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. Combating resistance has become a top priority for global policy makers and public health authorities. New mechanisms of resistance continue to emerge and spread globally, challenging our ability to manage common infections. Antibacterial and antifungal use in animal and agricultural industries aggravates selective pressure on microbes. A One Health approach is required urgently. The burden of AMR is difficult to quantify in some regions of the world, because enhanced surveillance requires personnel, equipment, and financial resources that are not always available. The worldwide impact of AMR is significant, however, in terms of economic and patient outcomes, because of untreatable infections or those necessitating antibiotic agents of last resort (such as colistin) leading to increased length of hospital stay, morbidity, death, and treatment cost. Raising awareness of antimicrobial resistance and promoting behavioral change through public communication programmes that target different audiences in human health, animal health and agricultural practice as well as consumers is critical to tackling this issue.
The World Health Organization (WHO) is now leading a global effort to address antimicrobial resistance. At the 68th World Health Assembly in May 2015, the World Health Organization 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.
One of the goals of this action plan is to promote public awareness and education about AMR. Raising awareness of antimicrobial resistance by education and dissemination of information to stakeholders may be an important factor in changing behaviors.
Although the current magnitude of the problem and its extent in both the community and the hospital can add the complexity of any intervention, healthcare workers play a central role in preventing the emergence and spread of resistance. An effective and cost-effective strategy to reduce AMR should involve a multi-faceted approach aimed at optimizing antibiotic use, strengthening surveillance and infection prevention and control, and improving patient and clinician education regarding the appropriate use of antibiotic agents.
Although the phenomenon of AMR can be attributed to many factors, there is a well-established relationship between antimicrobial prescribing practices and the emergence of antimicrobial resistant pathogens. However after they have emerged, resistant pathogens may be transmitted from one individual to another. Every infection prevented is one that needs no treatment. Prevention of infection can be cost effective and implemented in all settings and sectors, even where resources are limited.
In hospitals, cultural, contextual, and behavioral determinants influence clinical practice, and improving behavior in both infection prevention and control measures and antibiotics prescribing practices remains a challenge. Despite evidence supporting the effectiveness of best practice, many clinicians fail to implement them, and evidence-based processes and practices that are known to optimize prevention and management of infections tend to be underused in routine practice.
A range of factors such as diagnostic uncertainty, fear of clinical failure, time pressure, or organizational contexts can complicate both antibiotic prescribing decisions and preventing measures. Because of cognitive dissonance (recognizing that an action is necessary but not implementing it), however, changing behavior is extremely challenging and awareness of AMR is still low.
Every hospital worldwide should utilize existing resources to create an effective multi-disciplinary team for combating AMR. The best strategies for combating AMR are not definitively established and are likely to vary based on local culture, policy and routine clinical practice despite several guidelines on the topic.
We propose that the best means of improving programs to contain AMR should involve collaboration among various specialties within a healthcare institution. They should focus on collaboration between all healthcare professionals to shared knowledge and widespread diffusion of practice. Involvement of healthcare workers may rise their awareness on AMR.
It is essential for any programmes to have at least one member who is an infectious diseases specialist. Pharmacists with advanced training or longstanding clinical experience in infectious diseases are also key actors for the design and implementation of the stewardship program interventions. In any healthcare setting, a significant amount of energy should be spent on infection prevention and control. Infection control specialists and hospital epidemiologists should be always included in these programmes to coordinate efforts on monitoring and preventing healthcare-associated infections. Microbiologists should actively guide the proper use of tests and the flow of laboratory results. Being involved in providing surveillance data on antimicrobial resistance, they should provide periodic reports on antimicrobial resistance data allowing the multidisciplinary team to determine the ongoing burden of antimicrobial resistance in the hospital. Moreover, timely and accurate reporting of microbiology susceptibility test results allows selection of more appropriate targeted therapy, and may help reduce broad-spectrum antimicrobial use. Surgeons with adequate knowledge in surgical infections and surgical anatomy when involved may audit both antibiotic prescriptions and prevention practices, provide feedback to the prescribers and integrate best practices of antimicrobial use among surgeons, and act as champions among colleagues implementing change within their own sphere of influence. Infections are the main factors contributing to mortality in intensive care units (ICU). Intensivists have a critical role in treating multidrug resistant organisms in ICUs in critically ill patients. They have a crucial role in prescribing antimicrobial agents for the most challenging patients and are at the forefront of successful antibiotic prescribing policies. Emergency departments (EDs) represent a particularly important setting for addressing inappropriate antimicrobial prescribing practices, given the frequent use of antibiotics in this setting that sits at the interface of the community and the hospital. Therefore also ED practitioners should be involved. Without adequate support from hospital administration, these programs will be inadequate or inconsistent since the programs do not generate revenue. Engagement of hospital administration has been confirmed as a key factor for both developing and sustaining. Finally, an essential participant who has been often unrecognized and underutilized is the “staff nurse.” Although the role of staff nurses has not formally been recognized in guidelines they performe numerous functions that are integral to successful.
In our hospitals a cohesive approach in order to limit the emergence of antimicrobial resistance is mandatory. Successful in combating AMR should focus on collaboration between all healthcare professionals in order to gain the wider-possible acceptance, share knowledge and spread best clinical practices.