Category Archives: Uncategorized

Would you like some antibiotics?

This is part two of my blog from Cambodia. The first part is here What can $6m buy you

I have spend some time at Angkor Hospital for Children and have been amazed. Amazed at the challenges faced and amazed at the quality of infection control given the limited resources. The IC program consists of continous prospective surveillance of all HAIs, hand hygiene, feedback of infection data, environmental cleaning (twice a day), cleaning audits, training, good governance and the list goes on.  Hand hygiene compliance is above 80%, but not all moments have been introduced yet (1000+ moments a month observed). IMG_2308

The fact that a hospital here can undertake continous surveillance of all HAIs is quite amazing. They asked if I could benchmark them against some Australian hospitals/what the rates are in Australia. And there we ended back to where this blog always seems to – a lack of co-ordinated, meaningful HAI surveillance at the national level in Australia.  But enought of that, see Phil’s blog for the pub test.

Not all is of course perfect, but given the resources, I think it is quite extrordinary. Another difficultly (apart from ovecrowding, lack of resources, limited clean water etc etc) is a some local work suggesting 60+% of patients coming into the hospital are colonised with a MRGN, mainly resistant in some form. That got us talking a lot about strategies and future work, but I also have myself an challenge….

This test invovled me trotting up to a local pharmacy. It went like this “My wife has a cut on her arm, it is inflammed/red”. That is pretty much it. The response:

  • Pharmacy 1 – topical cream that consistent of gentamicin, erythromycin and clotrimazole, all combined in one convenient tube. I asked about oral amoxicillin and was told “antibiotics you swallow are only for infections on the inside, the don’t work anywere else”.
  • Pharmacy 2 – Ciprofloxacin was handed to me.

Dishartened, I changed my tack. I went to another pharmacy and said “My wife has a cough and fever”. They asked if it was a dry cough. I said no, productive sputum. I was handed paracetamol. Yeah! There is hope.

This blog, I hope, illustrates the challenges  in infection control (&AMR) in a resource deprived country. We need to support our colleagues in our region, in any way we can. OneHealth is a global issue.

(By the way, I did not purchase any of the antibiotics, so as not to contribute to the issue).

 

 

 

 

 

What can $6m buy you?

The ability to run a children’s hospital for a year of course.Image result for angkor childrens hospital

I am in Siem Reap (Cambodia) at present and spending some time at Angkor Children’s Hospital. The hospital run entirely on donations and is the only children’s hospital in Cambodia. All services provided free. I won’t bore you with some stats, but here are some impressive figures considering the budget:

  • 27,000 ED patients a year
  • 132,000 outpatient visits
  • 880 intensive care admissions a year
  • Average cost of an ER visit $7, ICU $820 a stay.

Cambodia is a very poor country with a neonatal mortality of 18 per 1000 live births. 32% of children under 5 are stunted, 24% are underweight. Just $500 will is enough to provide weekly lectures to nurses for year; $5000 enough to buy medication for all ICU patients for 6 weeks.Image result for angkor childrens hospital

The most common hospital diagnosis are respiratory infections, asthma, gastro and sepsis. Over the next few days, I am meeting the Cambodia Oxford Medical Research Unit team, spending some time looking at infection control issues and challenges and similarly with nursing education and development. On infection control, the issues are significant, Gram negative resistance is a real problem (more on that to come in another blog).

If you want to know more about Angkor Children’s hospital, try this Angkor Hospital Video

More to come on infection control successes and challenges.

