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ONLINE Julie Gerberding calls for

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FROM ADVERSITY TO HOPE – the world fights

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Antibiotic resistance

Dame Sally C Davies , Chief Medical Officer on why it is time to sit up and take note of the AMR issue P4

PHOTO: THE SUNDAY TIMES / NEWS SYNDICATION

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Professor Cooke on how a rapid diagnostics test could help towards a more appropriate use of antibiotics P8

Lord Jim O’Neill stresses the importance of research to prevent the spread of AMR

Online Get involved in the e-bug virtual science show from BSAC and Public Health England

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Beating antibiotic resistance together Antibiotics are medicine’s ‘wonder drugs’ that have, since the discovery of the antibacterial powers of Penicillium mould by Sir Alexander Fleming in 1928, transformed the potential and delivery of healthcare across the globe

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edicine progressed more in the first 20 years of antibiotic use than in the two millennia prior to their discovery. Antibiotics not only save, extend and improve the quality of life they also support a wide range of therapies that includes joint replacement surgeries, transplant surgeries, cancer chemotherapy regimens and more. Medicine as we now know it would not be possible without them and neither would our expectations of living long and healthy lives be met. Antibiotic resistance (AMR) refers specifically to the resistance to antibiotics that occurs in common

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bacteria that cause infections. The World Health Organisation (WHO) has named antibiotic resistance as “one of the three major health problems of the new century.” Therefore, there is no task more pressing than for us to seek to address the significant problems antibiotic resistance poses so that supplies of effective antibiotics are available now and in the future. You will read here how antibiotic resistance emerges, how it is a natural consequence of merely using antibiotics and how the inappropriate and overuse of antibiotics in human medicine, agriculture, veterinary practice, animal husbandry and other sectors has reduced, and continues to lessen, the effectiveness of antibiotics in preventing and treating

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existing, new and emerging multidrug-resistant infections.

Starting the conversation

Professor Dilip Nathwani OBE President, British society for antimicrobial chemotherapy, and consultant physician and honorary professor of infection, Ninewells hospital, Dundee

“AMR is one of the three major health problems of the new century” @MediaplanetUK

This campaign offers much cause for hope in the face of adversity, reporting on how governments around the world, led by the World Health Organisation, have set priority agenda and action plans to contain and reduce the burden of antibiotic resistance. It reports on how charitable organisations, research bodies, regulatory agencies, pharmaceutical and diagnostic companies are working collaboratively to engineer and implement innovative solutions. These solutions should see new drugs discovered and made available across a range of economies, healthcare professionals enabled and supported in

better and more rapid diagnosis of infections, all allowing more targeted and effective prescribing. Additionally, the public should be better informed about when to expect antibiotics, and alternative treatments when they are not needed. It is in this spirit of hope and positivity, and during the first World Antibiotic Awareness week, that we encourage readers to participate in providing solutions to curb the rise of antibiotic resistance and reduce its devastating impact. This publication informs not only about the problems posed and actions others are taking, but offers an opportunity to learn what steps and personal actions we each can take, as individuals and citizens, to contribute to the solutions needed.

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Why is there such a focus on antibiotic resistance at the moment? The focus stems from the fact that many of our precious medicines have lost their effectiveness to treat the bacteria which causes common infections, such as pneumonia, skin and kidney infections, gonorrhoea and tuberculosis

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eople with antibiotic resistant infections suffer with symptoms for longer, require more complex treatment and are more likely to die with invasive severe infection caused by antibiotic resistant bacteria. It is estimated that 25,000 people already die every year in Europe because of infections resistant to antibiotics. The development of new antibiotics will help in this fight but it is important that we take care of the antibiotics we have now. The loss of antibiotics will see us return to a 1930s style healthcare (pre-antibiotic era) where infections now considered trivial will once again be fatal. Infections related to pregnancy or superficial skin wounds, or illnesses such as pneumonia will once again become mass

killers. Prior to antibiotics, one in 10 healthy young people died from pneumonia and skin infections; now, thanks to antibiotics this is only one in 100. Deaths from childbirth related sepsis was three in 100 prior to antibiotics and is now less than three in 100,000 births. Don’t get me wrong, I know sometimes you will need to take antibiotics but for many infections we should try alternatives first. For example, antibiotics will not treat colds, flu and most coughs. As a working mum of two young children (six and three years old), I understand the stress and worry when our little ones are unwell, especially in the winter season. However I have also seen the impact of not having effective antibiotics to treat an infection. Antibiotics will not work against most winter ailments and therefore I encourage you to visit your local

“Infections now considered trivial will once again be fatal”

Dr Diane Ashiru-Oredope Pharmacist Lead for Antimicrobial Resistance and Lead for the UK Antibiotic Guardian Campaign

pharmacist and ask how to bring down temperature and reduce the pain from sore throats and headaches. I have, over the years, as a mother and pharmacist, learnt the importance of selfcare for myself and my family. It is essential that we preserve antibiotics for life-threatening infections such as sepsis and meningitis. We cannot eradicate antibiotic resistance, but there are a number of actions that the public and all health and social care staff can take to help reduce the spread of antimicrobial resistance. What can you personally do about this? I would encourage you to learn more by visiting the Antibiotic Guardian website, antibioticguardian.com where you can find out more about antibiotic resistance and what you can do to help save these vital medicines.

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THE FACTS

What is antibiotic resistance? The problem Antibiotics treat infections by killing bacteria, but now the bacteria are fighting back. Our medicines are becoming less effective which means more deaths and more complications for people receiving treatment in hospital. We have to tackle this problem before it gets worse.

