The current global crisis caused by antimicrobial-resistant organisms is the natural culmination of the battle between evolution and humanity's ability to develop new antimicrobial agents, a battle that it would appear the microorganisms are winning. Without effective antimicrobial treatments many healthcare interventions that are currently regarded as routine, such as chemotherapy, organ transplantation and elective surgical procedures, may no longer be possible due to the associated risks of infection.
Antimicrobial resistance (AMR) occurs naturally by genetic mutation and natural selection. When exposed to antimicrobial agents, sensitive strains are killed, leaving the resistant strains to survive and multiply. Ever since Sir Alexander Fleming discovered penicillin in 1928 microorganisms have inevitably been evolving and developing resistance to antimicrobial agents.
Meticillin-resistant Staphylococcus aureus (MRSA) emerged within 2 years of the drug meticillin being introduced in 1960. More recently, the world has seen the emergence and rapid global dissemination of some strains of bacteria, such as carbapenemase-producing enterobacteriaceae (CPE), which are resistant to virtually all available antibiotics.
AMR is not confined to bacteria, with drug-resistant strains of viral (e.g. Influenza) and fungal (e.g. Candida auris) infections also being identified (Ventola, 2015).
Drug-resistant microorganisms have significantly reduced the treatment options available for affected individuals, and increased the mortality and morbidity associated with previously treatable infections. A UK Government review estimated that globally 700 000 deaths per year are caused by AMR organisms and that this is likely to increase to 10 million by 2050, unless significant action is taken (O'Neill, 2014).
The UK Five Year Antimicrobial Resistance Strategy 2013 to 2018 has identified three strategic aims (Department of Health (DH), 2013a: 14):
Actions plans
The UK's 20-year vision for antimicrobial resistance (Department of Health and Social care (DHSC) 2019a) identifies that improved antimicrobial stewardship programmes are an essential component of the strategy to reduce AMR.
A number of such programmes are available, including the GP toolkit, Treat Antibiotics Responsibly, Guidance and Education Tool (TARGET) (https://tinyurl.com/target-rcgp). The aim of this programme is to support GPs' learning in relation to AMR and enable them to provide factual information to patients, particularly if they arrive with the pre-existing expectations that they need antibiotics when this is not clinically indicated.
However, it is estimated that 20% of all antimicrobial prescriptions in primary care are still inappropriate (Bostock, 2018), i.e. they are written up without sufficient diagnostic evidence of infection and this is compounded by a lack of public awareness about the risks associated with using antibiotics inappropriately or when not clinically indicated.
The support for research into the development of new antimicrobial agents and alternative treatments alongside improved vaccination programmes are included in the UK 2019–24 action plan. However, it should be noted that no new class of antibiotics has been identified since the 1980s, in part because the development of these drugs is regarded as unprofitable for pharmaceutical companies (DHSC, 2019b).
The world's first global action plan to address the issues of antimicrobial resistance was produced in 2015 and identified five strategic objectives (World Health Organization, 2015). Objective 3 describes the desire to reduce the incidence of infection by means of improving global access to effective sanitary facilities, safe food and water.
Preventive measures
Because many antimicrobial-resistant organisms arise in hospitals as a direct consequence of healthcare interventions, it is vital that robust infection prevention and control guidelines are implemented. The UK's 20-year vision for AMR also highlights the importance of infection prevention as one of the nine ambitions for change and for future action (DHSC, 2019a).
To be effective, standard body substance precautions, such as those described in Epic 3 (Loveday et al, 2014) need to be implemented in all healthcare settings for all patients. National infection prevention and control guidelines, such as those in place in Scotland, provide healthcare workers with clear advice in relation to the delivery of safe and effective care (NHS National Services Scotland, 2012).
The ability to undertake hand hygiene is central to the prevention of infection acquisition and transmission. To be effective it needs to be undertaken by staff, patients and visitors. Health professionals therefore have an obligation not only to comply with the ‘five moments for hand hygiene’ (Sax et al, 2007), but also to educate patients and visitors about the importance of hand hygiene and to facilitate this activity in circumstances where patients are unable to undertake this independently.
Patient care-associated equipment and the care environment can easily become reservoirs of infection. It is therefore important for staff to be trained to decontaminate equipment safely according to the manufacturer's guidance to remove this potential source of cross-infection.
The environment in which healthcare is delivered should also be designed in a manner to reduce reservoirs of infection and to facilitate effective decontamination. When refurbishing or designing new healthcare facilities, it is important to ensure that construction is in line with national guidelines such as the health building notes (DH, 2013b).
Conclusion
It is evident that the global crisis associated with antimicrobial resistance will require concerted efforts on a global scale. It is therefore important for healthcare professionals to understand how they can influence this in a positive way by delivering care based on evidence-based infection prevention and control practices.