AMR in Europe: main threats and consequences
Data reported to the European Antimicrobial Resistance Surveillance Network (EARS-Net) for 2016 shows that AMR remains a significant public health and patient safety problem in Europe. Resistance rates vary across the region, with greater levels of resistance registered in southern and south-eastern Europe (ECDC, 2017). The CDDEP has put together a series of global and regional maps containing resistance data for individual pathogens.
The main danger of AMR is losing our ability to treat serious infections, which can have fatal consequences. AMR is an increasing child health concern as children are most susceptible to infectious diseases – they may have not yet developed immunity to some diseases, attend nurseries and playgroups with other children, and may be less attentive to hygiene. New-borns are most at risk from perinatally-acquired infection such as Group B Streptococcus (GBS) and E. Coli. Infants and children will therefore be one of the groups most affected by AMR.
Respiratory tract infections and urinary tract infections are both common in children, and AMR is increasing in organisms known to cause these. For example, more than one third of Klebsiella pneumoniae(causing urinary and respiratory tract infections) are resistant to at least one antibiotic group (ECDC, 2017). Escherichia coli, commonly responsible for urinary tract and other invasive infections, had shown increasing resistance to third generation cephalosporins between 2013 – 2016 across the EU. More than half of the isolates reported to EARS-Net were resistant to one or more antibiotic groups. Ten of 26 countries reporting Acinetobacter sp. resistance showed combined resistance in more than 50% of cases, leaving these patients with severely limited treatment options (ECDC, 2017).
A study in 2012 showed that across Europe Paediatricians did not correctly estimate the risks and benefits of antibiotic therapy for upper respiratory tract infections (Grossman et al, 2012). Education on this is needed to preserve our antibiotics to treat serious bacterial infections.
Likewise, drug resistant tuberculosis (TB) is a significant health challenge. There were 600,000 cases of new multi-drug resistant TB in 2016 (WHO). Healthcare providers must ensure they choose the correct treatment agent, dose and duration, plus educate their patients and their carers about the importance of treatment concordance (CDC).
AMR is also increasing in organisms known to cause hospital acquired infections, such as methicillin-resistant staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (ECDC, 2017). This puts already vulnerable hospital patients, including children, at increased risk.
This data clearly shows that AMR is leaving patients vulnerable to infections that may in the near future become unresponsive to current treatment options. Without effective antimicrobial therapy, these infectious diseases can be fatal. Immunocompromised patients, like those receiving chemotherapy or following organ transplants, will be particularly vulnerable. Post-operative and other hospital-acquired infections will be increasingly complex and difficult to treat.
What are health organisations doing to tackle AMR?
A coordinated response is needed to tackle AMR. This must address all of the interconnected factors playing into AMR – isolated interventions will not be effective (WHO, 2018). Leading health organisations worldwide, including WHO, CDC, ECDC and IDSA, have repeatedly stressed the urgent need for improved surveillance of antimicrobial use and resistance patterns to evaluate evidence-based infection control and antimicrobial stewardship efforts.
The ECDC have launched a toolkit for the Antibiotic Awareness Day 2018 to support appropriate use of antibiotics in healthcare settings (EAAD, 2018). Reports show that aapproximately half of antibiotic prescribing in European hospitals is inappropriate: administration is often delayed, dosing or duration inappropriate, or the antibiotic chosen is from an excessively wide or (less commonly) too narrow spectrum. In addition, the antibiotic choice is often not reviewed or streamlined as soon as more information is available (ECDC, 2018).
Educational online courses on antibiotics and AMR offered by the WHO and ESPID (https://www.espid.org/default.aspx) aim to improve clinicians’ knowledge of, and competency in, AMR. Fighting antimicrobial resistance is also a core activity within ESCMID and GARDP. GARDPs neonatal sepsis programmes seek to provide an evidence base for the use of antibiotics in neonates with serious bacterial infections, as the currently available standard of care in many countries is increasingly becoming less effective due to antimicrobial resistance.
Education of the medical workforce is crucial. A European wide study on paediatricians’ attitudes and practice to antibiotic prescribing for upper respiratory tract infections found that 43.5% of respondents over-estimated the risks of not prescribing antibiotics, and over-estimated the clinical benefit of prescribing antibiotics, illustrating the need for further education and training (Grossman et al, 2012).
In the UK, a ‘Start Smart Then Focus’ initiative was launched by Public Heath England in 2015 to encourage appropriate antibiotic prescribing. Initiatives such as this encourage judicious evidence-based use of antimicrobials. ECDC found that hospitals that had implemented an antibiotic stewardship programme reduced inappropriate prescribing by 96%, length of stay and mortality by 65% and antibiotic resistance by 58% (ECDC, 2018).