To commence our themed day on antimicrobial resistance and healthcare associated infections as part of 'Protecting Health: Nursing and Midwifery Successes and Challenges,' I am delighted to introduce a blog by Professor John Watson, Deputy Chief Medical Officer, and Carole Fry, DH Nursing Officer for Infectious Diseases and Blood Policy.
In a book¹ written by the Chief Medical Officer, Sally Davies, a world is imagined where antibiotics are no longer effective. The CMO describes a scene in the year 2043 where it is a criminal offence for anyone with an infection to be in public, and those that are considered to be contagious are housed in infection sanatoriums.
This is not scaremongering. It could be the future where some infections are untreatable and medical interventions that we take for granted, such as surgery or cancer treatments, might be denied to many patients.
The World Health Organisation estimates that antimicrobials add, on average, twenty years to everyone’s lives. Penicillin was considered to be a wonder drug when it was first manufactured in 1943. In many ways it was, but resistance to penicillin developed very quickly after its introduction. Over the last fifty years or so, antibiotics have been taken for granted. When resistance to one antibiotic developed, another antibiotic was prescribed in its place. In 1969, the US Surgeon General said that ‘the time has come to close the book on infectious diseases and declare the war against pestilence won’. However, between 1940 and 2004, several hundred new infectious diseases have emerged demonstrating how wrong the Surgeon General was.
We know that the more antibiotics are used, the more resistance develops reducing the treatment options for patients with infection. We also know that very few new antibiotics have been developed in recent years, which means we need to safe guard existing antibiotics by only using them when they are needed. Some bacteria have now developed such high levels of resistance that antibiotics of ‘last resort’ are the only choice of treatment available. Some of these drugs have toxic side effects which are undesirable for patients.
So can anything be done to prevent the scenario CMO described in 2043? The answer is ‘yes’ and nurses have an important role in this.
One of the most important elements in preventing antibiotic resistance from spreading is good practice in infection prevention and control. A range of tools are available to help practitioners, including the recently revised national evidence-based guidelines for preventing healthcare-associated infections in hospitals. http://www.journalofhospitalinfection.com/article/S0195-6701(13)60012-2/abstract
Antimicrobial stewardship, a term used to describe the use of co-ordinated interventions to improve and optimise the use of these agents, is crucial and has three major goals:
• optimise therapy for individual patients
• prevent overuse, misuse and abuse
• minimise development of resistance at patient and community levels
All nurses have a role in public education on antibiotic resistance by explaining that antibiotics are losing their effectiveness at an increasing rate. The message that overuse of antibiotics is causing more bacteria to become resistant needs to be articulated clearly to the general public, as is the fact that antibiotics do not work for viral infections such as ordinary coughs and colds as these illnesses usually get better on their own.
Nurses need to work with other clinicians to change practice. For example, there is good evidence to demonstrate that surgical prophylaxis is important in reducing the risk of postoperative infection, but there is also evidence to suggest that surgical prophylaxis is not always administered appropriately. So there is a role for nurses to champion the WHO’s safer surgery checklist (WHO, 2009), which emphasises the importance of teamwork, including documenting the administration of surgical prophylaxis.
Nurses who are independent prescribers of antibiotics have a duty of care to their patients to ensure that they prescribe responsibly. Best practice means prescribing the right antibiotic, at the right dose, the right time, and the right duration for every patient. This decision should be clearly documented and the prescribing decision should be reviewed after 48 hours. The Department of Health has recently published antimicrobial prescribing and stewardship competences for all independent prescribers to help improve the quality of prescribing practice.
Preserving the antibiotics we have, so that they can remain effective for as long as possible, coupled with high standards of infection prevention and control, is the responsibility of all healthcare professional regardless of grade or discipline. We need to act now to ensure that there are effective antibiotics available for our children and grandchildren in years to come.
¹The Drugs don’t work – a global threat. Professor Dame Sally Davies. Penguin. 2013