A nation at risk

Antibiotic resistance has been named as one of the most dangerous global crises threatening our modern world

Every year in England alone, at least 5,000 people die because antibiotics no longer work for some infections. It is a global problem, with experts predicting that if things don’t change, in just 30 years antibiotic resistance will kill more people than cancer and diabetes combined. As such, the Government has pledged to halve inappropriate antibiotic prescribing by 2020.

Taking antibiotics when they’re not essential encourages harmful bacteria to become resistant. This means that when a person has a serious infection and really needs them, antibiotics may not work.

“Antibiotic resistance is not a distant threat, but is in fact one of the most dangerous global crises facing the modern world today. Without urgent action from all of us, common infections, minor injuries and routine operations will become much riskier,” says professor Paul Cosford, medical director of Public Health England (PHE). “It is important for people to understand that if they are feeling under the weather and see their GP or nurse, antibiotics may not be prescribed if they are not effective for their condition, but they should expect to have a full discussion about how to manage their symptoms.”

Implications for health

If we don’t address the problem of antimicrobial resistance (AMR) now, the World Health Organization (WHO) predicts 10 million deaths worldwide by 2050 as a result. AMR can affect anyone, of any age and there is a growing list of infections – pneumonia, tuberculosis, sepsis and gonorrhoea – that are becoming harder to treat as antibiotics become less effective, putting everyone at risk.

When infections cannot be treated with first-line antibiotics, more expensive drugs have to be used. It often means an illness lasts longer, with extended hospital stays needed and increased healthcare costs. Organ transplants, caesarean sections and chemotherapy all become much riskier without effective antibiotics to prevent and treat infection.

AMR: the facts

  • Four in 10 patients with an E.coli bloodstream infection in England cannot be treated with the most commonly used antibiotic
  • 5,000 deaths a year in England are caused by AMR
  • In 30 years, AMR will kill more people than cancer and diabetes combined
  • AMR was common in over one million UTIs caused by bacteria in 2016
  • Between 2012 and 2016, antibiotic prescribing reduced by five per cent
  • The number of antibiotic prescriptions dispensed in GP settings reduced by 13 per cent between 2012 and 2016
  • In 2016, one in 15 patients in acute hospitals had a healthcare-associated infection (HAI)
  • Antibiotic resistant HAIs can double the risk of death
  • One in 10 patients in hospital is affected by a HAI.

The ESPAUR report findings

In November, PHE published its fourth English Surveillance for Antimicrobial Utilisation and Resistance report (ESPAUR), which examines the state of antibiotic resistance in England. This year the report highlights an increased number of antibiotic-resistant bloodstream infections (BSIs) and UTIs.

The most common cause of BSIs was E.coli and of these, 41 per cent were resistant to the commonest antibiotic used to treat infections in hospital – co-amoxiclav – and almost a fifth of these were bacteria resistant to at least one other key antibiotic.

The Government plans to halve the number of healthcare-associated bloodstream infections by 2021. Part of this campaign involves more work in the prevention of infections, such as improving hygiene.

The report also highlights that AMR was more common in the one million UTIs caused by bacteria in 2016. Current guidelines recommend urine samples are sent for lab testing from those who don’t respond to initial treatment, have frequent or recurring UTIs, or are likely to have a resistant infection. Most of the samples taken in 2016 were from community settings. Trimethoprim resistance was common in 34 per cent of samples, but the current first-line recommended treatment – nitrofurantoin – was found to still be effective.

PHE is focusing on UTIs as they are so common and can lead to bloodstream infections. Better management of UTIs could help to reduce the number of these more serious infections.

Antibiotic use trends

The ESPAUR report examines current trends in antibiotic prescribing and found that overall there was a reduction of five per cent between 2012 and 2016. The number prescribed in GP settings fell by 13 per cent, mostly driven by reduced penicillin use. Dental practices dispensed a fifth fewer prescriptions in 2016 than in 2012. Secondary care settings have not seen a sustained reduction in prescribing, although hospital use of ultra-broad spectrum antibiotics has reduced.

