The World Health Organization (WHO) defines antimicrobial resistance (AMR) as the ability of a micro-organism (such as bacteria, viruses, and some parasites) to stop an antimicrobial (such as antibiotics, antivirals and antimalarials) from working against it.
Drug resistance is a natural evolutionary phenomenon. When micro-organisms are exposed to an antimicrobial, the more susceptible organisms succumb, leaving behind those resistant to the antimicrobial. They can then pass on their resistance to their offspring. Over the past years, the use and misuse of antimicrobials has increased the number and types of resistant organisms. Consequently, many infectious diseases may one day become uncontrollable. With the growth of global trade and travel, resistant micro-organisms can spread promptly to any part of the world (WHO, 2017).
Why is it important?
As a result of AMR, standard treatments become ineffective and infections persist and may spread to others. The O'Neill (2016a) report estimated that by 2050, 10 million lives a year and a cumulative $100 trillion of economic output will be at risk due to the rise of drug-resistant infections if we do not find proactive solutions to slow down drug resistance. Approximately 700 000 people die of resistant infections every year (O'Neill, 2016a). Antibiotics are a special category of antimicrobial drugs that underpin modern medicine as we know it. If they lose their effectiveness, key medical procedures (such as gut surgery, caesarean sections, joint replacements, and treatments that depress the immune system like chemotherapy) could become too dangerous to perform (O'Neill, 2016a).
What measures can reduce AMR acquisition?
Ten interventions were highlighted in the final O'Neill (2016a) report that could tackle the rise of AMR (Table 1). These can be split into four main areas:
- Antimicrobial development initiatives
- Reducing antimicrobial use
- Improving infection prevention and control (IPC)
- Improving international focus.
Table 1. Interventions to reduce antimicrobial resistance acquisition
| Antimicrobial development | Reducing antimicrobial use | Improving infection prevention and control | International focus |
|---|---|---|---|
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Focus on reducing antimicrobial demand by preventing infection and spread
Inappropriate use of antimicrobials drives drug resistance. Both overuse, underuse and misuse of medicines contribute to the problem (WHO, 2017). Antimicrobial stewardship programmes and government targets to reduce inappropriate prescribing of antibiotics are often highlighted as an important way to tackle AMR. However, reducing the need for antibiotic therapy by reducing the demand for antibiotics is also key to driving down AMR acquisition. The less people get infected, the less they need to use medicines such as antibiotics, and the less drug resistance arises (O'Neill, 2016a). Patients who are carriers of resistant micro-organisms can act as a source of infection for others. Poor infection prevention and control can increase the spread of drug-resistant infections (WHO, 2017).
Poor IPC practices will speed up the pace at which new drug-resistant infections emerge. A failure to control infections in care settings provides greater opportunities for resistance to occur, while high incidence of infection results in increased demand for antibiotics – a catalyst to rising drug resistance (O'Neill, 2016b).
Interventions that reduce the opportunities for infections to spread therefore have significant potential not just to lower the burden of mortality and morbidity associated with infections, but also to limit opportunities for drug-resistant strains to emerge. The simplest way that all of us can help counter the spread of infections is by proper hand washing (O'Neill, 2016a).
A patient who gets any type of healthcare associated infection will face greater suffering and a higher mortality risk, and this is even worse where the infection is a drug resistant strain (O'Neill, 2016a). The mortality rate associated with methicillin-resistant Staphylococcus aureus (MRSA), has been estimated to be about 50% higher than that for patients contracting methicillin-susceptible Staphylococcus aureus (MSSA) – an infection that responds far more readily to antibiotic treatment (Hanberger et al, 2011).
Vaccines can prevent infections and therefore lower the demand for antimicrobial treatments, reducing use of antimicrobials and therefore slowing the rise of drug resistance. This is true for vaccines that prevent bacterial infections and it is also true for vaccines that prevent viral infections, such as flu, which should not be treated with antibiotics but often is. Health professionals need to act in the short term to increase the use of existing vaccines and improve delivery of these in both the community and hospitals, as well as in farming systems (O'Neill, 2016c).