Brett

(Note: Pictures were not taken by me, rather publicly available)

 

#ACIPC16 Melbourne (part II)

screen-shot-2016-12-12-at-20-47-20In case you weren’t aware, many of the slides presented at #ACIPC16 are now available for viewing on the conference website

A/Prof Deb Friedman (@friedmanndeb) from Barwon Health had the unenviable task of presenting the Top Infection Control papers of 2016. Always a tough ask depending on your interests…however Deb covered pretty much everything including:

  • —Hand hygiene
  • IC activities
  • Contact Precautions/ Infection transmission/ CPE screening
  • Decontamination/ M. chimaera
  • —HCW vaccination
  • —Acinetobacter, RSV spread by air
  • —Norovirus spread
  • —Antimicrobial stewardship
  • —Chlorhexidine bathing/ FMT for MDROs
  • —Ebola virus/ PPE doffing
  • —Zika virus inactivation

It was all presented within time and with a story line! Clearly I cant mention them all, so here’s a couple. Pelat et al (1) demonstrated through the use of modelling that improving HH compliance from 55% before patient contact and 60% after patient contact to 80% before and after patient contact, would reduce the proportion of patients who acquire ESBLs within 90 days by 91%, they also found that antibiotic restriction had the lowest impact. Testament to the quality of local research, another top pair quoted was Mitchell et al (2) that identified from a survey of 40 infection prevention units: 36% of IP time was spent doing surveillance: 56% collecting data, 27% collecting data on compliance with IC activities, 17% feedback of HAI data. Casanova et al (3) demonstrated contamination post doffing recommending effective hand  hygiene afterwards.

Professor Gill Harvey from the University of Adelaide presented a keynote talk on Moving from Evidence to Practice, highlighting that good research is not enough to guarantee its uptake in practice. To improve the chance of interventions being implemented we need to get better at understanding what is being implemented, who is involved in the intervention, the culture and characteristics of the environment it is to be implemeted, and how the intervention effects everybody.

Finally, I really enjoyed the session on Communication. Presentations from Dr Becky Freeman (@DrBFreeman) from The University of Sydney, on Social Media and Public Health  who added to Maslow Hierarchy of Needs with “WiFi” holding up the pyramid! Becky posed the question, how many screens do we have in the house? (in a household of 5 adults I just counted 12 and thats not including TV’s). Mr Paul McNamara (@meta4RN) from Cairns presented on all the delights of using Twitter for professional purposes, Ms Claire Hewitt (@ClaireyHewitt) from St.Vincents Private Melbourne presented on the benefits of blogging, with a reminder that blogging allows you to control your own message, and demonstrated the excellent blog at St.Vincents, even the CEO blogs! This excellent session finished with Mr Anthony Carr from NPS presenting Communication in Practice  demonstrating the many ways NPS uses media to communicate.

Thanks to all those mentioned above, enjoyed your work.

Phil

Declaration – I am a Director of ACIPC and a member of the ACIPC Conference Scientific Committee.

  1. Pelat C et al Infect Control Hosp Epidemiol 2016;37(3):272-80.
  2. Mitchell et al, Infection,Disease and Health 2016;21(1):36-40
  3. Casanova LM, Infect Control Hosp Epidemiol. 2016 Oct;37(10):1156-61

 

 

#ACIPC16 Melbourne

screen-shot-2016-11-29-at-20-21-11Congratulations to all associated with the organising of the #ACIPC16 conference.

Once again we were privileged to hear from excellent international and local speakers. Without doubt, the quality of the free papers and posters at this annual conference continues to escalate, and I was impressed by all of those I was able to get to.

This brief blog is by no means a comprehensive round up of the conference, there were many sessions I just couldn’t get to. I believe a good blog is a quick blog, so for now I wanted to mention just a couple I attended, with more to come in future posts.

Congratulations to Oyebola Fasugba (Australian Catholic Univesity) who presented on behalf of Jane Koerner and was the recipient of the Elaine Graham Robertson award this year. Oyebola is an emerging infection prevention researcher and we look forward to her output in years to come. Her presentation on the systematic review undertaken on the effectiveness of antiseptic cleaning before and during catheter insertion for prevention of CAUTI will prove to be a resource for us all moving forward.

Holly Seale (@hollyseale) from the University of New South Wales presented on patient empowerment in preventing HAIs. For me, this is an emerging and welcome issue we need to embrace (including involving consumers in research, which Heather Loveday addressed on the final day of the conference, see below). Holly’s research found that although the majority of patients indicated they wanted to be involved in activities like reminding HCWs to wash their hands, when it came to the crunch, very few actually did. Holly emphasised that the authority of HCWs is very strong and patients remain uncomfortable in these situations. This doesn’t surprise me much, as I, and probably many of you, have lived that very experience. Sometimes I wonder if this is more reflective of the Australian (or inherited British) culture that we live in? I suspect the same study repeated in the USA would yield difference results. Good work Holly et al, important points.

