Tackling the rise of antimicrobial resistance is of international priority highlighted by the World Health Organisation… The UK has taken an international lead in this area with its NHS plan and O’Neal reports. O’Neal estimates that antimicrobial resistance will kill ten million people a year by 2050, with a cumulative cost of at least $100 trillion, more than 1.5 times today’s annual global GDP.
Although the focus has been on problems with multi resistant bugs in hospitals and intensive care units, primary care is responsible for 80% of prescribed antibiotics in the UK. Many of those prescriptions are for simple respiratory infections and could be avoided. Prescribing is linked to resistance so at least part of the problem lies in primary care.
This week in my practice I saw someone with an indwelling catheter keen to try and eradicate infection before they went on holiday. I had to explain that this was unrealistic since catheters are universally associated with local infection. Looking back through the records the most recent urine sample had been tested against six potential antibiotics and showed resistance to five from the six. So even in primary care for those with multiple exposures, multi-resistant infections are common. I emphasized to my patient that we should reserve treatment for any invasive infection.
Prescribing behavior is well-entrenched and patient expectations for an instant fix when they are feeling unwell also drive the problem. GPs worry about missing serious illness and lack plausible alternatives to offer their patients. Our research has tried to address these issues.
Better targeting of treatment
We have looked at the use of clinical scores and near patient tests to pick out those at higher risk of significant infection. Using a clinical score in sore throat reduces prescribing and improves outcomes. Using CRP risk stratification in lower respiratory infection reduces prescribing of antibiotics and is now recommended in the NICE guidelines.
Prevention of transmission
We have shown that a web-based hand washing intervention can reduce rates of respiratory infection and has a small subsequent effect on prescribing.
Alternative prescribing strategies
We have been the pioneers of the delayed prescription, which has benefits on reduced prescribing in sore throat, otitis media, conjunctivitis and lower respiratory infections.
We need to seek alternative approaches to infection management and prevention. The University of Southampton is at the forefront of this research: Work in this Faculty is looking at the role of manipulating the respiratory biome to protect from infection and there is a cross-Faculty initiative looking at engineering solutions with new materials, better cleaning and the role of biofilms.
In PCPS we are exploring the potential role of traditional herbal medicines which have been used historically for urinary infection and respiratory illness. We are running two intervention trials, one in acute urine infection using pelargonium, and a second in recurrent urine infection with traditional Chinese herbal remedies. We are conducting systematic reviews of other potential agents and involved in trials of near patient testing in urine infection, the role of antibiotics in children with LRTI and a trial of analgesic drops in ear infection.
The big challenge is to deliver these trials and to go on to influence future practice and hence protect antibiotics for future generations. In the mean time we can all do our bit and sign up to be an antibiotic guardian.