Editorials

Control of antimicrobial resistance: time for action

The essentials of control are already well known 

Until recently the medical community world wide has seemed incapable of reacting to the imminent crisis of antibiotic resistance. Several explanations exist for this lack of action, including the complex interaction between doctors, patients, and parents over antibiotic use ^{1 2} and the fact that the pharmaceutical industry has so far succeeded in developing new antibiotics when resistance to existing ones has emerged. Although we still need a better understanding of the factors involved in the emergence and spread of antibiotic resistance, action cannot wait until all the answers are available. The essentials of better control of antibiotic resistance are already well known.

Surveillance of bacterial resistance is a key element in understanding the size of the problem. The large number of existing networks for resistance surveillance need to be coordinated and the results made available.³ To help doctors choose appropriate antibiotics and to detect local epidemics of resistant bacteria surveillance at local level is necessary. Good quality local data provide a basis for national and international surveillance.

There are two ways of fighting the development and spread of resistant bacteria. The first is to reduce the use of antimicrobial agents to decrease selection of resistant bacteria. About 85-90% of antibacterial drugs are used in the community, and up to 80% of these are used to treat respiratory tract infections. Thus, major efforts have to be targeted on diagnosis and treatment of respiratory tract infections in the community. ^{4 5} Sales of antibiotics over the counter should be stopped. Statistics on the use of antimicrobial agents (including sales over the counter) are of key importance for changing prescription patterns but at present are available only in some countries. We also need to know the patterns of prescription of antibacterial agents in different infections to identify where clinical practice needs to be improved.⁴

To reduce antibiotic consumption we need a multifaceted approach that includes education of doctors; widely accepted recommendations for good clinical diagnosis and treatment; and follow up of compliance with such guidelines. Evidence exists that changing the way general practitioners are paid can change their prescribing behaviour.⁶ Measures to improve the public's knowledge about the risks and benefits of antimicrobial therapy are also important. A free return visit for patients not prescribed antibiotics at the first consultation for a respiratory tract infection has been used as one way of changing patients' expectations.⁷ Restriction policies such as the requirement for written justification or automatic stop orders may be useful in hospital settings. Integrated strategies have reduced antibiotic use or curtailed antimicrobial resistance.^7-10

The second major way to tackle resistance is by improving hygienic measures to prevent the spread of resistant bacteria. Only 40-50 years ago hygienic measures were the most important means of preventing the spread of transmissible diseases. Indeed, during this century Western societies have been transformed by major investments in preventing the spread of pathogenic bacteria: tap water and sewerage, as well as our kitchens with all their equipment. The question is simple: how much are we ready to pay to prevent the spread of resistant bacteria?

In hospitals effective prevention of cross infection and the development of strict antibiotic policies should be in the hands of experts.¹¹ Each hospital thus needs an infection control team with infectious disease specialists, clinical microbiologists, and infection control nurses and sufficient resources and a mandate to run the programme. One urgent practical question is how to raise the standard of hand hygiene in hospitals: at best hand disinfection is achieved on fewer than half the occasions it is required.¹²

Research is also a cornerstone in the fight against bacterial resistance. We have to improve our understanding of bacterial flora, the evolution of resistance, and the mechanisms of transmissibility of resistant bacteria. New diagnostic technologies to enable rapid identification of viral and bacterial infections are also necessary: for too long it has been easier for clinicians to prescribe an antibiotic than to make a specific diagnosis.