I will finish this blog with Heather Loveday‘s (@loveebhc) talk as mentioned above, involving the public in research. This is not about consumers being subject to research, but involving them in everything from design, method, analysis and dissemination of findings. Some of the key messages to come from Heathers talk is that public involvement in research adds value to the findings of the research, particularly when identifying what is important to them. It is also essential the public be involved in disseminating the findings of the research. Peer reviewed journals usually aren’t the best way to provide information to the public, more relevant forums need to be used to get key message out to the public. Magazines did I hear?

As mentioned, this is not intended to be a comprehensive review or a best of. Just a comment on a few that I was fortunate to get to. More to come…

Again, congratulations to all involved in the conference. We look forward to #ACIPC17 in Canberra next year!

NB: adding to Bretts earlier blog on the debate, it was great to see a large number of delegates in attendance. The last session of any conference always presents a challenge to maintain delegates interest. It was clear from the presenters view that those in attendance were keen to discuss the next initiative, as noted by the many questions. And thanks to Mary Dixon-Woods (@MaryDixonWoods) for her excellent insight and Martin Kiernan (@emrsa) for the twitter summary. For the record, despite the outcome of the voting, we need all three initiatives ASAP!

 

Phil

Declaration – I am a Director of ACIPC and a member of the ACIPC Conference Scientific Committee.

Next national HAI initiative – CAUTI of course #ACICP conference

To conclude the ACIPC conference in Melbourne this year, three different views were proposed for what the national national HAI initiative should be. Dr Phil Russo presented a case for national surveillance, while Prof Linsday Grayson presented a case for peripheral vascular devices. I had the job of presenting a case for CAUTI.

The debate allowed 15 mintes each for us to present, followed by a panel discussion, discusion and questions from the floor, in addition to questions from Twitter (for those not present but following online).

Following some great questions, humour and some lively discussion, in the end, Phil won the debate, with 50%, followed by peripheral vascular devices (30%) and CAUTI (20%). It was clear however, that all three projects had debatesupport and it was strongly suggested that all three be implemented with the next 5 years.

I did make a good come back, scoring up from a prepoll of 6%!

If you would like to see the CAUTI presentation I delivered, here it is: ACIPC presentation: Next national HAI Initiative, CAUTI or in pdf format here

Brett

Disclosure: BM was the Scientific Chair or ACICP 2016, PR was on the scientific committee.

 

Professional or Practitioner: What’s in a name?

Dr Deborough Macbeth from Gold Coast Univerity Hospital and a leader in professional ICP practice in Australia was asked to write a blog for our site. Deb has written a thought provoking blog that we hope generates some discussion.  Thank you Deb

Brett

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In 2008 the Association of Professionals in Infection Control (APIC) announwhat-is-in-a-name-2ced a change in the title of its members from ‘Infection Control Professionals’ to ‘Infection Preventionists’. The justification for this change reported in Infection Control Today by Kath Wayre, APIC’s CEO at the time, was that the new title “clearly and effectively communicates who our members are and what they do”.[1] In Australia, where the title ‘Infection Control Practitioner’ had been common for many years, news of this change filtered through prompting discussion and debate about our own title.

A range of issues informed this discussion and debate at that time in the Australian context. For me, two were particularly relevant. First, the establishment of a new nursing role titled Nurse Practitioner. The Nurse Practitioner role carried expanded practice rights including prescribing with specific additional educational requirements. Concerns were raised amongst the membership of the then College, known as the Australian Infection Control Association, around the ongoing use of ‘practitioner’ in our title and the possibility of other health professionals and members of the general public confusing our role with that of the Nurse Practitioner. These are used interchangeably in the literature, by members of the College and other health professions, without formal impediment or official restriction.

