active surveillance and collection of infection rate and antibiotic use data in your facility
- The surveillance data and focus on AMS strategies can be used to show Continuing Improvements (CIs) around audits.
What an AMS Programme can look like
There are several resources readily available to assist and guide you with the development and implementation of an antimicrobial stewardship program. Many of the links below contain outlines and resources:
- The Australian Government’s Antimicrobial Resistance: What you can do for Aged Care
- Centers for Disease Control and Prevention (CDC)’s The Core Elements of Antibiotic Stewardship for Nursing Homes.
- The CDC’s LTCF information resources.
- The NZ MOH https://www.health.govt.nz/our-work/diseases-and-conditions/antimicrobial-resistance/resources-antibiotic-awareness
- An AMS policy template is available at https://www.ncas-australia.org/aged-care-resources
AMS is central to Infection Prevention and Control. See also our blog post ‘What is ‘Infection Surveillance’ and why is it important in HAI prevention?’. If you have any other questions or concerns about infection prevention and control, please get in touch with us via our ‘Contact Us‘ page.