How this happened There are many reasons why antibiotics lose their effectiveness, but there are two key ones: Firstly we take medicines that we don’t need. Antibiotics don’t help most colds or coughs get better but we still request antibiotics for them. Secondly, we make things worse when we don’t take antibiotics exactly as prescribed, for instance missing doses. Never save antibiotics for future use or give them to some one else.

What can we do? Antibiotic resistance is one of the biggest threats facing us today but you can help. Please visit antibioticguardian.com and find out about simple steps you can take to save our antibiotics.

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NEWS

THE HISTORY

A world without antibiotics Pre-antibiotic age

Antibiotic age Since the 1940s our antibiotics have allowed us to fight infections and save millions of lives. But they are becoming ineffective against many infections because we aren’t using them properly. Post-antibiotic age If bacteria become ’resistant’ to our antibiotics many routine treatments will again become increasingly dangerous. Setting broken bones, basic operations, even chemotherapy all rely on access to antibiotics that work. Antibiotic resistance is one of the biggest threats facing us today but we have a chance to fight back. Find out how at: antibioticguardian.com

INFOGRAPHICS

Rapid diagnostics would reduce unnecessary prescription Out of 40m people who get given antibiotics for respiratory issues, annually in the US:

27m 13m

get antibiotics unnecessarily who need antibiotics get them

Source: Shapiro D J, Hicks L A, Pavia A T, Hersh A L. Antibiotic prescribing for adults in ambulatory care in the USA, 2007-09. Journal of Antimicrobial Chemotherapy 2013.

PHOTO: BSAC

In a world before antibiotics, as recently as the 1930s, people often died from infections like pneumonia or meningitis. Simple medical procedures and operations were risky due to the chance of infection. Antibiotics changed that.

World problem. The fight against AMR needs joint action

Only global action will save modern medicine Chief Medical Officer for England, Dame Sally C Davies: “This year marks the first ever Antibiotics Awareness Week. We have always marked 18 November as an awareness-raising day across Europe, but the fact that the WHO has now recognised this as a global week of action is further evidence of how important and serious the issue of antimicrobial resistance, or AMR, has become”

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MR has crept up on all of us, and now poses a catastrophic threat to the entire world. The sheer scale of the threat is quite remarkable. It is estimated that at least 25,000 people per year in Europe die of infections caused by resistant bacteria, and €1.5 billion in hospital and societal costs. Globally, by 2050 drug-resistant infections could cause 10 million extra deaths a year and have a cumulative cost of US$ 100 trillion. We have spent decades developing antibiotics which have allowed us to perform intricate and otherwise dangerous operations such as caesarean sections, treatment in intensive care and cancer therapy in a safe and effective way, as well as killing off serious bacterial infections which could have otherwise led to severe illness or even death. However, now we are seeing the antibiotics we have becoming scarcer as the bugs become resistant to the drugs currently available. The world’s medicine cabinet is looking a lot barer than it did 20 years ago. And we are already seeing drug-resistant infections such as gonorrhoea spreading throughout parts of the UK, a place where we pride ourselves on having one of the most developed healthcare systems in the world. So, what are we doing about this? Well, I am pleased that the issue of AMR seems to be slowly creeping into people’s conscious. The more I talk to staff, patients, and other

healthcare professionals the more the topic of AMR seems to be coming up. In fact, last year, the public voted for the £10 million Longitude Prize to tackle the issue of a lack of diagnostics for antibiotics, and the work on this is now underway. I am constantly asked what we are doing to tackle the growing threat of AMR. Well, let me tell you, this year, the UK has been pivotal in driving forward the international efforts to tackle the issue.

On the agenda By canvassing support across the globe, we are working to ensure that AMR is on the agenda at the 2016 UN General Assembly, as well as working closely with other G7 and G20 countries to accelerate progress in the field. The prime minister has just announced a brand new fund with China for innovation in the field of AMR and,on a domestic level we are working with GPs and the public to reduce unnecessary prescribing, as well as encouraging patients to adopt good hygiene, visit their pharmacies before going to a GP, and also using delayed prescriptions, to stop unnecessary antibiotics being used. All this needs to be shared across the globe and we need to look at how we can learn from others. And more and more we are focusing on this pivotal issue of antibiotic ‘stewardship’. The dictionary definition of stewardship reads as “the responsible overseeing and protection of something considered worth caring for and preserving”. To me, this sums it up

“Globally, by 2050, drugresistant infections could cause 10 million extra deaths a year”

Professor Dame Sally C Davies CMO for England

perfectly. Antibiotics, our lifeline to modern medicine, are something we must all care for and preserve. And now that this message seems to be seeping into peoples’ psyches, this is the time to step up our communal efforts even more. Through good stewardship of our antibiotics, we will preserve them for the next generation. And we are committed to this. We are investing heavily in projects such as the £195 million Fleming Fund, where we will work with low-income countries across the globe to encourage better laboratories and surveillance. Domestically, we must also im prove local leadership and accountability and embed good antibiotic stewardship across our own healthcare system. We need to make sure that all health and care staff receive the education and training they need in their day-to-day work in order to promote best practice. We are working with the Care Quality Commission to explore how infection prevention and control and antimicrobial stewardship aspects can be built into the key lines of enquiry used in their routine inspections. In short, we need to produce a fitfor-purpose model, where antibiotic stewardship is firmly embedded in all local AMR plans, and indeed all national ones. So, the good work continues, but there is much more to do. I encourage every one to play their part in this global challenge. The coming months and years will indeed be pivotal in our efforts to save modern medicine.

