Tackling antibiotic resistance

Tackling antibiotic resistance


Hello everyone I’m Professor Kevin Fenton, the national director of health and wellbeing at Public Health England. We’re here to talk today about
antibiotic resistance and the rise in antibiotic consumption. Public Health
England has just launched its second edition of Health Matters, which focuses
on what we know works to improve prescribing. I’m joined today by Professor Anthony Kessel, director of international public health at Public Health England, Professor Alastair Hay, GP and professor of primary care at the University of Bristol’s School of Social and Community Medicine, and by Dr Susan
Hopkins, consultant in infectious diseases and microbiology and healthcare
epidemiologist, at the Royal Free London NHS Foundation Trust. Anthony, let me begin with you. What’s the scale of the problem that we currently face with antibiotic resistance? Thank you Kevin. I’d like to make four
points. First the antibiotics that we use are under threat due to increasing amounts
of bacteria that are resistant to them. In England over the past four years there has been a 6.5 percent increase in antibiotic consumption, with most use in general practice. Next the number of individuals with antibiotic-resistant infections has
increased substantially over the last five years across a number of infections. The third point I’d like to make is that the more we use antibiotics, the less effective
they become against their target organisms. Because antibiotics use gives
resistant bacteria a greater chance to survive and spread. And last we all have
a role to play in solving the problem of overuse whether we are a health
professional, health leader or indeed a patient. I’m a GP and in general practice
there’s quite a variety of antibiotic prescribing levels across England suggesting that there is some unnecessary or over-prescribing. In fact in some practices rates
are 40 percent higher than in others. From the public’s point of view a third believe that antibiotics are necessary to treat coughs, colds. And one in five expect
antibiotics when they visit their GP. In fact estimates suggest that as many as
half of all patients who have visited their GP with a cough, cold or flu, leave
with an antibiotic. We all feel awful when we have one of these infections but
taking an antibiotic for most of us won’t change that. It just alters the
bacteria in our bodies killing the healthy bacteria and allowing the
bacteria that are resistant to the antibiotics to become predominant. This
means that when we do need an antibiotic it’s less likely to work. And there are
one or two traps for the unwary. For example although most coughs, colds,
sore throats and ear infections make us feel awful, they will get better
without antibiotic treatment. But if an antibiotic is used some patients will incorrectly conclude it was the antibiotic that made them better and
that perpetuates the belief that an antibiotic is needed for further similar
illnesses. So thank you both. Clearly this is a challenge in general practice, but Susan could you speak about the situation in the hospitals settings? Every week in hospitals I treat young women with last resort antibiotics for urinary tract kidney infections. This is frequently because they have already received an antibiotic in the community in the previous one to two years for another
infection usually a kidney infection but maybe something else. And that is wiped
out the susceptible bacteria and allows the resistant bacteria to grow and
flourish. Rather than giving them a simple three-day course of antibiotic
tablets to treat the infection, they end up sick in hospital often with sepsis
requiring seven days of intravenous antibiotic treatment or having to come
back on a day-to-day basis to the hospital. Broad spectrum and often last resort
antibiotics are used much more frequently in hospitals. This is driven by
patients presenting to the hospitals with a life-threatening infection such
as sepsis. In many cases they would’ve had antibiotics in the community that
had not worked. The priority for hospital prescribers to treat that
patient aggressively when they see them, but use the laboratory facilities to
diagnose what infection is this that’s been caused and what’s the best
treatment, and therefore stopping if it’s not a bacterial infection the antibiotic
that they started, or alternatively reducing it to the narrowest at spectrum
antibiotic that can be used. The spread of resistant bacteria is happening quickly and antibiotic resistance in E.coli, the most common bacteria causing
sepsis in Europe, has dramatically increased. Across Europe it is estimated that 25,000 people die each year as a result of hospital infections caused by five key resistant bacteria, including E-coli. So Anthony, not only is this in Europe, but antibiotic resistance is a global problem as well. Can you tell us a little bit more about it? Yes absolutely. There is a global concern about antibiotic resistance across richer and poorer countries. And in 2015, the World Health Organization launched a global action plan to combat the problem. The problem is compounded by the fact that
the discovery of new classes of antibiotics is at an all time low. It’s
been 30 years since a major new class of antibiotics was discovered, which means
we must preserve what we have. If I can give just give you one example of the problem. In 2013 there were 480,000 cases of multi-drug resistant tuberculosis. In some countries it’s becoming increasingly difficult to treat this MDR, or multidrug-resistant TB. Treatment options are limited. Recommended medicines are not always available, and patients experienced many adverse effect from the drugs. Thank you Anthony. So we’ve discussed the
nature and scale of the problem of antibiotic resistance and now would like us to discuss some of the possible ways to counter it. Now Susan, didn’t the recently published Espaur report, which you led, speak about this issue? It did. Their English surveillance programme for antibiotic utilisation resistance, or Espaur for short, is a program developed by PHE to improve the surveillance of antibiotic resistance, and antibiotic use data, and to support interventions and toolkits to improve antibiotic
prescribing in general practice and in hospitals. Antibiotic prescribing to hospital inpatients increased significantly by 11.7 percent into hospital
outpatients by 85.5 percent between 2011 and 2014. Secondary care hospitals prescribe
the highest proportion of broad-spectrum antibotics. Almost one in three antibiotics used in
hospitals are broad-spectrum. Hospitals need to focus their antibiotic
stewardship efforts on ensuring that these drugs are prescribed for the right