The second issue related to the increasing need to recognise non-nursing members of our profession. Once the Nurse Practitioner role was established in Australia, use of the term practitioner in our title tended to link the role exclusively to nursing. Ultimately the decision was made to adopt the title Infection Control Professional but what does this title mean?

Over the years I have reflected on these issues and question, leading me down a number of paths. The first is my recollection of when I was offered a chance to work in infection control for the first time, in 1993. I jumped at the opportunity for a number of reasons. I had just completed a secondment in sexual health where my main role had been working with patients who had Human Immunodeficiency Virus (HIV). That specific role involved a significant focus on education of both health professionals as well as the general public. As a consequence I had developed educational skills and had a firm grasp of infection control concepts including ‘Universal Precautions’ (now called Standard Precautions) and Transmission-based Precautions. I had also provided counselling in relation to testing for blood-borne viruses and treatment in terms of hepatitis B vaccination. While these experiences augmented my previous nursing knowledge and experience, it was my belief that I should have no difficulty filling the infection control role because after all, infection control is a key component of all roles in healthcare.

Of course, it took no time at all in my new role to discover the vast difference between a basic understanding of infection control principles and the professional practice of infection control. It can be compared to the difference between the amateur golfer who plays once a week and Tiger Woods or some other professional golfer.

Tiger Woods no longer simply plays golf. He tests and endorses golf clubs and assorted equipment, he designs golf courses that others pay to play. He could write the handbook on golf and people would be willing to pay large sums of money to have him teach them how to play. This is the divide we cross when we call ourselves Infection Control Professionals. Did you think of that when you took on your first role in infection control? I certainly did not.

Stepping away from the sporting analogy, consideration of what constitutes a professional creates in my mind thoughts of a body of knowledge that is evidence-based. The professional is aware not only of the principles, but also the evidence that underpins those principles and the professional practice it informs.

The professional can respond to challenges and work in unfamiliar contexts simply through the application of those same principles. Furthermore, the professional identifies the unknown and seeks to make it known through scientific inquiry and research. In this regard the professional generates new knowledge, adding to the evidence base and paving the way for those who come afterwards.

The professional is someone whom others consult looking for answers to complex problems. In this sense our work may be compared to architects or engineers. Ours is a deep understanding of all the elements at work in a specific scenario. We can see the competing tensions and strike the correct balance: safe and practical; simple and elegant.

The professional is constantly learning and refining his/her knowledge and skills. He/she undertakes formal education and gains extensive experience, recognising his/her limitations but also continues to push the boundaries of those limitations.

The professional seeks out and consults with other professionals. They develop networks for collaboration and support. These networks become formalised over time into professional bodies and through consensus, standards of practice are developed for the protection of the professional and those they serve. As the profession matures it becomes self-regulating, clearly defining who its members are, their scope of practice, and what it takes to be a professional in that context.

All these considerations underpinned my decision to adopt the title Infection Control Professional (ICP). These considerations direct my daily practice and my commitment to and involvement in the Australasian College of Infection Prevention and Control (ACIPC) as the professional body that represents me. These considerations sustain and nourish my desire to light the path for those who follow, clearly illuminating the way forward. These considerations give form and function to the new ACIPC credentiallinacipc-credentiallingg framework that provides a mechanism for acknowledgment not only of the expert ICP but those in various stages of their professional journey.

When I consider what it means to be an ICP, I continue to challenge myself to move beyond the petty trials and tribulations associated with my work each day and focus instead on the sleek and shining edifice of professionalism we are building. Those who went before us laid the foundations and we have built upon them. Although arguably we are still stretching our wings and finding the limits of our strength, others will come after us and push the boundaries further still.

When I refer to myself as an Infection Control Professional I do so based on all these considerations. It isn’t just a title I have adopted. For me it has deep meaning and carries great responsibility. It enables me to challenge myself about who I am, what I stand for, and who I’m claiming to be when I call myself a ‘professional’. What does it mean for you?