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INSPIRATION

VITAL STATISTICS

Long-term solutions to drug-resistant infections Research grants Translational grants Efficient regulation Market incentives Knowledge sharing Strong skill base

Drugs Diagnostics Surveillance Vaccines New therapies Infection control Source: Review on Antimicrobial Resistance

Professor Laura JV Piddock Professor of microbiology and deputy director of the Institute of microbiology and infection, University of Birmingham and director of Antibiotic Action

How antibiotic resistance emerges

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acteria that are resistant to antibiotic drugs develop through the natural process of evolution, where microbes undergo changes that help them survive in hostile environments, such as exposure to antibiotics. Bacteria grow and reproduce quickly, doubling their numbers every 20 minutes. At first, a few bacteria may be drug-resistant, but in the presence of antibiotics, all the susceptible bacteria die, and the resistant bacteria grow. These can reach huge numbers within one day. This happens in any environment, whether it be a person, an animal, soil, plants, oceans or our homes. Anywhere that antibiotics are used, drug-resistant bacteria occur. It is therefore vital that we only use antibiotics when necessary. This is why people are encouraged not to ask their doctors for antibiotics for coughs and colds. Doctors have also been urged to only prescribe antibiotics for bacterial infections – this is called good stewardship.

Quickly diagnosing the cause of most infections is difficult, but as some can be very serious, doctors urgently need new tests to help them decide when to use antibiotics. The Longitude Prize will be awarded for a new test that can do this anywhere in the world. Reducing the number of drug-resistant bacteria is difficult. Resistant bacteria are just as likely to cause infections as susceptible bacteria, and sometimes they transfer their resistance to other microbes. It is therefore essential that we prevent the spread of infection between people, animals, and the environment. This is why it is so important for people and animals to have clean water and good public health systems including closed sewers. There are many different types of drug-resistant bacterial infections throughout the world, they are easily transmitted and there are few effective new drugs. All non-essential use of these life-saving drugs must be stopped so that they remain effective for as long as possible.

Approximately

25,000 people in Europe

die every year from antibiotic resistant infections

Antibiotic resistant to infections kill

Antibiotic RESEARCH UK

D E V E LO P I N G N E W A N T I B I O T I C S

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Finding sustainable solutions to the threat of AMR The pharmaceutical industry has a vital role to play through the development of new drugs and diagnostics, but collaboration with government, doctors and the public is key By Lorena Tonarelli

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he epidemic of infections caused by bacteria and other microorganisms that don’t respond to treatment – known as antimicrobial-resistant (AMR) infections – is threatening the world’s health and economy. A review commissioned by the UK Prime Minister, David Cameron, estimates that by 2050 AMR will cause 10 million more deaths a year worldwide – more than those caused by cancer today – and will cost the global economy up to $100 trillion over the next 35 years. Antimicrobial resistance is a natural phenomenon. Bacteria, for example, can mutate to be resistant to certain antibiotics, making them less effective. But the chances of this occurring increase dramatically if antibiotics are used unnecessarily or incorrectly.

Industry’s role A pipeline of new antimicrobial drugs and a reliable supply chain are crucial, says Dr Virginia Acha, executive director of research, medical and innovation at the Assocation of the British Pharmaceutical Industry (ABPI). “There are 34 agents in development, including 15 for gram-negative bacteria, which are the more resistant to current antibiotics. The problem is, bacteria soon become resistant to whatever new drug you challenge them with, so you want to use novel treatments as prudently as possible, and hold them in reserve for when really needed.”

Delinking revenues from sales But, as Dr Acha notes, the above means that pharmaceutical firms cannot recuperate investment in the usual way. So, it’s crucial to delink revenues from use through insurance-based models, for example,

Dr Virginia Acha Executive director of research, medical and innovation, Association of the British Pharmaceutical Industry (ABPI)

“Better access to diagnostics can help doctors make right decisions when treating infections”

or premium-pricing schemes that reimburse only drugs used when and as needed. We need to think of both “push” and “pull” policy measures; “push” to advance the science and “pull” to ensure a sustainable pipeline and delivery of antibiotics, when and where they are needed. This way there will be an incentive structure that promotes both innovation and proper drug use.

Collaborative effort

Patient awareness

Looking ahead

“In addition, better access to diagnostics can help doctors make right decisions when treating infections, and explain these to their patients,” says Dr Acha. “It’s often patients who ask for antibiotics. We need to help them understand why antibiotics are not always the right choice for treatment. And this is something that the government can help with, together with anybody else who can help get the message across.”

Despite the challenges, Dr Acha is positive about the future. She says that, as scientists understand more about the biology of drug resistance and how our immune system works, we will see great potential for containing and, hopefully, eliminating the global threat of drug resistance. But, for this to happen, it’s key that the incentives are there for the industry, scientists and policy makers to continue the vital work they are doing in this area.

Dr Acha adds: “We want to ensure that people use antibiotics properly, so that these retain their potency. And for this we need collaborations between industry, government, healthcare professionals and the public. There is real potential for us to deal with antimicrobial resistance in increasingly innovative ways, which will help solve the problem.”

