Antimicrobial resistance (AMR) has emerged as one of the principal public health problems of the 21st century. This has resulted in a public health crisis of international concern, which threatens the practice of modern medicine, animal health and food security.
Its prevalence has increased alarmingly over the past decades. In 2008 the acronym “ESKAPE” pathogens which refers to Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa, and Enterobacter species was proposed to highlight those pathogens where amr is of particular concern and to emphasize which bacteria increasingly “escape” the effects of antibiotics. These organisms are increasingly multi-drug- (MDR), extensive-drug- (XDR) and pan-drug- resistant (PDR) and this process is accelerating globally.
The impact of AMR worldwide is significant, both in economic terms, and clinical morbidity and mortality because it may:
- lead to some infections becoming untreatable;
- lead to inappropriate empirical treatment in critically ill patients where an appropriate and prompt treatment is mandatory;
- increase length of hospital stay, morbidity, mortality and cost; and
- make necessary alternative antimicrobials which are more toxic, less effective, or more expensive.
The global nature of AMR calls for a global response, both in the geographic sense and across the whole range of sectors involved.
Emergence of AMR, combined with very few new antimicrobial agents in the drug development pipeline, indicates that awareness and understanding of antimicrobial resistance is necessary.
AMR is a natural phenomenon that occurs as microbes evolve. However, human activities have accelerated the pace at which microorganisms develop and disseminate resistance. Inappropriate use of antibiotics and other antimicrobials, as well as poor prevention and control of infections, are contributing to the development of such resistance.
Appropriate, careful and rational use of antimicrobials is an integral part of good clinical practice. This attitude maximizes the utility and therapeutic efficacy of treatment, and minimizes the risks associated with emerging infections and the selection of resistant pathogens.
The indiscriminate and excess use of antimicrobial drugs appears the most significant factor in the emergence of resistant microorganisms in recent years.
Clinicians should be aware of their role and responsibility for maintaining the effectiveness of current and future antimicrobials. They can help tackle resistance by:
- enhancing infection prevention and control;
- controlling source of infection when it is needed
- prescribing and dispensing antimicrobials when they are truly needed; and
- prescribing and dispensing the right antimicrobial(s) to treat the illness.
An antimicrobial-based approach should involve a delicate balance between the optimisation of empirical therapy, which has been shown to improve clinical outcomes, and the reduction of excessive antimicrobial use, which has been proven to increase the rate of emergence of anti-microbial resistant strains.
Although most clinicians are aware of the problem of antimicrobial resistance, most underestimate its importance; judicious antimicrobial management decisions is an integral part of responsible medication prescribing behavior.
Many calls to action on antimicrobial resistance have been made over the past years, but there has been little progress.
The World Health Organization (WHO) endorsed a global action plan to tackle antimicrobial resistance. It sets out five strategic objectives:
- to improve awareness and understanding of antimicrobial resistance;
- to strengthen knowledge through surveillance and research;
- to reduce the incidence of infection;
- to optimize the use of antimicrobial agents; and
- to develop the economic case for sustainable investment that takes account of the needs of all countries, and increase investment in new medicines, diagnostic tools, vaccines and other interventions.
Hospital based programs dedicated to improving antibiotic use, commonly referred to as “Antimicrobial Stewardship Programs” (ASPs), can both optimize the treatment of infections and reduce adverse events associated with antibiotic use. Of note, a recent systematic review and meta-analysis demonstrated that ASPs significantly reduce the incidence of infections and colonization with antibiotic-resistant bacteria and Clostridium difficile infections in hospital inpatients. Therefore, every hospital worldwide should utilize existing resources to create an effective multi-disciplinary team. The preferred means of improving antibiotic stewardship should involve a comprehensive program that incorporates collaboration between various specialties within an healthcare institution including, infectious disease specialists, hospital pharmacists, clinical pharmacologists, administrators, epidemiologists, IPC specialists, microbiologists, surgeons, anaesthesiologists, intensivists, and underutilized but pivotal stewardship team members, the surgical, anaesthetic and intensive care nurses in our hospitals.
ASP policies should be based on both international/national antibiotic guidelines, and tailored to local microbiology and resistance patterns. Facility-specific treatment recommendations, based on guidelines and local formulary options promoted by the APS team, can guide clinicians in antibiotics selection and duration for the most common indications for antibiotic use. Standardizing a shared protocol of antibiotic prophylaxis should represent the first step of any ASP. Since physicians are primarily responsible for the decision to use antibiotics, educating them and changing the attitudes and knowledge that underlie their prescribing behavior are crucial for improving antibiotic prescription.
Education is fundamental to every ASP. A range of factors such as diagnostic uncertainty, fear of clinical failure, time pressure or organisational contexts can complicate prescribing decisions. However, due to cognitive dissonance (recognising that an action is necessary but not implementing it), changing prescribing behaviour is extremely challenging. Efforts to improve educational programs are thus required and this should preferably be complemented by active interventions such as prospective audits and feedback to clinicians to stimulate further change. It is also crucial to incorporate fundamental ASP and infection prevention and control principles in under- and post graduate training at medical faculties to equip young doctors and other healthcare professionals with the required confidence, skills and expertise in the field of antibiotic management.