reason and the right duration. This will ensure that these last-resort
antibiotics are used appropriately and can be preserved for when they’re really
needed. Alistair, what are the learning points in primary care? So I think there are two main points to highlight. First is that healthcare professionals should prescribe only when patients have clinical symptoms that meet specific criteria. For example those laid out in the recent Nice respiratory tract infection guidelines. And they should prescribe for the shortest duration that
is necessary and occasionally consider a delayed prescribing. Most patients without
underlying chronic illnesses who present to their GP with coughs, colds, sore
throats, and ear infections, won’t benefit from, or need an antibiotic. But in a
minority of circumstances and where there is some clinical uncertainty, there
is evidence for delayed prescribing and this is where a GP will write a
prescription but advise the patient not to use it immediately, but to wait and see, and only take it to the pharmacy if their symptoms subsequently worsen. So thank you Alastair. Now Public Health England has developed two national toolkits to help reduce antibiotic prescribing, and to
support improved prescribing in England. Anthony can you tell us more about this
product? Yes, yes of course. These are important.
These two Public Health England toolkits, who endorsed in the Nice guideline on
antimicrobial stewardship which recommends that primary care and
secondary care healthcare professionals assess their antibiotic prescribing
rates against others. And one of these is called Start Smart then Focus. It’s for
secondary care, and it’s an antimicrobial stewardship toolkit for English
hospitals. It’s recommendations include not starting antimicrobial therapy
unless there’s clear evidence of infection, and then reviewing the
clinical diagnosis and the continuing need for antibiotics at 48 to 72 hours
and documenting a clear plan of action. From the Espaur report that Susan mentioned, we know the 46 percent of hospitals had an action plan to
implement their antimicrobial stewardship toolkit, so we are making
progress, but there’s a lot further to go. The second toolkit Kevin, is one for primary care, and it’s called Target, which stands for Treat Antibiotics Responsibly Guidance
Education Tools. Alistair do you want to perhaps a few words about the usefulness
of Target in primary care? Sure, so Target is designed for the whole of the primary care team both GP practices, and in the out-of-hours setting. And it aims to help
prescribers and patients change their attitudes, social norms, and their
perceived barriers to optimal antibiotic prescribing. We mentioned earlier that some GPs can feel pressured to prescribe. Well the Target toolkit includes
leaflets designed to be shared with patients during the consultation which
aim to improve patients’ confidence to self-care and to improve prescriber’s
communication with patients. The Nice guideline on antimicrobial stewardship, which I led, also recommends developing systems to provide regular updates to
individual prescribers and their prescribing leads on their individual prescribing so that it can be benchmarked against local and national antibiotic prescribing rates and trends collated by Public Health England. Thank you Alastair. Now at this point I want to mention the Antibiotic Guardian campaign that PHE has launched. It’s a campaign designed to raise
awareness of the risks posed by antimicrobial resistance, and to change
everyone’s behaviours around antibiotic use. Now, as well as awareness-raising
and education, the campaign engages directly with both
healthcare professionals and members of the public, encouraging them to become antibiotic
guardians by choosing a tailored pledge about how
they can personally make better use of antibiotics. So for example the consumer
can make a pledge that for infections that our bodies are good at fighting off
on their own, like coughs, colds, sore throats, and flu, they will try treating
the symptoms for at least five days rather than going first to the GP. A
community pharmacist could pledge that every time a consumer or customer
presents with a self-limiting respiratory infection they will use
patient information leaflets to explain the potential duration of illness and
how to treat their symptoms. And a hospital nurse could pledge that
every time they give antibiotics they would prompt the prescriber to review
and document their antibiotic decision. So, thank you everyone. We’ve talked about
this scale of the problem of antimicrobial resistance, and how there are
measures and practical steps that can be taken in both primary and secondary
care. But of course there are many other types of stakeholders who have a role to
play in tackling antibiotic resistance. What are some of the roles of these
other stakeholders? Well local authorities can work with stakeholders
to provide information and advice to the public about when antibiotics are necessary and why their doctors might decide against them. CCGs can work with local acute
trusts to ensure effective antimicrobial stewardship and support the
implementation of the Nice guideline on antimicrobial stewardship. And healthcare professional undergraduate and postgraduate training curricular can
include topics on antibiotic use and resistance. And directors and every area
of healthcare delivery should ensure that they have an active surveillance
program for antibiotic resistance and antibiotic use. Also antimicrobial
stewardship and microbiology teams should ensure that their local
laboratory is testing the bacteria against key antibiotics as recommended
nationally, and also report their antibiotic resistance data to Public
Health England. So, thanks everyone. It’s been a really interesting discussion with a number of thought-provoking concepts and practical tools that can be used. And if
I can sum up. Clearly we cannot afford to lose the power of our antibiotics. They
are a vital to the modern medicine and not just for the treatment of infections.
We also need them to avoid infections during chemotherapy, Caesarean sections,
and other surgeries. Unless action is taken to address the problem of
antibiotic resistance, the routine operations could become deadly in just
20 years, as doctors lose the ability to fight infection. The reality is we all have a role to
play in ensuring responsible and less frequent use of antibiotics and it will
require the full commitment and engagement of healthcare professionals,
the public, and other stakeholders in local authorities. In other words everyone has a responsibility and everyone has a role. Thank you for joining us.

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