Routine operations will soon be impossible Without new antibiotics it‘s going to get much worse

Antibiotic RESEARCH UK

D E V E LO P I N G N E W A N T I B I O T I C S

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INSPIRATION

ANTIBIOTIC RESISTANCE IN NUMBERS

25,000 The number of people who die each year across Europe from infections resistant to antibiotics

̆ǍώǏ A recent study showed that the likelihood of GPs prescribing antibiotics for coughs and colds increased by 40% between 1999-2011

30 years The period of time since a new class of antibiotics was last introduced despite the fact that growing numbers of infections are resistant to antibiotics

րǍӺǏ Research has shown that only 10% of sore throats and 20% of acute sinusitis benefit from antibiotic treatment but the prescription rates are much higher than this

€1.5 billion Annual EU-wide cost of healthcare expenses and lost productivity due to antibiotic-resistant bacteria

Knowing that matters. TM

On the spot test key to reduce inappropriate antibiotic prescribing

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0.7

1.0

A simple finger-prick blood test taken in GP surgeries or pharmacies could cut antibiotic prescriptions by up to 42 per cent, saving the NHS £56 million a year By Lorena Tonarelli

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nown as point-ofcare (POC) C-Reactive protein (CRP) testing, this allows doctors, nurses and pharmacists to differentiate between bacterial, self-limiting and viral or more serious infections within just five minutes, right at the point of prescribing, helping towards a more appropriate use of antibiotics. Its impact on patients and health systems could be enormous. As noted in the latest re-

port of the review on antimicrobial resistance (AMR) led by Lord Jim O’Neill, rapid diagnostics can revolutionise the treatment of infections, by making antibiotic prescribing more targeted and therefore more effective and less likely to generate resistance, increasing significantly the chances of reducing AMR. Professor Jonathan Cooke, visiting professor of infectious diseases at Imperial College, London and the University of

Manchester, says: “The technology and the evidence is there. We need to promote its use among healthcare professionals and other stakeholders, including policy makers. European countries where POC CRP testing is implemented widely, such as the Netherlands, Germany, Denmark, Norway and Sweden, have lower rates of GP antibiotic prescribing than Britain. What’s more, the test is associated with a high degree of patient satisfaction with

Helping to reduce unnecessary antibiotic prescribing in primary care.

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ANTIBIOTIC PRESCRIPTIONS IN ENGLAND This heat map shows the number of antibiotic prescriptions per head for the year to July 2015 prescribed in England by GPs, grouped by LSOA region. The information was released by the Government’s Health and Social Care Information Centre using data sourced from the NHS Business Services Authority. The source data contains 602 million rows and was analysed by analytic database provider EXASOL for Antibiotic Research UK. Hotspots in rural communities can be attributed to high prescribing by a single practice

The Lincolnshire and Norfolk coast has the highest prescription rates in England Clacton-on-Sea is the UK’s most deprived area Prescriptions are almost twice the national average

London prescribes 21% fewer antibiotics than the North

TOTAL ANTIBIOTIC PRESCRIPTIONS*

2011

36.8 million

2012

37.8 million

2013

37.9 million

2014

36.8 million

2015

36.5 million

*Year end 31st July

˦ǍǺ Ǐ ˰Ǎǰ Ǐ ˱Ǎǯ Ǐ ˦ǍǺ Ǐ ˣǍǽ Ǐ

AVERAGE ANTIBIOTIC PRESCRIPTIONS PER HEAD PER ANNUM Isle of Wight prescribes 15% more anitibiotics than the average in the South

London

0.52

North

0.67

;Ǎ͖ Ǐ ДǍʶ Ǐ

Midlands & East 0.65 South

0.63

ЀǍ˔ Ǐ ϬǍ˨ Ǐ

Data source: NHS Business Services Authority; Data analysis: EXASOL; Published: November 2015

the consultation due to quicker, more certain diagnoses, even when no antibiotic is prescribed.”

Massive reductions “In the UK, GPs prescribe around 80 per cent of all antibiotics, about half of which is for respiratory tract infections (RTIs). There is evidence from randomised trials that POC CRP could reduce antibiotic prescriptions by up to a massive 42 per cent,” says Professor Cooke. According to the Straight to the Point

report, published in June by a multidisciplinary panel of leading experts, this could mean up to 10 million fewer antibiotic prescriptions per year, saving the NHS £56 million annually. Respiratory tract infections such as colds, coughs and sore throats are typically caused by viruses, against which antibiotics don’t work. Yet a 2014 study in BMJ Open found that most general practices in the UK prescribe antibiotics to up to 80 per cent of adult patients who present

Professor Jonathan Cooke Visiting professor in infectious diseases, Imperial College, London and University of Manchester

Point of care C-Reactive protein (CRP) testing has been shown to reduce unnecessary antibiotic prescriptions by up to 42% and is recommended by NICE for people presenting with symptoms of lower respiratory tract infection.1 Alere Afinion™ CRP is a simple to use, point of care test for CRP which provides actionable results within 4 minutes from a fingerstick sample.

Visit alere.com for more information 1. Cooke, J. et al. Narrative review of primary care point of care testing (POCT) and antibacterial use in respiratory tract infection (RTI). BMJ Open Resp Res 2015;2:e000086. doi:10.1136/bmjresp-2015-000086. © 2015 Alere. All rights reserved. The Alere Logo, Alere, Afinion and Knowing now matters are trademarks of the Alere groups of companies. GB00332-01 07/15

with a respiratory infection, including the common cold. “There are initiatives to widen the use of POC CRP testing, including financial rewards for Clinical Commissioning Groups if their GPs reduce antibiotic prescribing,” explains Professor Cooke. “The Care Quality Commission is also monitoring the intensity of antibiotic prescribing, and you can see that there is quite a range across the UK, with some practices prescribing very high levels of

antibiotics, including those that can cause resistance.” Both Public Health England and the National Institute for Health and Care Excellence (NICE) endorse POC CRP testing in primary care, to improve diagnostic precision right at the point of prescribing and reduce the burden of drug resistance. Professor Cooke concludes: “It is a very important system, with the potential to reduce unnecessary antibiotic prescribing and make a difference in the future of healthcare.”

