Antimicrobial resistance: the threat to public health

Abstract

Inappropriate use of antibiotics encourages the emergence of antibiotics resistance. Dr Girija Dabke, Specialist Registrar in public health and Dr Elizabeth Sheridan, Head of the HPA's Healthcare Associated Infections and Antimicrobial Resistance Department, look at the important role of public health professionals in raising awareness and ensuring that robust antibiotic policies are in place. The global rise in antimicrobial resistance (AMR) is a major public health threat. Illnesses caused by resistant organisms are often prolonged, with higher risk of death. Resistance to first-line antibiotics leads to use of more expensive and often prolonged treatments, increasing healthcare costs. Resistance is posing a threat to the global control of diseases such as tuberculosis and malaria. According to the World Health Organization (WHO), about 440,000 new cases and over 150,000 deaths occur from multi-drug-resistant tuberculosis annually worldwide. Mandatory surveillance in England has shown decreasing trends in Methicillin Resistant Staphylococcus aureus (MRSA) bacteraemia and Clostridium difficile infections in recent years, proving that concerted action (infection control, hand hygiene and antibiotic policy) can be successful. On the other hand, we have seen emergence of resistance in other organisms, such as Neisseria gonorrhoeae with increasing resistance to azithromycin and cephalosporins, emergence of oseltamivirresistant influenza viruses, increasing resistance to third-generation cephalosporins among enterobacteriaceae such as E. coli and Klebsiella pneumoniae (ESBL) and more recently, resistance to carbapenems, the last line of antibiotic defence, in these species. Emergence of bacteria almost totally resistant to all current antibiotics is a worrying development, with few rational treatment options left in such cases, and not many drugs in the research and development pipeline that could be marketed anytime soon. Inappropriate use of antibiotics encourages the emergence of AMR. Consistent correlation exists between levels of antibiotic consumption and AMR at population level. Levels of AMR vary greatly between countries, even within Europe. Despite a robust national policy that controls antibiotic use, antibiotic prescribing rates in the UK continue to remain higher than in other Northern European countries. Significant variations in prescribing practices suggest that there is still room for improvement through training of health professionals and evidence- based prescribing. Patients' expectations often make it difficult for clinicians to implement restrictive measures. Misconceptions among the population regarding antibiotics, and the lack of awareness of the benefits of safeguarding normal flora may impact on patient expectations and demand for antibiotics. Decade-long efforts to increase awareness and reduce prescribing rates in the UK have resulted in transient success. Multifaceted approaches are required that target both public and professionals, and address both the individual's perceptions and the confidence he or she feels in being able to achieve change. Key messages need to be repeated during peak prescribing periods, placed in locations such as pharmacies, patient waiting areas and schools and verbally reinforced during consultations. …