Antimicrobial resistance (AMR) occurs when bacteria, viruses, fungi and parasites change over time and no longer respond to antimicrobials and is emerging as one of the major public health problems of the 21st century.
A global action plan to tackle the growing problem of AMR was endorsed at the Sixty-eighth World Health Assembly in May 2015. One of the five key objectives of the plan is to improve awareness and understanding of AMR through effective communication and education.
The problem of AMR is especially relevant to antibiotic resistance (ABR). Beginning with the discovery of penicillin by Alexander Fleming in the late 1920s, antibiotics have revolutionized the field of medicine. They have saved millions of lives each year, and have even been used prophylactically for the prevention of infectious diseases. However, bacteria are acquiring the ability to resist the effect of antibiotics which they were initially sensitive to. This is resulting in a public health crisis, threatening the practice of modern medicine, animal health and food security. Although the current magnitude of the problem and the need for a "one health" approach, healthcare workers play a central role in preventing the emergence and spread of ABR.
Inappropriate use of antibiotic agents, as well as poor infection prevention and control IPC practices, contribute to the development and spread of ABR.
If all together around the world we will participate in this global fight, we will be pivotal leaders in addressing this challenge. Otherwise, we will be contributors to the worst crisis that the world health is facing.
Below we report 10 key points for an appropriate use of antibiotics in hosptals around the world.
Enhance infection prevention and control
Prevention is better than cure and it is important that all helthcare workers depend on evidence-based IPC interventions to reduce demand for antibiotics by preventing healthcare-associated infections (HAIs) from occurring in the first place, and making every effort to prevent transmission when they occur.
Control the source of infection
Source control encompasses all measures undertaken to eliminate the source of infection, reduce the bacterial inoculum and correct or control anatomic derangements to restore normal physiologic function. In critically ill patients with sepsis or septic shock these principles can be applied at different times in the same patient. Appropriate source control is of outmost importance in the management of surgical infections. Intra-abdominal infections along with soft tissues infections are the sites where a source control is more feasible and more impactful. In these settings an appropriate source control can improve patients' outcome and reduce antibiotic pressure allowing short course of antibiotic therapy.
Prescribe antibiotics when they are truly needed
Antibiotics can be life-saving when treating bacterial infections but are often used uselessly.
The first step in prescribing antibiotics is of course to give them to the right patient, identifying which patient needs antibiotics.
Antibiotics should be used after a treatable bacterial infection has been recognized or when there is a high degree of suspicion for bacterial infection.
Prescribe the appropriate antibiotic(s) at the right time
Most antibiotic are prescribed as empiric therapy, without or before knowing the pathogen and its susceptibility to antibiotics because microbiologic data (culture and susceptibility results) may not be available for up to 48–72 hours to guide targeted therapy.
Empiric antibiotic therapy should be based on local epidemiology, individual patient risk factors for difficult to treat pathogens, clinical severity of infection, and infection source.
The need to speed up diagnostic testing is a central theme in recent policy initiatives to combat ABR. One of the major goals for combating ABR is to advance the development and use of rapid and innovative diagnostic tests for identifying and characterizing resistant bacteria, to improve their treatment, enhance infection control, and facilitate outbreak detection and response.
Prescribe antibiotics with adequate dosages
The antibiotic dosing regimen should be established depending on host factors and properties of antimicrobial agents. Antibiotic pharmacodynamics integrates the complex relationship between organism susceptibility and patient pharmacokinetics. Antibiotic pharmacokinetics describes the fundamental processes of absorption, distribution, metabolism, and elimination and the resulting concentration-versus-time profile of an agent administered in vivo. Commonly encountered situations in which pharmacokinetics change and dosing individualization may be necessary include renal and hepatic dysfunction. Knowledge of the pharmacokinetic and pharmacodynamic antimicrobial properties of each drug including may provide a more rational determination of optimal dosing regimens.
Reassess treatment basing on microbiologic culture, susceptibility testing, and clinical improvement
Reassessment of antibiotic therapy based on microbiologic culture, susceptibility testing, and clinical improvement not only promote antimicrobial stewardship but may be associated with improved outcomes in serious infections. The patient should be always reassessed when the results of microbiological testing are available. The results of microbiological testing may have great importance for the choice of therapeutic strategy of every patient, in particular in the adaptation of targeted antimicrobial treatment. They provide an opportunity to expand antimicrobial regimen if the initial choice has been too narrow but also allow de-escalation of antibiotic therapy if the empirical regimen has been too broad.
Use the shortest duration of antibiotics based on evidence
Duration of therapy should be shortened as much as possible unless there are special circumstances that require prolonging antimicrobial therapy such as immunosuppression, or ongoing infections. There is good evidence that shorter durations of antibiotics can reduce adverse effects associated with their use. Furthermore, many studies have found that clinical outcomes are similar between short and long courses for many common infections. Given the relatively high rates of prescribing, we can all play a significant role in reducing the burden of inappropriate antibiotic use by prescribing short-course therapy when appropriate.
Support surveillance of healthcare-associated infections (HAIs) and monitor of antibiotic consumption
HAIs are a patient safety and quality of healthcare issue which contributes to poor patient outcomes and additional costs to the health care system. Surveillance to determine the incidence of HAIs is an important part of the strategy to minimise the occurrence of these infections. Monitoring of antibiotic consumption should be implemented and feedback provided to all prescribers.
Education in antibiotic prescribing practice is fundamental. A range of factors such as diagnostic uncertainty, fear of clinical failture, time pressure or organisational contexts can complicate prescribing decisions. However, due to cognitive dissonance (recognising that an action is necessary but not implementing it), changing prescribing behaviour is extremely challenging. Efforts to improve educational programs are thus required and this should preferably be complemented by active interventions such as prospective audits and feedback to stimulate further change. It is also crucial to incorporate fundamental antimicrobial stewardship and infection prevention and control principles in under- and post graduate training at medical faculties to equip young doctors and other healthcare professionals with the required confidence, skills and expertise in the field of antibiotic management.
Support an interdisciplinary approach
Promotion of antimicrobial stewardship across clinical practice is crucial to their success to ensure standardization of antibiotic use within an institution. We propose that the best means of improving antimicrobial stewardship should involve collaboration among various specialties within a healthcare institution including prescribing physicians. Successful the antimicrobial stewardship should focus on collaboration between all healthcare professionals to shared knowledge and widespread diffusion of practice.
Join us now as we embark on this global cause, by pledging support for this manifesto and accepting the responsibility for maintaining the effectiveness of current and future antibiotics.
Prescribe the right antibiotic, for the right patient, at the right time, at the right dose and for the right duration!
Global Alliance for Infections in Surgery