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INSPIRATION

COLUMN

The spread of drug-resistant bacteria

Few bacteria are drug-resistant Antibiotic exposure increases numbers of drug-resistant bacteria Drug-resistant genes passed to some ‘sister’ bacteria as well as to ‘daughter’ bacteria

Mutation on chromosome gives drug-resistance which is passed to ‘daughter’ bacteria

Source: Nonmedical Uses of Antibiotics: Time to Restrict Their Use? Richard William Meek, Hrushi Vyas, Laura Jane Violet Piddock, Institute of Microbiology and Infection, University Of Birmingham

The collective power of action in tackling antimicrobial resistance Antimicrobial resistance (AMR) offers unprecedented threats to global health, a fact both evidenced and undisputed. Arrays of statistics are available to demonstrate its projected impact between today and as far ahead as 2050, and countless stories about so called ‘super-bugs’ have been published over recent years

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uch projections and stories can make for alarming reading and, at first sight, appear to leave little room for hope. However, one may argue that the experience of such adversity and the drive to rise above it are themes that characterise the human condition. Therefore, while combating AMR will be challenging the goals are potentially achievable but will require dramatic changes to practices, attitudes and behaviour across global sectors including human health, veterinary practice, animal husbandry, agriculture, aqua culture, legislative authorities and within society. The task ahead is significant, but it is one laced with hope rather than despair. Over the past decade there has been an awakening amongst political, scientific, medical, commercial, regulatory, philanthropic and public sectors. There is global acknowledgment of the critical need for action. There is evidence of widespread and growing action to identify and implement sustainable solutions to contain and minimise the collateral damage that antibiotic resistance causes. Interest and actions

extend beyond human medicine. This is demonstrated by the global One Health Initiative which is dedicated to improving the lives of all species—human and animal—through the integration of human medicine, veterinary medicine and environmental science.

Global priority AMR now sits alongside climate change and terrorism on the Global Risk Register. The World Health Organisation Strategic Action Plan on AMR is supported by no less than 14 global, regional and national strategies across all continents, including the UK 5 Year Antimicrobial Resistance Strategy 2013 to 2018. Numerous changes in legislation have been introduced. The GAIN Act in the USA facilitates accelerated approval processes for bringing new antibiotics to market more quickly to ensure we have effective antibiotics to treat resistant infections. In India the Drugs and Cosmetics Act 1940 was amended to prohibit, from 1 March 2014, the direct sale of antibiotics to the public in an effort to halt excessive, unnecessary use.

These and others are all starting points. Governments worldwide have had to set ambitious targets and have outlined key policies to combat resistance. The UK 5-Year Antimicrobial Strategy identifies seven key areas for action, from improving infection prevention and control practices in healthcare facilities to improving professional education, training and public engagement. The biggest challenge governments face moving forward is translating policy into practices that lead to improvements in drug research and development, infection prevention and control practices, antibiotic prescribing practices and professional and public education and understanding. This cannot be done alone and society must harness the resources it has, and governments must work with those who are already active in the field to deliver their targets and achieve the changes that are needed. Engagement and harnessing the active support of the public and healthcare professionals with expertise in this area is a key driver for success. One such resource is the professional medical charity sector,

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UK 5-YEAR AMR STRATEGY AND THE BRITISH SOCIETY OF ANTIMICROBIAL CHEMOTHERAPY’S CONTRIBUTION

KEY AREA 1

KEY AREA 2

KEY AREA 3

KEY AREA 4

KEY AREA 5

KEY AREA 6

KEY AREA 7

IMPROVING INFECTION PREVENTION AND CONTROL PRACTICES

OPTIMISING PRESCRIBING PRACTICE

IMPROVING PROFESSIONAL EDUCATION, TRAINING AND PUBLIC ENGAGEMENT

DEVELOPING NEW DRUGS, TREATMENTS AND DIAGNOSTICS

BETTER ACCESS TO AND USE OF SURVEILLANCE DATA

BETTER IDENTIFICATION AND PRIORITISATION OF AMR RESEARCH NEEDS

STRENGTHENED INTERNATIONAL COLLABORATION

Align the Infection Control and Stewardship Agenda

Collaborative Multi-disciplinary Working

Collaborative Multi-disciplinary Working

Collaborative Multi-disciplinary Working

Collaborative Multi-disciplinary Working

Collaborative Multi-disciplinary Working

Collaborative Multi-disciplinary Working

Measure Infection Rates and Antibiotic Consumption

Expert Conferences, Workshops & Events

Evidence-Based Guideline Development

Expert conferences, Workshops & Events

Evidence-Based Guideline Development

Expert Conferences, Workshops & Events

Evidence-Based Guideline Development

Implement Quality Improvement Agenda and Improvement Science

Professional & Public Education Campaigns Funding Programme Preceptorship Support International Collaborations Data Collection Systems to Measure Antibiotic Use National Sentinel Surveillance Programme National Susceptibility Testing Methodology Advisory Role to Government Quality Improvement / Behavioural Science

Professional & Public Education Campaigns

Expert Conferences, Workshops & Events

Antibiotic Action Funding Programme

Professional & Public Education Campaigns

Expert Conferences, Workshops & Events

Advisory Role to Government

International Collaborations

International Collaborations

National Sentinel Surveillance Programme

International Collaborations

Data Collection Systems to Measure Antibiotic Use

Advisory Role to Government Quality Improvement / Behavioural Science

National Sentinel Surveillance Programme

Advisory Role to Government

National Susceptibility Testing Methodology

Provision of Research Grants

Advisory Role to Government

Collaboration with Industry

Development of an online resource for Antimicrobial Resistance arc.com

Expert Conferences, Workshops & Events

Antibiotic Action Funding Programme Preceptorship Support

International Collaborations

Preceptorship Support

Professional & Public Education Campaigns

National Susceptibility Testing Methodology

Professional & Public Education Campaigns Antibiotic Action Preceptorship Support International Collaborations Data Collection Systems to Measure Antibiotic Use Advisory Role to Government

