Monday, 16 March 2015

UK Five Year Antimicrobial Resistance Strategy 2013 to 2018 - Part I of II

The other day I was on my way to Birmingham to attend the debate on Antimicrobial Resistance. The event was organised by the Institute of Microbiology and Infection (University of Birmingham), the British Science Association and also by Antibiotic Action (an independent UK-led global initiative funded by the British Society for Antimicrobial Chemotherapy). It was Monday after a full day of work, but antimicrobial resistance is a passion of mine and I couldn't miss it for anything in this world. I will therefore save a post just for unveiling the movie and debate that followed it. I took loads of interesting notes and really think it will be great to share these with those of you who couldn't make it. 

Anyhoo, on my way to Birmingham I opened and summarised these forty-odd pages of a document I found online by randomly searching for news on antimicrobial resistance. I speak of the "UK Five Year Antimicrobial Resistance Strategy 2013 2018" (access here for PDF). You know, I didn't want to be there just to attend or just to observe, even though I knew whatever participation I had in this event it would always be great for me. But I needed more; I needed insight, technical perspectives, political positions, action. Yes, I needed to know what action was being undertaken to tackle the ever growing issue of antimicrobial resistance in this little world of ours.

I am hereby summarising the red hot paragraphs that were ratified by the Northern Ireland Executive, the Welsh Government and the Scottish Government. I hope that my little work here is appreciated and you get to understand a bit better what is in motion regarding antimicrobial strategies in the UK.


Executive Summary

The scale of the threat of antimicrobial resistance (AMR) and the case for action was set out in the ‘Annual Report of the Chief Medical Officer, 2011’, 2 published in March 2013. This ‘UK Five Year Antimicrobial Resistance Strategy 2013 to 2018’ sets out actions to address the key challenges to AMR.

... antibiotic resistance cannot be eradicated ... This Strategy sets out how the UK intends to address the challenges detailed in the ‘CMO’s Annual Report’... The Strategy has been informed by input from a wide range of experts in different disciplines and its delivery will involve many partners and require cross organisational co-operation at local, national and international levels.

The overarching goal of the Strategy is to slow the development and spread of AMR. It focusses activities around 3 strategic aims: 
• improve the knowledge and understanding of AMR, 
• conserve and steward the effectiveness of existing treatments, 
• stimulate the development of new antibiotics, diagnostics and novel therapies.


The initial emergence of resistance is random, arising by mutations (errors as DNA is copied in bacterial replication) or gene exchange among bacteria. The use of antibiotics then favours the spread of those bacteria that have become resistant. 

... travel and changes in population demographics also help resistant bacteria to spread.

In 2009, it was estimated by the European Centre for Disease Prevention and Control (ECDC) that AMR costs the EU about €1.5 billion in healthcare expenses and lost productivity each year.

Examples of actions taken in the UK to improve prescribing practice and other measures to tackle antibiotic resistance

Since 2008, ‘European Antibiotic Awareness Day’ (EAAD) is held in November each year...

‘Treat Antibiotics Responsibly, Guidance and Education Tool’ (TARGET) was developed by the [then] Health Protection Agency... 

There is another similar initiative, ‘Stemming the Tide of Antibiotic Resistance’ educational programme (STAR).

In recent years, hospital use of antibiotics has improved through the introduction of antimicrobial stewardship programmes...

... a number of measures [...]  focused on reducing the overall use of antibiotics, reducing the use of cephalosporin and quinolone antibiotics (associated with an increased risk of Clostridium difficile infection), and recommending a 3 day course of trimethoprim for uncomplicated urinary tract infections, rather than longer courses. These measures are underpinned by authoritative, evidence based guidance developed by NICE.

... the addition [...] of a requirement within the ‘Code of Professional Conduct for Veterinary Surgeons 2012’ for veterinarians to use antimicrobials responsibly...

... formation of the Responsible Use of Medicines in Agriculture (RUMA) Alliance ...

... production of ‘leaflets on responsible use’...

A voluntary ban by the British Poultry Council on the use of certain antibiotics ...  

The UK Clinical Research Collaboration (UKCRC) ‘Translational Infections Research Initiative’ is a £16.5 million partnership of funders (DH / NIHR, MRC, Wellcome Trust and others) which runs from 2008 to 2015 to carry out research relevant to AMR and infection control. 

To date, £20 million has been invested to support the development of point of care diagnostics and to improve the ability of UK businesses to provide solutions for the global marketplace, boost UK economic performance and provide higher quality public services.

