Health care systems and antimicrobial resistance Laura J. Shallcross and Dame Sally C. Davies Our health care systems are facing new and extreme challenges in the face of an ageing global population. The combination of better health care, disease prevention and declining fertility has led to a worldwide doubling of people aged 60 years or above since 1980.1 By 2050 an estimated 30 per cent of the population in highincome countries will be aged 80 years or more (Christensen et al., 2009). This is good news: we have made enormous advances in health care across the globe. But our success brings major challenges in terms of how we deliver and configure health care services in the future. Ageing is almost always accompanied by chronic and multiple diseases, physical frailty and disability. More than half of all elderly people are diagnosed with at least two chronic diseases (Marengoni et al., 2011), and the risk of multiple diseases increases with age and social deprivation. The elderly are disproportionately affected by antimicrobial resistance (AMR), largely because of intersecting factors that combine to increase their susceptibility to infection (Adam et al., 2013; Miller et al., 2007). Elderly patients have more age-related chronic ill health, such as heart and respiratory disease, kidney disease and diabetes, and patients with these conditions are more likely to develop infection. If they are admitted to hospital they tend to have lengthier hospital stays compared to younger people because they have complex health and social care needs (Shrivastava et al., 2013). This increases their exposure to drug-resistant infections; it also increases the likelihood they will be treated with an antibiotic, further increasing their future risk of drug-resistant infection. When they attend hospital, the elderly are more frequently dehydrated or malnourished compared to younger people, making it more likely that they will be treated with intravenous drugs or fluids, using a percutaneous device that will then act as a potential route for infections to enter the bloodstream. For all of these reasons, elderly patients experience a heavy burden of drug-resistant and health careacquired infections, such as Clostridium difficile (CDI) and Methicillin-resistant Staphylococcus aureus (MRSA).2 For CDI and MRSA in particular, infection is often attributed to poor standards of infection control or treatment with specific antibiotics in hospital.3 In short, we may be able to reduce the number of these infections by improving how we deliver health care and preventing people from being admitted to hospital in the first place. Towards universal health coverage If we want to make an impact on AMR we must work towards universal health coverage (UHC) so all patients have access to affordable health care.4 For elderly populations in particular we need to improve the provision of efficient, well-run preventative and longterm condition management services in the community that are linked through to specialist services in hospital. This means preventing infection, including good hygiene and, in particular, separating potable water from sewage and implementing infection control, such as scrupulous hand hygiene. In primary care we must improve the uptake of vaccinations and promote judicious use of antibiotics to halt the emergence of resistance. This would be much easier if we had rapid diagnostic technology. Antibiotics should not be available over the counter or via the internet, but only on prescription from a health practitioner who follows guidance informed by local laboratory surveillance, with the exception of remote areas where this approach would prevent access. In our hospitals we need robust and reliable systems to diagnose infection, with laboratories that undertake regular quality assurance. This must be supported by health information systems that feed into population surveillance at local, regional, national and international levels, so that surveillance is embedded into health care systems to directly inform antibiotic treatment guidelines. Antibiotic conservation and stewardship should be an integral part of prescribing, and in practice this requires effective leadership across all clinical specialties, including veterinary and agriculture. There must be a robust system of quality assurance, from audit through to systems for medicines management, to ensure drug supply and quality (and exclude falsified and counterfeit medicines), and improve prescribing quality. This will help to protect the lifespan of new and existing drugs. All of these efforts would be greatly helped by electronic medical records and, in particular, electronic prescribing. None of these aims will be realised without a skilled workforce. Everybody working in health care and veterinary services should receive training in infection prevention, with specialist training in stewardship for those who prescribe antibiotics. Within our hospitals, agriculture and communities we need motivated individuals to act as ‘antibiotic champions’ to promote good practice and drive up prescribing quality. The current levels of investment in infrastructure and resources to tackle AMR are inadequate in most parts of the world, with a clear need for training and capacity-building. The costs of remedying this are both significant and long term, and are likely to present a barrier to action, particularly in low-income countries. Recently, Public Health England (PHE) led the development of an innovative Commonwealth laboratory twinning programme in which high-income countries partner with low- or middle-income countries. This will support Commonwealth countries’ response to AMR for their own populations and contribute to wider regional and national efforts. In the future, twinning may extend from laboratory capacity-building to epidemiological partnering, strengthening disease surveillance and sharing wider expertise. Through this programme, PHE partnered with the Caribbean Public Health Agency (CARPHA) to deliver a two-day AMR workshop for 48 Commonwealth Health Partnerships 2015
Commonwealth Health Partnerships 2015
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