Supporting out of Hospital Treatment Programmes

organisations such as the British Society for Antimicrobial Chemotherapy (BSAC) who, through the expertise and dedication of its professional members is able to offer significant contributions and solutions to tacking AMR. The Society has, amongst a broad portfolio of activities, funded over £4.1 million in research, operates national programmes to measure antibiotic resistance and developed software to measure how many antibiotics are prescribed and to help improve prescribing and patient outcomes. In 2011 BSAC appointed its first Chair in Public Engagement, Professor Laura Piddock, Professor of Microbiology at the University of Birmingham. She also serves as Director of Antibiotic Action, a BSAC initiative which championed the establishment of the All Party Parliamentary Group on Antibiotics, chaired by Zac Goldsmith MP. BSAC partnered with the University of Dundee and FutureLearn to deliver the first global course on antimicrobial stewardship, providing access to free education on prescribing to all health economies internationally. The Society has a long-standing reputation for

developing good quality and pragmatic evidence-based guidelines but has also recognised the need to implement core practice more effectively within the “real world healthcare setting”. Led by Professor Peter Davey, a previous President, the society is at the forefront of embracing the use of improvement and social sciences in the context of AMR. The Society was the first charitable body of its kind to partner on an EU Innovative Medicines Initiative project – DRIVE-AB, a multi-disciplinary, pan-European project looking for new economic models for antibiotic development.

ABOUT BSAC The British Society for Antimicrobial Chemotherapy is an inter-professional organisation with over 40 years of experience, achievement and leadership in: Tracey Guise Chief executive officer, British society for antimicrobial chemotherapy

• Promoting the extensive and pivotal role of antibiotic therapies in improving patient outcomes in modern medicine. • Combating the harmful clinical and economic impact of antimicrobial resistance through its core activities of supporting antimicrobial stewardship, surveillance, informatics and new treatment for infections. Fig 1: Federation of Infection Societies British HIV Association, British Infection Association, British Paediatric Allergy, Immunology & Infection Group, British Society for Antimicrobial Chemotherapy, British Society for Medical Mycology, Central Sterilising Club, Clinical Virology Network, Healthcare Infection Society, Infection Prevention Society, Microbiology Society, Scottish Medical Mycology Group, Society for Anaerobic Microbiology, The Children’s HIV Association, The National Travel Health Network and Centre, United Kingdom Clinical Pharmacy Association Infection Management Group, Welsh Microbiological Association

Utilising resources BSAC is just one of many such professional bodies in the infection management arena, many of whom belong to the Federation of Infection Society Fig 1, an overarching body that meets annually to share its collective expertise and wisdom. Through such societies, both within the UK and globally, there is a wealth of resources and opportunity to tackle the problem of AMR and improve patient care and outcomes. Unfortunately, in many instances the

Professor Dilip Nathwani OBE President, British society for antimicrobial chemotherapy and consultant physician and honorary professor of infection, Ninewells hospital, Dundee

Read more at globalhealth action.co.uk

inability of such human and capital resource to come together towards a common goal either through lack of awareness, leadership, co-ordination or the lack of desire or ambition to adapt and adopt has led to waste and often lost opportunity. New ways are needed to align the work of professional organisations from diverse geographical and resource settings with that of health administrations, government organisations supporting health and

innovation and other stakeholders nationally and internationally to accelerate the pace of change and meeting the challenges of the global AMR agenda. We believe harnessing professional engagement through societies such as BSAC globally has a significant role in our ability to provide the cohesive professional response we need. This editorial aims to highlight what we do but more importantly what we can do together.

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INSPIRATION

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COLUMN

Nancy W Mendoza Communications specialist, Society for applied microbiology

We need new antibiotics, but that’s not all…

A

large number and variety of diseases and infections are caused by microbes, from ‘flu to athlete’s foot, malaria, and tuberculosis. Since the mid 20th century antimicrobial medicines have been developed to kill many of the viruses, fungi, protozoa and bacteria that make us ill. Inevitably, microbes are becoming increasingly resistant to our arsenal of antimicrobials, not least because of how we over use these life-saving medicines. We need new medicines as well as a better understanding of why, how and where resistance to antimicrobials develops; we need to be able to rapidly detect infection and find the best treatment options, as well as investigating alternatives to current antimicrobials. This requires research into the biology, chemistry, pharmacology and genetics of microbes, and observing how microbes behave in different environments such as the human gut, on farms, and in water treatment plants and hospitals. New diagnostics are needed to rapidly detect causes of infection and ensure patients are given effective and appropriate medicines. To this end, a group of learned societies – the Learned Society Partnership on Antimicrobial Resistance (LeSPAR) – is looking to find suggestions and solutions from among their collective community of 75,000 researchers and beyond. LeSPAR aims to provide a single, unified voice and mobilise the UK’s collective research community in order to enhance understanding and knowledge-sharing between academia, industry and clinicians. The group is focused on taking action, championing best practice and raising awareness of the global challenge of antimicrobial resistance by: Supporting researchers in creating, sharing and applying knowledge. Organising focused events to enable networking and knowledge exchange, and to promote effective collaborations across disciplines and sectors. Engaging with government and other funders to achieve policy and funding support for the antimicrobial research community and connecting expertise from our membership to policy makers. Assembling information on relevant resources and meetings. LeSPAR comprises: Biochemical Society; British Society for Antimicrobial Chemotherapy; British Pharmacological Society; Royal Society of Chemistry; Society for Applied Microbiology; Microbiology Society; Society of Biology

