The NHS is using too many antibiotics and the accompanying rise in antimicrobial resistance risks exhausting our reserve of effective medicines to treat bacterial infection. A coalition of five health leadership organisations has called for national targets to roll back prescribing rates to 2010 levels.
The Royal Pharmaceutical Society (RPS), the Royal College of General Practitioners, the Royal College of Physicians, the Royal College of Nursing and the Faculty of Public Health came together to debate how reductions could be achieved at an antimicrobial resistance summit at the RPS London headquarters on 6 November 2014. If growing levels of resistance to antibiotics are to be curbed, this show of unity must now translate into action, supported by everyone, from patients to policymakers.
Antibiotic use in the NHS rose by 6% between 2010 and 2013 — increasing by 4% in general practice and 12% in hospitals, according to the October 2014 ‘English surveillance programme for antimicrobial utilisation and resistance (ESPAUR) report’ from Public Health England (PHE). The rise was linked to growing drug resistance; for instance, Escherichia coli bloodstream infections rose by 12%, with a substantial increase in resistance to antibiotics to treat the infection.
The bigger picture
The real-world impact of resistance cannot be understated: an estimated 5,000 patients across England, Wales and Northern Ireland die of Gram-negative sepsis each year, half from a resistant organism.
Reducing antibiotic use has been shown to correlate with reduced resistance — even at the individual general practice level. National, and perhaps local, targets are an opportunity to ensure the whole healthcare system pulls in one direction. The metrics behind these targets and how commissioners should respond to outliers will be crucial to engaging health professionals. Any incentives, particularly financial, must be considered carefully to avoid distorting good clinical practice.
Patient outcomes must also be monitored to ensure that any negative consequences of cutting antibiotic prescribing (increased hospital admissions for pneumonia, as a hypothetical example) are identified and managed.
Moreover, clinicians must take personal responsibility for changing their own prescribing habits. The five professional bodies produced a ‘Joint statement on antimicrobial resistance’ in July 2014, which emphasised that the ‘better safe than sorry’ attitude to antimicrobial prescribing needs to be addressed.
It is unacceptable for prescribers to order antibiotics without a clear indication. The pressure from a patient intent on obtaining a prescription should be balanced against the wider societal duty to ensure antibiotics remain effective in the future. Providing an antibiotic prescription ‘just this once’ is not in anyone’s best interests.
One way to boost responsibility for treatment decisions could be to mandate the inclusion of indication on antibiotic prescriptions, where appropriate. Such a measure would enable pharmacists to challenge inappropriate prescribing at the point of dispensing.
Indeed, educating patients about appropriate antibiotic use must become standard practice in all areas of the NHS, particularly community pharmacy and general practice. Greater use of delayed prescriptions (whereby patients can have their antibiotic dispensed at a later date after laboratory confirmation of a sensitive bacterial infection) and selection of narrow-spectrum antibiotics, where possible, will also help.
Yet antimicrobial resistance cannot be eradicated. And use of antibiotics within UK healthcare is but one facet of a global problem. For instance, more needs to be done to tackle the misuse of antibiotics in animals and the wide availability of antibiotics to the public in many countries.
The UK government showed a willingness to lead on these issues with the launch of its five-year antimicrobial resistance strategy in 2013. PHE has already set out its support for the reduction in prescribing to 2010 levels. At the time of publication, the Department of Health had yet to offer overt backing for the target when asked by The Pharmaceutical Journal. It should do so and provide leadership to ensure the target can be achieved.
The collaboration of doctors, nurses, public health professionals and pharmacists to address antimicrobial resistance is a landmark step. Their proposal of top-down targets is to be welcomed. But this action must be met with a change in attitude to antibiotics by healthcare professionals and patients alike.