Chain of infection and interventions at each stage
There are many different infections inside and outside of the healthcare setting. Despite the variety of viruses and bacteria, they spread from person to person through a common series of events. Therefore, to prevent bacteria and viruses from infecting more people, we must break the chain of infection. There are six points at which the chain can be broken and an infection can be stopped from reaching another person. The six links include:
- The infectious agent: the pathogen (germ) that causes diseases. Break the chain with effective diagnosis and management ensuring antimicrobial stewardship
- Reservoir: includes places in the environment where the pathogen lives (this includes people, animals and insects, medical equipment, soil and water). Break the chain by effective cleaning of environment, decontamination of equipment, disinfection where required and pest control
- Portal of exit: the way the infectious agent leaves the reservoir (through open wounds, aerosols, and splatter of body fluids including coughing, sneezing and saliva). Break the chain by effective hand hygiene (the when and how are key), personal protective equipment, control of aerosols and splatter, observing and teaching respiratory etiquette, correct waste disposal
- Mode of transmission: the way the infectious agent can be passed on (through direct or indirect contact, ingestion, or inhalation). Break the chain by effective hand hygiene, personal protective equipment, aseptic technique, safe sharps management, food safety, cleaning of the environment, decontamination of equipment and disinfection where required, isolation
- Portal of entry: the way the infectious agent can enter a new host (through broken skin, the respiratory tract, mucous membranes, and catheters and tubes). Break the chain by effective hand hygiene, personal protective equipment, aseptic technique, safe sharps management, wound management, personal hygiene, first aid, removal of unnecessary catheters and lines
- Susceptible host: this can be any person (the most vulnerable people of who are receiving healthcare, who are immunocompromised or have invasive medical devices including lines, devices, and airways). Advise, administer appropriate vaccinations, treat underlying disease (eg sugar control in diabetes, provide patient with education and heathy living advice on topics such as smoking cessation and healthy eating).
The way to stop infection spreading is by interrupting this chain at any link (Association for Professionals in Infection Control and Epidemiology, 2016)
Vaccination
Examples of infection prevention and the impacts on antibiotic use include improved water and sanitation infrastructure, particularly in urban areas, which has always played a crucial role as countries industrialise and develop economically. Across four middle-income countries (Brazil, Indonesia, India and Nigeria), at least 494 million cases of diarrhoea are treated each year with antibiotics. (O'Neill, 2016b). But with universal access to improved water and sanitation in these four countries, the volume of antibiotics consumed to treat cases of diarrhoea caused by inadequate water supplies and sanitation could be reduced by at least 60% (O'Neill, 2016b).
Vaccines are considered among the most cost-effective ways to prevent morbidity and mortality from infectious disease by controlling, and in some cases eradicating, many diseases, both viral (eg smallpox, measles and polio) and bacterial (eg diphtheria and tetanus). Globally, vaccination against smallpox is estimated to have prevented five million deaths, and vaccinations against measles and tetanus are estimated to save 29 million and 12 million disability-adjusted life years (DALYs) respectively (O'Neill, 2016c). Vaccines do not experience resistance in the same way that antibiotics often do, though the disease burden of vaccine-preventable diseases can shift to non-vaccine strains (O'Neill, 2016c).
‘Even simple, proven steps such as hand washing or following checklists do not always happen in practice. In places where hand hygiene compliance by clinicians is established as a target or performance indicator, very high rates of adherence (sometimes 90% or more) will frequently be reported. However, figures of this type could be obtained through open observation (and therefore liable to be skewed as a result), or influenced by the very existence of a performance target
Bacterial infection
One category of vaccines prevents bacterial infections commonly acquired by the general population, thereby protecting individuals while also negating the need for antibiotics, reducing the opportunity for bacteria to develop resistance (O'Neill, 2016c).
One such example is the infant 13-valent pneumococcal conjugate vaccination (PCV13) that was introduced to the UK in 2010. The baseline overall incidence for hospitalised community-acquired pneumonia (CAP) and pneumococcal CAP was 79.9 (95% CI 76.6–83.3) and 23.4 (95% CI 21.6–25.3) per 100 000 population, respectively. A decline in CAP (incidence rate ratio (IRR) per year 0.96, 95% CI 0.94–0.99, P=0.016) and pneumococcal CAP (IRR per year 0.84, 95% CI 0.80–0.89, P<0.001) was observed over 5 years.
Between the pre- and post-PCV13 periods of the study, the incidence of CAP due to serotypes included in the PCV7 declined by 88% (IRR 0.12, 95% CI 0.08–0.20, P<0.001), and CAP due to the additional 6 serotypes in PCV13 declined by 30% (IRR 0.70, 95% CI 0.51–0.96, P=0.024). Incidence of adult pneumococcal pneumonia declined over 5 years, with serotypes included in PCV13 declining post-PCV13 introduction, indicating early herd protection effects from PCV13 infant vaccination on adult non-bacteraemic disease (Rodrigo et al, 2015).
