Antimicrobial Resistance

The O'Neill review of AMR - 2016

The UK Government under the leadership of the then Prime Minister, David Cameron, commissioned a review of AMR chaired by Jim O'Neill and published in 2016. A bold statement in the opening paragraphs was that the group estimated that if left unchecked, AMR would account for 10 million global deaths by 2050. Whilst some have questioned the magnitude of these claims, there is no doubt that AMR is a significant global issue. However, a systematic analysis of AMR published in The Lancet medical journal in 2022 estimated there were 4.95 million deaths in 2019 associated with AMR and 1.27 million of those directly attributable to AMR. A further publication by the Global Burden of Diseases (GBD) Antimicrobial Resistance Collaborators forecast that by 2050 AMR there  couldbe1.91 million deaths attributable to AMR and 8.22 million deaths associated with AMR. Furthermore, whilst the risk in children is decreasing, the risk is largest in those aged 70 years and older. 

The review made 10 key recommendations which although a UK review should be global aspirations.

In 2022, reflecting on progress, six years on from the publication of the review, O'Neill was pleased progress had been made with reducing agricultural antimicrobials but disappointed that diagnostic technology was not yet embedded in clinical practice. There was even the suggestion from O'Neill that the global toll could be greater than Covid. Professor Alison Holmes of Imperial College and president of the International Society for Infectious Diseases stressed that since 20% of antibiotic prescriptions in hospitals are to treat hospital acquired infections, preventing infections in healthcare establishments is essential.

UK Government 20 year vision for AMR - 2019

In January 2019 the UK Government published a vision that by 2040 AMR would be effectively contained, controlled and mitigated. In collaboration with the global community, the UK would achieve this vision by:

1. A lower burden of infections, better treatment of resistant infections and minimised transmission.
2. Optimal use of antimicrobials.
3. New diagnostics, therapies, vaccines and interventions

The vision put forward nine ambitions. Controlling AMR requires an international effort, continuing to be a global partner is the first ambition, working with other countries and organisations. Other ambitions include driving innovation, minimising infection, minimising environmental spread and perhaps most importantly engage the public.

Implementation of the plan will be through a series five year UK national action plans. The first five year action plan began in 2019.

The UK Government web page has information and resources for healthcare professionals and the general public to help achieve the 20 year vision.

In 2015 the WHO launched a Global Action Plan on AMR but conceded that six years on little progress had been made. In 2023 a priority research agenda was published with no fewer than 40 priorities (narrowed down from 175); seven priorities focus on Mycobacterium tuberculosis the causative organism of tuberculosis (TB). TB is the number one global fatal infectious disease responsible for 1.8 million deaths per year. Drug-resistant TB is the most common and lethal airborne antimicrobial resistant disease in the world causing 250,000 deaths per year.

The 40 research priorities in 11 AMR areas across five themes.

Prevention

• Water, sanitation and hygiene (WASH) including hand hygiene and waste management
• Infection, prevention and control strategies
• Immunisation

Diagnosis

• Point of care diagnostic tests
• Rapid antimicrobial susceptibility testing and resistance detection

Treatment and care

• Antimicrobial stewardship
• Antimicrobial use and consumption
• Antimicrobial medicines

Cross-cutting

• Antimicrobial resistance epidemiology, burden and drivers
• Antimicrobial resistance awareness and education for the public, media, healthcare professionals and policy makers
• Policies and regulations related to AMR

Drug-resistant TB

• Prevention
• Diagnosis
• Treatment and care

Antibiotics in primary care in England

Dolk et al (2018) published data on prescribing of antibiotics in England over a three year period (2013 - 2015). Data were obtained from The Health Improvement Network (THIN) for year in 825 practices in England. There were some interesting results which are summarised in the box below.

Achieving an appropriate balance in public health policy is key. Whilst most respiratory tract infections (RTI) are self limiting and and short-lived some rare complications can result in morbidity, or worse, mortality. Guilliford et al (2016) reported the results of their cohort study that examined if the incidence of serious complications (pneumonia, peritonsillar abscess, mastoiditis, empyema, meningitis, intracranial abscess and Lemierre's syndrome) was higher in practices that prescribe fewer antibiotics for self limiting respiratory tract infections.

Data from 610 UK general practices for a 10 year period were obtained and analysed. Over the study period there was, as previously observed, a continued reduction in the rate of consultation for RTI and a reduction in the rate of antibiotic prescribing for RTIs. There was a trend for declining incidence rates of peritonsillar abscess, mastoiditis and meningitis but a small increase in pneumonia of 0.4% annually.

The results showed that in practices that prescribed fewer antibiotics for RTIs there was a slightly higher incidence of pneumonia and peritonsillar abscess. based on the results of modelling, the authors suggested that in an average sized general practice (7,000 patients) if the proportion of RTI consultations with antibiotic prescribed was reduced by 10% they might encounter one additional case of pneumonia each year and one additional case of peritonsillar abscess each decade. There was no evidence that the other complications might increase.

The complications of RTIs are uncommon and are still treatable with antibiotics if they arise. The authors suggest that this does not justify the widespread use of antibiotics for initially uncomplicated RTI presentations.

Gulliford et al (2019) undertook a cluster randomised trial in 79 UK general practices comparing an antimicrobial stewardship (AMS) intervention to usual care on the rate of antibiotic prescriptions for respiratory tract infections (RTI). The AMS intervention comprised three elements delivered electronically to practices. First, a short webinar explaining the trial interventions. Monthly prescribing reports to provide feedback on the number of respiratory consultations and antibiotic prescriptions for the practice compared to the previous 12 months. Thirdly, decision support tools were incorporated in to the practice software which provided patient information sheets and advice on the positive indications for antibiotic prescribing for RTIs.

The prescribing rate was reduced in the AMS group for adults aged 15 to 84 years old but not for children under 15 or adults over 85 years of age. The frequency of bacterial complications (including pneumonia, scarlet fever, empyema, septicaemia) was no different in the AMS  to the usual treatment group.