Deb Macbeth

 

References

[1] Infection Control Today July 11, 2008. http://www.infectioncontroltoday.com/news/2008/07/apic-announces-new-name-for-infection-control-pro.aspx

 

Spending Money to Harm Patients

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Professor Nick Graves is a leading health economist. He has done some fantastic work in the area of infection prevention and control and has an interest in improving health services. I invited Nick to write a blog and he hasn’t disappointed with a blog to stimulate debate and discussion. @Nick_disco_G

Thanks for the blog Nick – Brett

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The notion that scarce health care resources are used to fund technologies and clinical services that harm patients is difficult. Common sense tells us this would never happen. Yet up to 1/3 of all spending in the US is on medical spending for services that do not improve health (1), and evidence that Australia pays for low value or even harmful care is emerging (2, 3).

That fact we do this as part of infection prevention practice is a worry. The community prides itself on improving safety and saving costs, rather than the opposite. The culprit is the continued use of laminar air flow in operating rooms.

In 1969 Charnley and Eftekhar published evidence for reduced numbers of airborne bacterial counts and lower rates of sepsis when laminar air flow was used (4), and in 1978 Lowbury and Lidwell published the findings of a multi-centre randomised trial that showed the incidence rate of joint sepsis was 50% lower in patients that had surgery in an ultraclean environment (5). The Achilles heal of the randomised study was that antibiotic prophylaxis was not included in the analysis, and this might confound the finding about laminar air. Since this study, evidence against laminar air flow has emerged from Germany (6), New Zealand (7), the US (8) and Norway (9). All these data were synthesised in a meta-analysis that provides effectiveness estimates for a wide range of infection prevention bundles for joint replacement (10). It showed that adding laminar airflow to systemic antibiotics and antibiotic-impregnated cement, when compared to conventional ventilation attracted an odds ratio of 1.96 (95% CI 0.52-5.37). So laminar airflow increases risk of infection in joint replacement. And before you worry about statistical significance, remember that a p-value of 0.05 is arbitrary and tells us nothing useful about whether laminar air flow should be part of health services (11, 12).

A decision to continue to use laminar air flow and the impact this has for health services was shown by a recent HTA report completed for the NHS (13).

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An extra 260 patients will suffer a deep infection each year. Treating them will require 127 extra one stage revisions, an extra 150 DAIR procedures (debridement, antibiotics, irrigation, and retention) and 50 extra two stage revisions. This will cost the NHS £5,053,528 in treatment and services and patient health outcomes will of course be worse. A study for Australia (14) showed that continuing with laminar air flow could result in an extra 179 cases, increased costs of $4,592,200AUD and four extra deaths.

There are likely to be many reasons why this practice is not stopped: making a change is risky for altruistic individuals, and I cannot think of anyone who would really want to blow this whistle; the evidence for a making a change can be poked for holes by supporters of laminar airflow; patients are poorly informed and cannot adequately express their preference for safety. This problem is common among health services, and this is one example.

 