Despite these efforts, AMR has continued to escalate and further action is needed...

The UK Commitment to Action

The UK used its presidency of the G8 in June 2013 to host a meeting of G8 Science Ministers where AMR was discussed. It was agreed that AMR is a priority issue that demands an urgent global cross-sectoral response and research to better understand the origin, spread, evolution and development of resistance. The UK is also supporting work on AMR that will be considered at the ‘World Innovation Summit for Health’ in Doha in December 2013. 

Strategic Aims and Approach

i) improve the knowledge and understanding of AMR,

ii) conserve and steward the effectiveness of existing treatments,

iii) stimulate the development of new antibiotics, diagnostics and novel therapies.

The 7 key areas for future action

i) improving infection prevention and control practices 

ii) optimising prescribing practice

iii) improving professional education, training and public engagement

iv) developing new drugs, treatments and diagnostics

v) better access to and use of surveillance data

vi) better identification and prioritisation of AMR research needs

vii) strengthened international collaboration.

The 7 Key Areas for Future Action

Key area 1: improving infection prevention and control practices
...  limit the emergence and spread of multi-drug resistant organisms in human and animals. For example, the significant fall seen in recent years, across the UK, of MRSA bloodstream infections and improvement in hand hygiene illustrates that with concerted effort... Particular national and international attention is needed on Gram Negative organisms like Klebsiella species, where resistance to critical antibiotics is emerging and spreading.

Key area 2: optimising prescribing practice
Indiscriminate or inappropriate use of antibiotics is a key driver in the spread of antibiotic resistance. [...] most prescribing is carried out in the absence of adequate information... we equally need to ensure use of the right drug, right dose at the right time and for the right duration to limit unnecessary antibiotic exposure. Genomic technologies have potential to provide a valuable means to improve appropriate, prompt, patient treatment.   

Key area 3: improving professional education, training and public engagement
Clinicians involved in prescribing need to remain up to date with emerging evidence on resistance and appropriate antibiotic usage... Patients frequently believe, incorrectly, that antibiotics will help them recover from all respiratory tract infections faster. In addition, studies have shown17 that up to 25% of patients in England do not finish their course of antibiotics or keep them for later use, all practices that encourage AMR.

Key area 4: developing new drugs, treatments and diagnostics
Human and veterinary rapid diagnostics are urgently needed to help differentiate between bacterial and viral infections, as well as to enable fast identification of highly-resistant strains. 

The discovery and development of new drugs takes time (about 10 to 15 years) and a barrier to developing new antibiotics is their relatively low commercial return on investment, relative to investments in other therapeutic areas. This low return on investment is driven by: 
• scientific difficulty of finding new agents, 
• risk of inadequate return on investment given that duration of drug use is limited compared to drugs for chronic conditions, 
• concerns over the cost and complexity of the regulatory approval process, 
• uncertainty about the regulatory environment for new antimicrobials. 

Regulatory uncertainty is dissuading pharmaceutical companies from developing new antimicrobial products for veterinary use. Pharmaceutical companies have expressed concern that potential new controls and additional data requirements may limit the market for any new products and thus limit return on investment.

Equally important is the research and development of novel approaches to the treatment and prevention of infections. This includes using substances to strengthen the immune response to bacterial infection, such as pre and probiotics. Naturally occurring bacteriophages, their enzymes and vaccines are already under consideration.

Key area 5: better access to and use of surveillance data
Better sharing of [...] information and data [...] 

Key area 6: better identification and prioritisation of AMR research needs
... the Biotechnology and Biological Sciences Research Council (BBSRC)28 provides ongoing support for research activities with a focus on AMR, including EU-level coordination. 

[...] research is needed to provide a more detailed understanding of the significance of different transmission pathways between the environment, humans, animals and the food supply chain in promoting transfer or increase of resistance in human and veterinary pathogens [and]  to develop new technologies, including human and veterinary rapid diagnostic tests to differentiate between bacterial and viral infections, enable fast identification of the organisms causing disease, and to identify high-risk strains and their resistance.

Key area 7: strengthened international collaboration
The UK is playing a leading role in influencing European and international thinking, seeking support, securing commitments to prioritise the issue and mobilising action to deliver the scale of change needed. 

More joint initiatives like the ‘EU /USA Transatlantic Task Force on AMR’ (TATFAR), 29 and the ‘European Research Network, ERA-NET Scheme’, 30 are also needed to help foster a culture of data and technology sharing/transfer between animal and human health fields. 

To be continued...

1 comment:

  1. Very important Recommendation!!!!