Viral infections
Another example is vaccines that prevent viral infections. Antiviral vaccines have no direct effect on the organisms causing antibiotic-resistant disease. However, because antiviral vaccines largely target viral diseases that cause acute febrile illnesses, a reduction in the rates of these illnesses should result in a reduction of antibiotics prescribed (often inappropriately) for these episodes (Klugmana and Black, 2018).
In addition, influenza infection is known to increase the risk of secondary bacterial infections such as pneumonia and otitis media, which then require antibiotic treatment. In a prospective blinded study in children, influenza vaccination significantly reduced the risk of otitis media during the influenza season (Ozgur et al, 2006). In a study comparing children who received influenza vaccine with a control group that did not, Marchisio et al (2009) observed that vaccinated children had 13.2% fewer antibiotic prescriptions during the 6-month observation period in their study. Study children had 54.8% fewer otitis media episodes, which likely contributed to the reduction in antibiotic use (Marchisio et al, 2009).
In the UK, in a self-control study using The Health Improvement Network (THIN) database, there was a 14.5% reduction in amoxicillin prescribing during the period of influenza virus circulation in vaccinated children (Hardelid et al, 2018). This occurred despite not all children in the cohort being vaccinated (Hardelid et al, 2018).
Regulation and guidance on IPC for nurses in community settings
The Health and Social Care Act 2008 Code of Practice of the prevention and control of infections and related guidance was updated in 2015. The code now reflects the changes required to meet The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and the role of infection prevention (including cleanliness) in optimising antimicrobial use and reducing AMR.
The Care Quality Commission has enforcement powers that it may use if registered providers do not comply with the law. NHS bodies providing regulated activities, including primary medical care providers, have been required to comply with the full set of registration requirements since April 2012. Examples of interpretation for primary medical care for each of the 10 criteria can be seen in Table 2.
Table 2. The 10 compliance criteria for the Code
| Compliance criterion | What the registered provider will need to demonstrate |
|---|---|
| 1 | Systems to manage and monitor the prevention and control of infection. These systems use risk assessments and consider the susceptibility of service users and any risks that their environment and other users may pose to them |
| 2 | Provide and maintain a clean and appropriate environment in managed premises which facilitates the prevention and control of infections |
| 3 | Ensure appropriate antimicrobial use to optimise patient outcomes and to reduce the risk of adverse events and antimicrobial resistance |
| 4 | Provide suitable, accurate information on infections to service users, their visitors and any person concerned with providing further support or nursing/medical care in a timely fashion |
| 5 | Ensure prompt identification of people who have or are at risk of developing an infection so that they receive timely and appropriate treatment to reduce the risk of transmitting infection to other people |
| 6 | Systems to ensure that all care workers (including contractors and volunteers) are aware of and discharge their responsibilities in the process of preventing and controlling infection |
| 7 | Provide or secure adequate isolation facilities |
| 8 | Secure adequate access to laboratory support as appropriate |
| 9 | Have and adhere to policies designed for the individual's care and provider organisations that will help to prevent and control infections |
| 10 | Providers have a system in place to manage the occupational health needs and obligations of staff in relation to infection |
The National Institute for Health and Care Excellence (NICE) (2012) guideline covers preventing and controlling healthcare-associated infections in children, young people and adults in primary and community care settings. It provides a blueprint for the infection prevention and control precautions that should be applied by everyone involved in delivering NHS care and treatment.
This guideline includes recommendations on:
- Hand decontamination
- Use of personal protective equipment
- Safe use and disposal of sharps
- Waste disposal
- Long-term urinary catheters
- Enteral feeding
- Vascular access devices.
Infection prevention and control is also included in the Nursing and Midwifery Council's Code. Failure to comply with the Code may bring fitness-to-practice into question.
Specifically, section 19: ‘be aware of, and reduce as far as possible, any potential for harm associated with your practice.’ To achieve this, health professionals must:
- Keep to and promote recommended practice in relation to controlling and preventing infection
- Take all reasonable personal precautions necessary to avoid any potential health risks to colleagues, people receiving care and the public.
Barriers to effective IPC
Even simple, proven steps such as hand washing or following checklists do not always happen in practice. In places where hand hygiene compliance by clinicians is established as a target or performance indicator, very high rates of adherence (sometimes 90% or more) will frequently be reported. However, figures of this type could be obtained through open observation (and therefore liable to be skewed as a result), or influenced by the very existence of a performance target (O'Neill, 2016b).