The majority of antibiotics are prescribed in GP settings (74 per cent), followed by hospital inpatients (11 per cent), hospital outpatients (six per cent), dental practices (five per cent) and other settings (three per cent). The three groups of antibiotics most frequently prescribed were penicillins (45 per cent), tetracyclines (22 per cent) and macrolides (14.8 per cent).

“The ESPAUR report found that younger [people] and those falling into lower social grades were most likely to have misconceptions on antibiotic use and needed more information,” explains Dr Diane Ashiru-Oredope, lead pharmacist, AMR programme, at PHE. “Another 2016 study examining patient/carer expectations found people under 65, those who never attended university and those speaking a language other than English at home were more likely to expect antibiotics for a cold or flu,” she adds.

Antimicrobial stewardship

The report highlights the importance of antimicrobial stewardship programmes to encourage sensible prescribing and includes a study to examine how stewardship can be developed in community pharmacy.

It concludes that community pharmacists and their teams have considerable potential to help reduce AMR by providing self care advice and recommending OTC remedies for common infections. However, more materials are needed to support pharmacy staff in infection self care and antibiotic compliance advice. The study also concluded that having a patient’s diagnosis recorded on the prescription would help pharmacy staff to identify when antibiotics are an unnecessary treatment.

Become an Antibiotic Guardian

The Antibiotic Guardian campaign invites health professionals, educators and members of the public to make an online pledge to show how they will make better use of antibiotics. This year, community pharmacy teams are invited to register their pharmacy premises to lead promotional activities for antibiotic awareness days and the Guardian campaign.

“The campaign encourages everyone to join in and help protect antibiotics against the growing threat of AMR. You can choose one of the organisation pledges to share what AMR activities you are leading or participating in as a pharmacy,” says Dr Ashiru-Oredope, lead for the Antibiotic Guardian campaign. “Social media channels and community networks can also be used to promote key messages on AMR throughout the winter season [via] #AntibioticGuardian. Earning the CPPE Antibiotic Guardian Pharmacy Champion badge can also be a way to get involved and increase knowledge on the role pharmacy teams play.”

For more information, visit: Antibiotic Guardian and CPPE.

Pharmacy staff role

Sore throats should be soothed with warm
drinks and OTC remedies, not antibiotics

“It is important the public are aware of the impact of taking antibiotics when they are not needed. PHE recently launched the Keep Antibiotics Working campaign. This aims to inform the public that taking antibiotics when they are not needed puts them and their family at risk and urges people to follow their health professional’s advice,” says Dr Ashiru-Oredope.

Pharmacy staff can help by displaying information posters and leaflets from the campaign, which are available to download from the PHE campaign resource centre.

“Pharmacy teams can help the public understand which conditions antibiotics work for, for example STIs, and when they are inappropriate, for example colds, reinforcing key messages on the personal threat of AMR.”

Giving advice on taking antibiotics correctly if they are prescribed – at regular intervals, for the length of time prescribed, by returning any unwanted medicines, not saving antibiotics or sharing with family or friends – can also be useful.

Dr Ashiru-Oredope adds that “explaining the likely duration of self-limiting infections and the symptoms that require medical attention are important contributions in managing patient expectations.” (See panel for more information.)

Pharmacy teams can also help to prevent spread of infection by promoting good hygiene measures. A recent Royal Pharmaceutical Society survey shows that 84 per cent of British adults don’t wash their hands for long enough to clear infection-causing bacteria. The recommended time to spend washing hands is 20 seconds – as long as it takes to sing ‘Happy Birthday to you’ twice.

How long will symptoms last?

Pharmacy teams can help to discourage misuse of antibiotics by educating customers on how long they can expect a common illness to last for. If patients don’t improve during these guide times, or get worse, they should be advised to see their GP:

  • Ear ache/middle ear infection: eight days
  • Sore throat: seven to eight days
  • Sinusitis (adults): 14-21 days
  • Cold: 14 days
  • Cough or bronchitis: 21 days.

OTC product recommendations and the following self care tips can also be passed on to customers to help manage the symptoms of these common illnesses:

  • Drink plenty of fluids
  • Rest
  • Use paracetamol to reduce a fever if necessary
  • Wash hands well and use tissues to avoid spreading infection.

In just 30 years antibiotic resistance will kill more people than cancer and diabetes combined

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