The Reducing AMR in Indian Hospitals project will make recommendations for a training framework

Breaking barriers: Beating antibiotic resistance in India through innovation and sustainable change In what is deemed a landmark moment, a consortium of UK-India health professionals have been awarded funding for the first health project to be supported under the UK FCO’s Prosperity Fund, in India

The UK Foreign & Commonwealth Office Prosperity Fund is a dedicated annual fund supporting prosperity work overseas. Through targeted projects, it aims to support the conditions for global and UK growth: openness, sustainability, opportunity and reputation. Led by the British Society for Antimicrobial Chemotherapy (BSAC) and leading physicians in India, the project Reducing Antimicrobial Resistance in Indian Hospitals in support of the PM’s Global Campaign against AMR will help implement in India the UK government’s International Strategy on tackling AMR. The project will work with a range of public and private hospitals to define and make recommendations for an educational training framework that is expected to support development and implementation of interventions that will improve effective prescribing, and reduce antibiotic resistance rates across India.

Dr Himangi Bhardwaj Senior health adviser, British high commission, India

Professor Dilip Nathwani OBE President of BSAC

Speaking about the project Dr Himangi Bhardwaj, Senior health adviser, British high commission said: “We are delighted to learn about this project being commissioned in the health sector, especially on such a high profile and important topic. This underlines the importance of health to global and UK prosperity.

Antimicrobial stewardship has been identified as a key intervention in combating AMR by the World Health Organisation and is the top recommendation of the Chennai Declaration against AMR published in 2012 in India.” She continued: “We expect this project to deliver a much needed blueprint for the development and implementation of a national framework for locally relevant training that will support existing or new stewardship activity within Indian hospital settings. Such training is needed in what is a diverse and challenging landscape.” Professor Dilip Nathwani OBE, President of BSAC, responded by saying: “Our Society is both delighted and feels privileged to be working with leaders across India to deliver this, the first health-related project, under the UK FCO’s Prosperity Fund, in India. The project builds on the work we are already doing in India and the Gulf Region to share expertise and facilitate training in antimicrobial stewardship. It offers a real opportunity to demonstrate what collaborative, innovative working can achieve in a short space of time.” The project, which commenced in October 2015, will deliver its results and reports to the British High Commission in March 2016.

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Class action. Education about antibiotic resistance should start in the classroom

Raising awareness around antibiotic resistance through grassroots education initiatives Antibiotic Action Antibiotic Action is an independent UK-led global initiative wholly funded by the British Society for Antimicrobial Chemotherapy (BSAC). Antibiotic Action seeks to inform and educate all about the need for discovery, research and development of new treatments for bacterial infections. It is vital to the health of all nations that antibiotics remain the mainstay of modern medicine and are available to all who need them. YOU CAN HELP BY BECOMING AN ANTIBIOTIC ACTION CHAMPION – find out how by visiting antibiotic-action.com

Global education for all

Free online course: Antimicrobial Stewardship: Managing Antibiotic Resistance: bit.ly/1BwCErB

Massive Open Online Course on Antimicrobial Stewardship While designed for healthcare professionals this free course is of value to anyone wishing to learn more about antibiotic resistance, what antimicrobial stewardship is and how it can be implemented to tackle antibiotic resistance. The intention of the course is to stimulate and encourage further inquiry and learning in this important area.

REGISTER NOW! Next course opens Monday 8 February 2016

Antibiotic Resistance and You FREE TO ATTEND | Two events from Public Health England Birmingham: Wednesday 2 Dec 2015 | London: Wednesday 24 Feb 2016 Antibiotic resistance affects you, but do you know how? Come and join the discussion on how we can work together to combat antibiotic resistance! Find out what antibiotic resistance really means to you and your family by attending one of our events. These free events will: REGISTER NOW! bit.ly/1iX6qxd or email: [email protected] with your name and contact details

Educate you about the causes of antibiotic resistance and why it is a threat. Inform you about what you can do to help solve this problem by taking simple, everyday steps. Explain the roles and responsibilities of the government, policy makers, and healthcare professionals in tackling this problem. Show you how you can join the fight against antibiotic resistance. Allow you to contribute to the debate about antibiotic resistance and to the solution.

DRIVE-AB DRIVE-AB is a €9.4 million public–private consortium, funded by the EU Innovative Medicines Initiative, that aims to define a standard for the responsible use of antibiotics and to develop, test and recommend new economic models to incentivize investment in producing new anti-infective agents. Comprising 16 public and seven private partners from 12 countries the project is a joint undertaking between the European Union and the European Pharmaceutical Industry Association (EFPIA). For further information visit drive-ab.eu

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NEWS

DIAGNOSTICS

New rapid diagnostics would optimise treatment Sick patient

Doctor

Empirical diganosis

Traditional diagnostic test

Treatment may fail: second empirical Optimal treatment delayed prescription

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New, modern tools are needed to aid in the decision-making process of prescribing antibiotics

Optimal treatment may never be achieved

Rapid diagnostic test

OPTIMAL TREATMENT REACHED QUICKLY Source: AMR Review

THE FUTURE

Action is needed to minimise the economic impact of AMR Antibiotic resistance is not inevitable but will require collaboration By Lorena Tonarelli

T What are we doing to help #savemodernmedicine? We’re tackling antibiotic drug resistance by: Taking steps to prevent people getting infections in the first place Giving doctors the tools they need to make good antibiotics-prescribing decisions Raising awareness among the public of what illness antibiotics can and can’t treat Working with scientists to develop new treatments Raising the issue on a global level to find worldwide solutions

What can you do? Sign up to be an antibiotic guardian: antibioticguardian.com #AntibioticAwarenessWeek

he threat posed by antimicrobial resistance (AMR) is virtually global. “If no action is taken, 35 years from now we could have 10 million more people dying every year globally due to AMR – more than 10 times the number of AMR-related deaths occurring today,” says Lord Jim O’Neill, Commercial Secretary to the Treasury. “The increased mortality would substantially reduce the size of the workforce, resulting in a loss of global economic output of $100 trillion by 2050 – a huge cost to society.”