More reliable and systematic observations place actual typical rates of hand hygiene compliance by hospital clinicians as low as 30–40%, and consistently lower among doctors than nursing staff (Erasmus et al, 2010).
With actual adherence to something as straightforward and as powerful as hand hygiene so imperfect, we need to consider how our growing understanding of human behaviour can improve how things are done. Although designing ‘nudges’ towards better behaviour is increasingly of interest to academics and policy-makers, it is a science that has so far been applied to IPC and hand hygiene only on a very limited basis. Research in this area has the potential to deliver simple, low-cost, but highly effective ways of improving adherence to what is already accepted good practice (O'Neill, 2016b).
When undertaking surgical procedures, aseptic procedure (ie the steps that must be taken by the surgeon and their team to reduce the risks of infection) is generally well established, and yet surgical site infections remain a considerable concern. The use of checklists, however, has the potential to significantly reduce the chances that any of these important steps will be missed out (O'Neill, 2016b).
IPC compliance in community setting
While much of the research in this area has been undertaken in the hospital setting, research in primary and community care support the same assessment of compliance. This includes activities such as hand hygiene, glove use, sharps management and the re-use of single use devices. It is vital that nurses identify barriers to safe practice and work to address them. Reasons for non-compliance identified in the literature include time, workload, a lack of facilities, risk perception, job demands, management commitment and lack of knowledge (Ward et al, 2014). There can be many challenges to implementing IPC in primary care, considering the increasing number of patients being cared for in this setting with multiple risk factors for infection. Practicing good IPC and identifying and addressing barriers to good practice should be an important aspect of any nurse's role, reducing the risk of infection to both staff and patients (Ward, 2014)
One study in Brazil in primary care conducted four focus groups with 20 professionals (11 community health workers, 5 nursing assistants and 4 nurses), to identify themes for non-adherence to IPC precautions. Four categories emerged: low risk perception, weaknesses in knowledge, insufficient in-service training and infrastructure limitations (Maroldi et al, 2017). Participants expressed their weaknesses in knowledge of standard and transmission based-precautions, mainly for hand hygiene and tuberculosis. A lack of appropriate resources and standardisation in sharps disposal management was also highlighted by the participants (Maroldi et al, 2017).
Interventions to improve IPC
The use of basic visual or even smell-based prompts, designed to subconsciously ‘prime’ individuals to wash their hands or use alcohol hand gels, could be a simple but important way to promote better hand hygiene. Demonstrating this potential, one study found that placing a picture of eyes above a hand gel dispenser or piping a ‘clean’ smell into the entrance to a hospital ward improved adherence to good hand hygiene practice among staff and visitors by factors of two and three, respectively (King et al, 2016).
Embedding better practices in any organisation requires effective internal leadership and professional ownership. IPC issues (like microbiology and aspects of AMR more broadly) are afforded only limited coverage in general training curricula for doctors and nurses. Improved training and education at undergraduate and post-qualification levels on IPC and AMR are vital.
It is often the case that the person responsible for IPC in an organisation is a relatively junior member of staff, and there are limited formal standards for training and accreditation. It is thus easy to see that individuals responsible for overseeing and improving IPC may lack the influence necessary to guide budget and procurement decisions, or to change ingrained practices and shift priorities across multiple clinical disciplines. Hence the recommendation in the final O'Neill report to improve the number, pay and recognition of people working in infectious disease (O'Neill, 2016a).
Conclusion
IPC is key to reducing demand for antimicrobial use and therefore reducing the acquisition of AMR. IPC in community settings is as important as IPC in an acute setting. Vaccinations are a fundamental intervention to prevent infection in the susceptible host. Effective leadership is vital and nurses are central to promoting the IPC agenda. They also have major roles in leading on IPC compliance and ensuring uptake of vaccination in primary care.
KEY POINTS
- Infection prevention and control (IPC) is key to reducing demand for antimicrobial use and reducing the acquisition of antimicrobial resistance
- Poor IPC can increase the spread of drug-resistant infections
- IPC in community settings is as important as IPC in an acute-based settings
- Key interventions are to improve sanitation and prevent the spread of infection by effective hand hygiene
- Promotion of the use of vaccines is a key intervention in primary care
- IPC is also included in the Nursing and Midwifery Council's Code. Failure to comply with the Code may bring fitness-to-practise into question