A strategy for tackling antimicrobial resistance: It’s more than a prescribing problem

The 20-year vision for antimicrobial (AM) resistance published by the UK Government on 24 January 2019 recognises the importance of a global approach to tackling the problem. However, it also points to the immense challenges this presents, with the global consumption of AM agents in humans predicted to increase by 30%, and in animals by 67%, over the next 20 years (Global & Public Health Group, 2019).

The accompanying UK 2019–2024 five-year national action plan for tackling AM resistance aims to put some ‘flesh on the bones’ of the nine ambitions outlined in the ‘vision’. It is focused on three key aims:

• lowering the burden of infection;

• optimal use of antimicrobials; and

• developing new diagnostics, treatments and vaccines.

However, as was the case with the 2013–2018 strategy, while infection prevention is recognised as an essential component it is not accompanied by specific plans as to how such goals are to be achieved. Rather, it highlights generic regulations and activities that have been in place for many years in UK hospitals such as the Health and Social Care Act, healthcare worker training in hand hygiene and aseptic technique, and audit. Similarly, while the World Health Organization (WHO) components of an infection prevention and control (IPC) programme are cited as a useful structure, they are primarily focused on systems and processes for establishing IPC programmes rather than specific strategies for preventing healthcare-associated infection (HCAI) (WHO, 2018). Such systems are already well established in the UK.

The emergence of resistance is commonly attributed to misuse of AM agents, but this overlooks other drivers of resistance such as intense and high-volume exposure to AM agents that are used appropriately to treat infection (Barbarosa and Levy, 2000). This is a critical issue given that there is plenty of evidence over the decades since antibiotics first came into use in the 1950s that, over time, many microorganisms will acquire resistance to the AM agents they are exposed to. Just focusing on ‘inappropriate prescribing’ is therefore equivalent to focusing only on the tip of the iceberg; far more important is focusing efforts on preventing the infections that result in the need for AM agents.

To be effective, IPC strategies must be about more than just ‘hand hygiene’. The experience of controlling MRSA in the UK is testament to this. The significant and sustained decline in bloodstream infections caused by these organisms was achieved in conjunction with a programme of infection prevention strategies that were targeted at the underlying causes of these infections, e.g. better management of intravenous devices and screening and decolonisation of carriers (Duerdin et al., 2015).

The previous five-year plan (2013–2018) also included IPC as the first priority, but in reality most of the effort was focused on AM stewardship; there were some notable successes such as reducing AM use in animals by 40% and in humans by > 7%. However, no evidence is provided of major successes in relation to IPC; indeed, given the inexorable rise in Gram-negative bloodstream infections, the opposite appears to be the case.

The UK’s new five-year national action plan suggests targeting ‘priority infections’ (Escherichia coli bloodstream infections and carbapenamase producers) but is light on infection prevention strategy. The focus appears to be ‘stronger surveillance’ and some vague reference to understanding the ‘chain of causality’. The former is of limited value if we do not understand the latter; in the case of E. coli bloodstream infections, we know very little about what is driving the increase in these infections or how to prevent them. In such circumstances, attempts to reduce AM prescribing seem doomed to fail.

Compounding this problem, three-quarters of E. coli bloodstream infections occur outside the hospital, primarily in association with urinary tract infections. In this context, avoiding repeat AM treatment can only be achieved by improving the care of the patient to minimise the risk of infections, e.g. supporting hydration, taking urinary catheters out, and more accurately diagnosing and treating symptoms of UTI when they occur (Wilson, 2018).

The problem of healthcare-associated pneumonia is not considered a key priority, despite it consistently being the most common HCAI and driving the use of broad-spectrum AM agents. Again, the solutions must be focused on preventing these infections occurring in the first place, yet we know little about what strategies might be effective in achieving this and it should be a key research priority. Unfortunately, research priorities are too often focused on understanding the transmission of resistant pathogens rather than understanding the causes of primary infections and testing prevention strategies. This five-year plan is no different in this respect.

Equipping professionals for effective IPC across large and disparate healthcare systems is recognised as a challenge and improving IPC professional capacity and capability to support ‘strategies that are most likely to result in behaviour change’ at the front line a key aim. However, the numbers of IPC networks continue to decline, especially in non-acute care settings where E. coli prevention activity is most needed. More training on hand hygiene and the adoption of the Scottish IPC manual and care standards are unlikely to have an impact without a strong and consistent approach to implementation that is based on more than education and passive dissemination of policy. These are recognised to be the least effective approaches to achieving behaviour change (Cafazzo et al., 2012).

As the national professional organisation representing expert practitioners in IPC across the UK, the Infection Prevention Society is uniquely positioned to influence and drive this agenda. We look forward to working collaboratively with Her Majesty’s Government to support the system-wide changes in practice and behaviour that are required to prevent more infections and meet the ambitious targets set by the five-year national action plan to tackle AM resistance.