Improving surveillance “A major challenge is that the available data on resistance are not particularly good,” adds Lord O’Neill. “So anything we say about present and future economic consequences, we must bear in mind that we need better surveillance.” The government is already pursuing this. In March, it launched the £195 million Fleming Fund, which aims to improve surveillance networks for drug-resistant infections in developing nations.

Moving forwards Lord O’Neill was appointed by the government to lead an independent review that looks at the impact of AMR on the world’s health and economy. The review, which has published so far a series of four interim reports, identifies possible strategies to avoid a global crisis. Amongst the key recommendations

is the need to boost the development of new antimicrobial agents. There are three key steps to take in this regard, says Lord O’Neill. “Firstly, we need to encourage more postgraduate research on drug resistance. It is quite striking how few people work in this field of medical research. Secondly, we proposed in May the creation of a $2 billion global fund to help organisations pay for early-stage research related to the development of new antibiotics. “Thirdly, we recommend providing financial incentives for the production of 15 new antimicrobial drugs every 10 years, which our analysis suggests would be useful in ensuring an adequate supply of antimicrobials for future generations.”

“We need to encourage more postgraduate research on drug resistance”

Using antimicrobials wisely While developing new drugs is paramount, it is unrealistic to think that this alone can help minimise the global human and economic impact of drug resistance. As Lord O’Neill notes, it’s just as crucial to reduce the misuse of antimicrobials, particularly antibiotics. He highlights four ways to achieve this: encouraging people to wash their hands frequently to stop the spread of infections; developing global awareness campaigns that educate the public on the dangers of misusing antibiotics; promoting innovation in diagnostics to ensure appropriate prescribing, for example by providing physicians with new, modern tools that can inform their decision as to whether or not

to prescribe antibiotics to patients; and increasing the use of alternative therapies, especially vaccines. The last point is of particular importance, says Lord O’Neill, “because if we can develop effective vaccines for illnesses we take antibiotics for, then we wouldn’t need the latter.”

Global commitment How can we ensure that the above strategies are implemented and stay in place? Lord O’Neill says we need more analyses that look at the macroeconomic consequences of AMR, and to make sure that they are influential at a global level. He adds: “In line with this, we are actively pushing for a United Nations agreement, in September 2016, whereby all UN countries agree to fundamental changes, with regard to both antibiotic usage and interventions to boost the supply of new drugs. In addition, and crucially I hope, we are trying to encourage China to place antimicrobial resistance as a priority on the G20, which the country will chair next year.”

Not inevitable

Lord Jim O’Neill Chairman of the Review of antimicrobial resistance and commercial secretary to the Treasury

According to Lord O’Neill, we can avoid the economic cost of drug-resistant infections, and a return to the dark age of medicine, when antibiotics didn’t exist. Central to this is a collaborative effort to develop new drugs and diagnostics and to reduce drug misuse through improved awareness, prevention and vaccine use.



Antibiotic Guardian Challenge Crossword





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 Across 3 Veterinarians may prescribe antibiotics to these (7) 5 Antibiotics will most commonly be given to adults in these forms (7) 6 This type infectious agent will cause the common cold, coughs and the flu (5) 9 Medicine used to help treat fungal infections (10) 11/ As an Antibiotic _11_, my actions help _19_ antibiotics for 19 the children of tomorrow (8,7) 16 The main immune system cells for defending against bacterial infections (3 words: 5,5,5) 17 Antibiotics will most commonly be given to children in this form (5) 18 You require one of these for antibiotics (12) 20 These medicines should be used as prescribed and only when needed for bacterial infections (11) 22 Main professional group that administer and may prescribe antibiotics (5) 24 This infectious agent includes yeasts and moulds (6) 25 When the antimicrobials are no longer effective the microbes have developed this (10) 27 You often generate more of this when you have a cough, cold or flu and ranges in colour from yellow to green (6) 29 Professional who may prescribe antibiotics for humans (6) 30 Clean your hands to prevent the spread of these (5) 31 Medicine used to treat viral infections (9)



Down 1 You can get a vaccination jab against this viral seasonal illness (3) 2 When you have a viral illness you should consume lots of this (6) 4 Your body’s natural defence system against infections (2 words: 6,6) 7 A common symptom of coughs, colds and flus (2 words: 4,5) 8 Runs from your nose, especially when sick with a viral infection (4) 10 This term covers antibiotics, antivirals and antifungals (13) 12 When you are ill and can make others ill with the same bug you are ______ (10) 13 A viral infection that causes sore throat and runny nose (4) 14 When you have a cough, cold or flu you should ask your pharmacist how to treat your _______(8) 15 Professional who may prescribe antibiotics for animals (12) 19 The first antibiotic discovered (10) 21 Taking antibiotics unnecessarily can lead to ______ such as diarrhoea (2 words: 4,7) 23 Ask this healthcare professional which over-the-counter medicines are best to treat your symptoms (10) 26 Misuse of antibiotics allows _____ to develop resistance (8) 28 Often a symptom of a respiratory tract infections caused by viruses (5) 

Get your answers on globalhealthaction.co.uk