Antimicrobial Resistance

Antimicrobial resistance is considered by many to be one of the biggest threats to global health and food security. The direct consequences of antimicrobial resistance can include longer illness, prolonged hospital stay, increased mortality, and an overall increase in healthcare costs. This Antimicrobial Awareness Week, the World Health Organization (WHO) is raising awareness and encouraging best practices to limit the emergence and spread of antimicrobial resistance globally.

In Australia, antimicrobial resistance is already a major healthcare problem. The Australian Commission on Safety and Quality in Health Care and the Council of Presidents of Medical Colleges recently released a joint statement on the issue. This statement calls for improved compliance with prescribing guidelines to stem the rise in antimicrobial resistance. The results of the National Antimicrobial Prescribing Surveys (NAPS), available from the National Centre for Antimicrobial Stewardship, are referred to as evidence of the need for change.

The following is a brief summary of results from the 2018 hospital NAPS:

• 21.4% of prescriptions for antimicrobials were assessed as being inappropriate (compared to 22.4% in 2017);
• Documentation of review or stop date was 45.2% (up from 40.7% in 2017);
• Rate of documentation of indication was 80.3% (up from 77.7% in 2017); and
• Surgical prophylaxis that extends beyond 24 hours was 28.0% (down from 30.0% in 2017).

The NAPS program forms part of the Antimicrobial Use and Resistance in Australia (AURA) surveillance system. The 2019 AURA report reveals some interesting trends in microbial resistance around the country. While the national rate of antibiotic resistance has remained relatively constant for a number of priority organisms, the following changes may be important to consider in the clinical setting:

• Escherichia coli – resistance to common therapies continues to increase which may translate to higher rates of treatment failure and increased use of last-line agents, such as carbapenems;
• Enterococcus faecium – the absolute number of isolates with vancomycin resistance is increasing (although the overall rate of vancomycin resistance is declining). The prevalence of vancomycin resistance in this bacteria is higher in Australia than any European country;
• Neisseria gonorrhoeae – the total number of notifiable cases is increasing along with increasing rates of resistance to azithromycin;
• Neisseria meningitidis – the number of notifiable cases is increasing as well as high rates of reduced benzylpenicillin susceptibility and increased rates of benzylpenicillin resistance;
• Salmonella Typhi and Salmonella Paratyphi – high rates of ciprofloxacin resistance;
• Staphylococcus aureus – community-associated methicillin resistance has increased in remote and very remote regions.

New antimicrobials are needed to increase the treatment options for drug-resistant infections. However, new drugs alone will not solve the problem. The Global Action Plan on Antimicrobial Resistance, endorsed by the WHO, details the following five objectives to minimise antimicrobial resistance:

1. Communication, education, and training to improve awareness and understanding of antimicrobial resistance;
2. Surveillance and research to strengthen the evidence base;
3. Improved sanitation, hygiene, and infection prevention measures to reduce the incidence of infection;
4. Optimise antimicrobial use in both human and animal health; and
5. Increased investment in new medicines, diagnostic tools, vaccines, and other inventions.

While the issue of antimicrobial resistance is a global challenge, individuals can play an important role. Healthcare professionals can limit the emergence and spread of resistance by referring to current guidelines and clinical information when diagnosing infections and prescribing and dispensing antimicrobials. Prevention of infection is also an important part of minimising antimicrobial resistance. All healthcare workers play an important role here by adhering to and promoting infection prevention and control principles.

The Antimicrobial Stewardship Clinical Care Standard is an excellent reference to support clinical decision making and to facilitate quality improvement processes within a healthcare service. This should be used in conjunction with the current version of the Therapeutic Guidelines: Antibiotic, or local antimicrobial formulary.