The widespread use of antimicrobials to treat a broad range of infections has been standard practice within both medical and veterinary settings since the first use of penicillin in the 1940s. However, an increased rate of antimicrobial resistance is now being reported in over 100 countries worldwide. Infections that have for so long been seen as commonplace could soon become associated with increased rates of morbidity and mortality.

As reported by the World Health Organization (WHO 2015), one of the largest threats to global health is the rise in antimicrobial resistance. In response to this threat, a worldwide response is thought to be required; a response that addresses the safe and effective use of antimicrobial resistance (AMR) across multiple healthcare settings and into the community.

What are antimicrobials?

Antimicrobials encompass all anti-infective therapies. This includes anti-viral, anti-fungal, anti-bacterial and anti-parasitic medication, administered orally, parenterally or topically (UK NICE Guidelines 2015).

The global rise of AMR

Inappropriate use of antimicrobial drugs across human, animal, and eco-systems has been recognised as the key causative factor in the rapid emergence of drug resistant bacterial strains (Australian Government, DoH, 2015).

When first introduced in the 1940s to clinical settings, penicillin successfully cured previously untreatable infections and was considered an extraordinary breakthrough in medical science. However, indiscriminate and widespread use of penicillin led to the need for increased doses and the development of newer antibiotics to continue to effectively treat infections.

However, it wasn’t until the 1980s that the impact of antimicrobial resistance was identified as a significant issue in global population health (LaMorte, W. 2016).

Today, there is widespread evidence of antimicrobial resistance, with previously treatable conditions now challenging the effectiveness of the most recently developed antibiotic therapies.

Recent examples include:

• Gonococcal infections: Resistance has been reported in several countries, impacting on health in areas such as infertility, neonatal blindness and other complications;

• An increase in the incidence of antimicrobial resistance to the common E Coli related urinary tract infections, a condition commonly seen in aged care services and the community;

• Increased resistance in malaria, HIV, TB, and influenza worldwide (WHO 2015). To address the rapidly increasing rate of antimicrobial resistance, both the UK and Australia have responded, with the release of the following documents to guide best practice:

1. The UK NICE Guidelines 2015: Antimicrobial stewardship: Systems and processes for effective antimicrobial medicine use provides a systems approach to the introduction of antimicrobial stewardship programs, antimicrobial prescribing, and the introduction of new antimicrobials.
2. The National Antimicrobial Resistance Strategy 2015-2019 (Australian Government, Department of Health, 2015) recognises the growing risk posed by antimicrobial resistance and identifies the role that human, animal, and eco-systems have in tackling this issue.

• Antibacterial Stewardship

The cornerstone of activities to decrease the rate of antimicrobial resistance are described within antimicrobial stewardship programs. These programs describe any activity or strategy implemented in any health setting to improve antimicrobial use (MacDougall & Polk, 2005).

Elements of antimicrobial stewardship programs include:

• Use of antimicrobials only when needed and where there is evidence of benefit;
• Encouraging the use of narrow spectrum therapy;
• Use of safe and effective doses (CEC 2016)

Whilst these guidelines target a multitude of health settings (in Australia at least), strategies within primary health care require further attention associated with the delivery of safe and effective antimicrobial practices. The risk of community acquired antibiotic resistance associated with GP overprescribing of antibiotics remains a significant concern.

As reported by Woodhead (2015), despite the inclusion of antimicrobial guidelines by the Royal Australian College of General Practitioners (RACGP), not all general practices are accredited. As such, they are not required to implement these guidelines in their practice. In addition, unlike their hospital counterparts, the RACGP guidelines are considered less demanding. Despite these concerns, the elements included in the antimicrobial guidelines include:

• Adherence to Infection Prevention and Control Standards (5th edition)
• Support of systems related to the collection and evaluation of data for appropriate antimicrobial use
• Antimicrobial stewardship programs
• Communication and education strategies

Other strategies targeting the reduction of antimicrobial resistance in primary healthcare settings include:

• the role of the newly established Primary Health Networks in supporting general practice stewardship programs;
• increasing the uptake of influenza vaccinations across communities;
• increasing access to improved decision support; and
• increasing the availability of best practice guidelines.

In addition, online learning modules are available from NPS MedicineWise, focusing on antimicrobial prescribing in hospital settings.

Antimicrobial resistance is now recognised as a global threat to health. No longer can antibiotics be seen as the easy answer to a range of illnesses. The era of indiscriminate use and over prescribing of antimicrobials has ended with the recognition of the risk this has on the effective treatment of infections. The increased identification of the threat of antimicrobial resistance, in association with the introduction of best practice guidelines, points to a shift in practice. All health professionals are integral to facing the challenges ahead.


References:

1. WHO. (2015). Antimicrobial resistance, Fact sheet N°194
http://www.who.int/mediacentre/factsheets/fs194/en/

2. Wayne W. LaMorte, MD, PhD, MPH. (2016). The Evolution of Antimicrobial Resistance,
http://sphweb.bumc.bu.edu/otlt/MPH-Modules/PH/PH709_DNA-Genetics/PH709_DNA-Genetics212.html

3. Australian Government, Department of Health. (2015). National Antimicrobial Resistance
Strategy 2015-2019

4. UK NICE Guidelines. (2015). Antimicrobial stewardship: systems and processes for effective antimicrobial medicine use
https://www.nice.org.uk/guidance/ng15

5. Woodhead, M. (2015). Antibiotic strategy to target GPs, Australian Doctor, 3 June.

6. MacDougall C, Polk RE. (2005). Antimicrobial stewardship programs in health care systems, Clinical Microbiology Review,
Oct. 18 (4): 638-656.

7. NSW Health, Clinical Excellence Commission (CEC).(2016). Quality Use of Antimicrobials in Healthcare,
http://www.cec.health.nsw.gov.au/programs/quah

8. RACGP. (2016). RACGP Infection prevention and control standards
http://www.racgp.org.au/your-practice/standards/infectioncontrol/

9. http://www.nps.org.au/medicines/infections-and-infestations/antibiotics