References

  1. Fisher ES, McClellan MB, Bertko J, Lieberman SM, Lee JJ, Lewis JL, et al. Fostering accountable health care: moving forward in medicare. Health Aff (Millwood). 2009;28(2):w219-31.
  2. Elshaug AG. Over 150 potentially low-value health care practices: an Australian study. Reply. Med J Aust. 2013;198(11):597-8.
  3. Runciman WB, Hunt TD, Hannaford NA, Hibbert PD, Westbrook JI, Coiera EW, et al. CareTrack: assessing the appropriateness of health care delivery in Australia. Med J Aust. 2012;197(2):100-5.
  4. Charnley J, Eftekhar N. Postoperative infection in total prosthetic replacement arthroplasty of the hip-joint. With special reference to the bacterial content of the air of the operating room. Br J Surg. 1969;56(9):641-9.
  5. Lowbury EJ, Lidwell OM. Multi-hospital trial on the use of ultraclean air systems in orthopaedic operating rooms to reduce infection: preliminary communication. J R Soc Med. 1978;71(11):800-6.
  6. Brandt C, Hott U, Sohr D, Daschner F, Gastmeier P, Ruden H. Operating room ventilation with laminar airflow shows no protective effect on the surgical site infection rate in orthopedic and abdominal surgery. Annals of surgery. 2008;248(5):695-700.
  7. Hooper GJ, Rothwell AG, Frampton C, Wyatt MC. Does the use of laminar flow and space suits reduce early deep infection after total hip and knee replacement?: the ten-year results of the New Zealand Joint Registry. The Journal of bone and joint surgery British volume. 2011;93(1):85-90.
  8. Miner AL, Losina E, Katz JN, Fossel AH, Platt R. Deep infection after total knee replacement: impact of laminar airflow systems and body exhaust suits in the modern operating room. Infect Control Hosp Epidemiol. 2007;28(2):222-6.
  9. Engesaeter LB, Lie SA, Espehaug B, Furnes O, Vollset SE, Havelin LI. Antibiotic prophylaxis in total hip arthroplasty: effects of antibiotic prophylaxis systemically and in bone cement on the revision rate of 22,170 primary hip replacements followed 0-14 years in the Norwegian Arthroplasty Register. Acta orthopaedica Scandinavica. 2003;74(6):644-51.
  10. Zheng H, Barnett AG, Merollini K, Sutton A, Cooper N, Berendt T, et al. Control strategies to prevent total hip replacement-related infections: a systematic review and mixed treatment comparison. BMJ Open. 2014;4(3):e003978.
  11. Claxton K. The irrelevance of inference: a decision-making approach to the stochastic evaluation of health care technologies. J Health Econ. 1999;18(3):341-64.
  12. Goodman SN. Toward evidence-based medical statistics. 1: The P value fallacy. Ann Intern Med. 1999;130(12):995-1004.
  13. Graves N, Wloch C, Wilson J, Barnett A, Sutton A, Cooper N, et al. A cost-effectiveness modelling study of strategies to reduce risk of infection following primary hip replacement based on a systematic review. Health Technol Assess. 2016;20(54):1-144.
  14. Merollini KM, Crawford RW, Whitehouse SL, Graves N. Surgical site infection prevention following total hip arthroplasty in Australia: a cost-effectiveness analysis. Am J Infect Control. 2013;41(9):803-9.

 

 

 

 

What do we know about antimicrobial use in Australian residential aged care facilities?

The National Centre for Antimicrobial Stewardship (NCAS) is a multidisciplinary collaborative funded by the NHMRC with a strong track record of innovation and Capturesuccessful translation into clinical practice. We asked Dr Noleen Bennett from NCAS to write about a national antimicobial prescribing survey in aged care. It has brought up some interesting findings.

Thanks for Noleen for this blog – Phil, Brett and Ramon.

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The short answer is we know antimicrobial use in Australian residential aged care facilities (RACFs) needs to be improved. The unacceptable risk otherwise is the emergence of multi drug resistant infections and other adverse consequences in this vulnerable population.

In 2015, 186 RACFs participated in the pilot Aged Care National Antimicrobial Prescribing Survey. Key areas for improvement were identified and included:

  • inadequate documentation
    • 31.6% of prescriptions did not have an indication justifying their use
    • 65.0% of prescriptions did not have a review or stop date documented.
  • the use of antimicrobials for unspecified skin infections
    • 17.5% of antimicrobials were being used for unspecified skin infections.
  • prolonged duration of prescriptions.
    • 31.4% of prescriptions had been prescribed for longer than six months.

All Australian RACFs and multi-purpose services are now strongly encouraged each year to participate in acNAPS. Participation assists in ensuring compliance with national guidelines and targeting local and national actions to support appropriate antimicrobial use.

For further information, the friendly NAPS team can be contacted via email support@nasp.org.au or phone (03) 9342 9415. The data collection period for the 2016 acNAPS has been extended. Data can now be collected and entered prior to Friday 9th September.

Declaration: Dr Noleen Bennett is employed at the National Centre for Antimicrobial Stewardship and is the Project Officer for the Aged Care National Antimicrobial Prescribing Survey

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Brett: For those interested in other Australian data in residential and aged care (infection and antimicrobials related) here are some links to articles. (This is not an exhaustive list)

 

 

What does the evidence say?

