Antimicrobial Resistance
practices include appropriate sanitation and housing, safe food and water, public education and vaccination programmes. For selected organisms such as MRSA, specific public health recommendations for high-risk activities or settings, such as team sports and closed populations (e.g. army camps and prisons) have been developed to decrease the risk of transmission of community acquired-MRSA.
S. pneumoniae vaccine includes some penicillin-resistant serotypes and a decreased prevalence of penicillin resistance has been reported when resistant clones no longer circulate following widespread childhood immunisation for S. pneumoniae.39-41
Other bacterial
vaccines prevent travel-associated infections, such as typhoid and cholera. Appropriate use of antiviral vaccines, such as those for measles or influenza, may prevent secondary bacterial pneumonia caused by S. pneumoniae, S. aureus or other bacteria.
Limiting Antimicrobial use in the Community Antimicrobial stewardship in community populations is an important strategy for control of antimicrobial resistance.21
requires global partnerships with agriculture and industry, as well as local initiatives.
Healthcare Infection Control Programmes Infection control programmes in healthcare settings have a role in limiting the transmission of and infection with resistant organisms.24,26,48–50 Important activities include optimising hand hygiene, appropriate use and care of invasive devices, sterilisation and disinfection of reusable devices and appropriate environmental cleaning. Specific barrier practices to limit the transmission of some resistant organisms are also recommended for infected or colonised patients.24
Nationwide campaigns
that incorporate interventions to limit community antimicrobial use have been implemented in some countries.42,43
These discourage antimicrobial
For minor S. aureus skin infections, antimicrobial therapy provides no additional benefit beyond incision and drainage.45,46
use for respiratory tract infections where antimicrobials have limited, if any, benefit, such as otitis media, acute bronchitis, sinusitis and pharyngitis.44
Short
courses of antimicrobial therapy should be used when appropriate, such as for the treatment of acute cystitis.
As well as monitoring the use of antimicrobials, community programmes provide education. They inform the public that antimicrobials are not beneficial for some infections, that when a prescription is given the full prescription should be completed and to tell people to avoid self-treatment. During a 10-year campaign in Sweden, outpatient antimicrobial prescriptions decreased from 15.7 to 12.6 defined daily doses per 1,000 population per year, with the greatest decline in young children.42
However, while decreased antimicrobial use is consistently reported in national campaigns, it is not yet clear whether lower rates of antimicrobial resistance are also achieved.30,43
Use of Antimicrobials in Agriculture
Antimicrobial use in agriculture is intense and widespread. In addition to therapeutic use for individual sick animals, antimicrobials are incorporated in low doses in animal feeds as ‘growth promoters’ and used as prophylaxis in intensive farming for whole herds.16,18
More
than 50 % of the total antimicrobial production in Europe and the US is estimated to be used in animal feeds.16
The type of use and specific antimicrobials used vary between countries, depending on local legislation and practice. Banning the use of specific antibacterial products for growth promotion has been followed by a decrease in the prevalence of drug resistance in human pathogens. When avoparcin, an antimicrobial related to vancomycin, was banned in European countries, there was a subsequent decrease in VRE cases in human populations.16
When
fluoroquinolones were removed from use in poultry in the US, a decline in fluoroquinolone-resistant Campylobacter infections in humans followed.47
Addressing antimicrobial use in agriculture is an important component of any strategy to limit antimicrobial resistance. It
EUROPEAN INFECTIOUS DISEASE
Antimicrobial use in Healthcare Facilities Antimicrobial stewardship programmes in healthcare facilities are developed to optimise antimicrobial therapy and minimise the emergence of antimicrobial resistance.53–56
These programmes are
usually multidisciplinary, with participation by pharmacists as well as professionals working in microbiology and infection control.57 Programmes include:
• • •
•
the collection and analysis of data describing antimicrobial use; guidelines for antimicrobial use, including surgical prophylaxis;
some element of antimicrobial restriction, such as formulary control or mandatory consults; and infrastructure to support the programme.
Some activities previously recommended, such as antimicrobial cycling in critical care units to decrease the emergence of resistance,
95
The use of routine surveillance cultures for early identification of MRSA-colonised patients remains controversial as prospective, randomised studies have not reported a benefit with this approach and screening is costly.24,51
While infection control policies and practices are clearly effective in controlling outbreaks of antimicrobial-resistant organisms in healthcare settings, the impact on endemic resistance prevalence and infections is less clear.24
Antimicrobial therapy for
the decolonisation of individuals with MRSA is generally discouraged because of low efficacy and the potential for further bacterial resistance.
An important experience in the UK has been reported. A national programme for the control of MRSA was developed mandating specific practices for all hospitals. At the same time, hospital MRSA bacteraemias were monitored through nationwide surveillance. A substantial decline in MRSA bacteraemia has been reported, with predetermined targets for reduction achieved.52
Despite these positive
results, observational studies such as this are subject to confounding if there is a waning epidemic strain and the specific benefit of any single intervention or combination of interventions is not clearly defined.
Long-term care facilities are a unique environment. The risks posed by antimicrobial-resistant organisms appear to be limited. This is likely because of the relatively limited use of invasive devices in most facilities. Benefits attributed to infection control programmes or specific practices instituted to decrease the prevalence of antimicrobial resistance or infections in these settings have not been critically evaluated. The introduction of restrictive policies to limit antimicrobial resistance must be balanced by quality of life considerations. Practices for a given institution should focus on prevention of infection, rather than colonisation, and will vary with the nature of the patient population and institutional characteristics.25
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