Although antimicrobial medicines, including antibiotics have been hailed the wonder drug discovery of the 20th century, their misuse and inappropriate use create drug-resistant pathogens, a phenomenon known as antimicrobial resistance (AMR). Recognised since the discovery and commercialisation of penicillin by Alexander Fleming in 1928, AMR happens naturally when infection-causing organisms evolve ways to survive the effects of treatments (Aminov, 2010). The impact of AMR on humans and animals is so severe, that the World Health Organization (WHO) has declared it is one of the top 10 threats facing humanity today (WHO, 2021).
Infections caused by antimicrobial-resistant pathogens are very difficult and occasionally impossible to treat with antibiotics. This problem is increasing because some pathogens are now known to be resistant to all our current antibiotics. This means that treatments for these infections must involve more toxic drugs taken over longer periods (WHO, 2015). In terms of the patient experience, these treatments not only often take longer to complete, but also involve unpleasant side-effects and potentially much longer hospital stays. In some cases, prolonged resistance may lead to extensive surgery and limb amputation (HM Government, 2019).
The fight against AMR in the UK is outlined in a 20-year vision, accompanied by a 5-year national AMR action plan (HM Government, 2019). Since 2014, each action plan has built on the work of its predecessor. Currently, the 2019 action plan seeks to contain and control antimicrobial resistance by (HM Government, 2019):
- Reducing the need for, and unintentional exposure to, antimicrobials
- Optimising the use of antimicrobials
- By investing in innovation, supply and access to antimicrobials.
Importantly, antimicrobials, particularly antibiotics, have saved millions of lives since they were first discovered—and our generation and that of our parents have benefited enormously from these important medicines. However, no new classes of antibiotic have been developed since the 1980s, yet we often continue to use them inappropriately, which means that we are rapidly heading towards a world in which our antibiotics no longer work (WHO, 2015).
Antimicrobial stewardship
Research shows that many people are unfamiliar with the purpose of antibiotics and how best to take them. For example, more than one third of the population surveyed thought that antibiotics were an effective treatment for viral infections, such as a sore throat (McNulty et al, 2019).
We also know that some people, including those from minority ethnic groups, and those from deprived communities, are less likely to have received any advice or information about antibiotics (McNulty et al, 2019). Therefore, they may actively seek antibiotic treatment when it is not medically indicated and feel disappointed when they do not receive a prescription. Some people may also stop the antibiotic treatment before completing the full course, choosing incorrectly to save ‘left over’ antibiotics in case they may ‘need’ them in the future.
Antimicrobial stewardship (AMS) is the system-wide approach adopted by all health and care organisations to preserve the effectiveness of antimicrobials by promoting and monitoring the way individuals use them (National Institute for Health and Care Excellence, 2018.
Our nursing role involves protecting the public by helping them to be as healthy as possible and so reducing their risk of developing an infection. As the largest registered workforce in the NHS, as nurses we frequently meet patients and are likely to see them on more than one occasion.
We should therefore take every opportunity to help people understand the actions that they can take to reduce the risk of antibiotic resistance. This includes talking to people about the ways that frequent hand-washing and good hydration can reduce their risk of infection. Nurses also have a vital role in helping people understand their medication and how best to take it to achieve optimal results, including the importance of completing a course of antibiotics, as well as the reasons for prescribing antibiotics (see the WHO recommendations for preventing and controlling the spread of antibiotic resistance set out in Box 1).
Box 1.Recommendations for preventing and controlling the spread of antibiotic resistanceAll health professionals including nurses must:
- Prevent infections by ensuring your hands, instruments and environment are clean
- Only prescribe and dispense antibiotics when they are needed, according to current guidelines
- Report antibiotic-resistant infections to surveillance teams
- Talk to your patients about how to take antibiotics correctly, antibiotic resistance, and the dangers of misuse
- Talk to your patients about preventing infections (for example, vaccination, handwashing, safer sex, covering nose and mouth when sneezing
World Health Organization, 2015
Enhancing knowledge and action on AMR
To support all health and care professionals to enhance their knowledge and, more importantly, to take greater action on key public health issues such as AMR, Public Health England (PHE) has published free online e-learning resources as part of a programme entitled All Our Health (Health Education England (HEE), 2019). The AMR e-learning resource aims to support professionals and is already being accessed by thousands of health and care professionals, enabling them to:
- Understand specific activities and interventions that can prevent infections and reduce AMR
- Think about the resources and services available in local areas that can help people prevent infections, reduce the need for antibiotics, yet, when needed, use them in the best possible way
- Identify which resources are currently available and how AMR and the prevention of infections impact on everyone's daily practice.
Building back better
As we start to focus on the recovery phase of the COVID-19 pandemic, it will be essential for the nursing and midwifery workforce to appraise the lessons learnt and consider what changes need to be made to ensure that we genuinely build back better and fairer. This will require our profession to use the 2020s as a decade that sees transformation across the nursing and midwifery workforce, placing as much focus on managing and treating disease as we do on preventing, protecting and promoting the public's health.
Given the significant threat that AMR plays in causing preventable ill health and premature death, nurses must prioritise this area of practice as we move forward. The All Our Health programme provides a useful framework, allowing our profession to consider the evidence-based interventions nurses can implement or champion at individual, community and population levels.
Case study
As a practice nurse, in a GP surgery, you notice that you have seen Mrs Begum several times during the past 6 months for self-limiting viral infections. Each time she has expressed the need for antibiotics to make her better. She has come to the surgery today because of a sore throat and the GP has asked you to join her consultation so that you can help reinforce the need for measures other than a course of antibiotics.
Mrs Begum tells you she does not have time to be unwell because she is responsible for a large family, a busy household and works part-time as a shop assistant, which often involves unsocial hours. She needs to feel better soon, so she can do all her jobs. On discussion, you find out that it is not unusual for her to have fewer than four drinks of water a day and she often feels thirsty, but she forgets to drink. She also tells you that her youngest child has just started school and has a runny nose, but is otherwise well and enjoying playing with her new friends.
Your GP practice team has recently completed the All Our Health e-learning module about antimicrobial resistance and you are beginning a new role as Antibiotic Guardian for the practice, so you are familiar with some of the measures that Mrs Begum can take, not only to make her feel better, but also to reduce the risk of future viral infections (HEE, 2019).
After explaining why the sore throat will not improve with antibiotics, you suggest ways to help Mrs Begum remember to drink water during the day, for example, by carrying a bottle of water with her during her shift in the shop, something she has never done before. You also suggest ways to increase air circulation in her home, by opening the windows, especially since it is such a busy household.
You arrange to see Mrs Begum again in 10 days because you now know that many viral infections are self-limiting, and symptoms resolve within 7–10 days. Having another opportunity to listen to Mrs Begum and find out if the actions you suggested have made a difference will allow you to provide additional information to help cement her understanding.