The Australian Commission for Safety and Quality in Health Care has recently developed 16 “Hospital acquired complications” (HACs) that have been published on their website.

Whilst the website provides information on the development of these HACs, it does not specifically detail their purpose. One of the 16 HACs is “Healthcare Associated Infection”, which is comprised of eight different HAI “diagnoses”, including “multiresistant organisms” and “gastrointestinal infections”.

There is clear evidence, both locally and internationally, that coding data does not accurately identify HAIs, and any attempt to do so would misrepresent the truth.

Successful infection prevention efforts rely on valid data. If the data are not accurate, then not only do we run the risk of misdirecting interventions and misinterpreting the outcome of interventions, we are also wasting precious resources.

It is a wonder why, in this field where so often we don’t have good evidence for certain practices, that when good evidence does exist, it still does not seem to influence policy and practice.

Phil

Declaration: Philip Russo is a member of the ACSQHC HAI Advisory Committee. 

The ‘I’ and the ‘We’ of antimicrobial resistance

 

Not a day goes by where there isn’t a report somewhere about the threat of antimicrobial resistance. Our media is awash with grim stories about ‘superbugs’ emerging in patients and hospitals, with dire predictions about the future of healthcare and even humanity and the planet as we know it. There is much that we know about antimicrobial resistance. We know that antimicrobial resistance is a significant global health and security threat. We know that it is something that is increasingly the focus of the work of busy infection control professionals, ID physicians and pharmacists. We know that governments, non-government organisations and all manner of other organisations and groups around the world are marshalling resources, and launching campaigns and strategies to slow the pace and spread of antimicrobial resistance. We know that use of antimicrobials is the primary driver of resistance, and we know that this is accelerated by what is commonly described as overuse, misuse or inappropriate use.  We also know that there is considerable international evidence demonstrating the relationship between antibiotic overuse, misuse or inappropriate use of antibiotics and resistance, and we know the kinds of very many problems that arise from this. Recently here in Australia the First Australian Report on Antimicrobial Use and Resistance in Human Health[1] by the Australian Commission on Safety and Quality in Health Care documented the extent to which Australia has contributed to the rise of global problem. The news this report brought was mixed: in some areas it was cause for celebration; in others our worst fears were realised. We know there is much, much more work to be done.

There are other aspects to this, however, that are not well known to all. There are aspects of this that ‘we’ don’t know well or appreciate. We tend of overlook, forget, and even not appreciate that for millions of people around the world the concepts of antibiotic overuse, misuse or inappropriate use are completely alien.  For millions and millions of people around there world there is no access, or very limited access, to antibiotics. Antibiotics are precious commodities that many only dream of having. In their recent commentary in The Lancet Pamela Das and Richard Horton argued that focusing on resistance in terms of misuse or overuse fails to take a global perspective on the needs of the many for whom antibiotics are a precious resource.[2] As they rightly point out, we tend to overlook, or lack an appreciation for, the fact that many more people die from the lack of access, or delayed access,to antimicrobials than from resistant organisms. While this stark reminder should of course in no way serve to discourage efforts to more prudent use of antibiotics in settings where overuse, misuse or inappropriate use occurs, we must also turn our minds to how we can bring about both sustainable access and sustainable effectiveness for all. We must enhance non antimicrobial-based initiatives to reduce the burden of disease, such as immunisation to improve health outcomes with a system of Universal Health Coverage. We know that this is but one critical intervention to realising the efforts for our wider goal to conserve antibiotics and reduce selection pressure that drives resistance. Moreover, we must all think long and hard about who we actually are when it comes to antimicrobial resistance. In doing so we must all work just as hard to ensure fair access to antibiotics as we do to tackling excess.

Ramon

 

 

[1] Declaration of Interest: Professor Shaban was the project leader of a research consortium at Griffith University contracted by Australian Commission on Safety and Quality in Health Care to contribute to this report. No other interests to declare.

[2] Das P & Horton R. (2015) Antibiotics: achieving the balance between access and excess. The Lancet, Vol 387, Issue 10014, p102-104.