Antimicrobial resistance
“The problem with this system is that you need extremely complex models, at the moment, to determine the value of antibiotics and, therefore, their contract value,” commented Prof. Wilcox. The models break down antibiotics into the so-called STEDI principles: Spectrum: Benefits of being able to treat with a narrow-spectrum agent in some settings. Transmission: Benefits from avoiding the spread of infection. Enablement: Benefits from making it safe to receive medical care. Diversity: Using varied antibiotics reduces resistance pressure. Insurance: Value of having to hand, in case of sudden need.
“Going through each of these and reviewing the data is very time-consuming,” Prof. Wilcox commented, adding that the framework for value assessment of new antimicrobials is 174 pages long. As we move forward, in awarding ‘volume-
divorced contracts’ for antibiotics, based on their value, a new system is needed. A consultation was underway, at the time of the presentation, on a ‘system two’ scoring system. You can see the new award categories for
antimicrobial evaluation in Figure 1. “It is hoped that this approach will drive the
evidence base that new antibiotics come to the market with, so that they can be scored, and their value measured accurately,” Prof. Wilcox explained. Moving on, he outlined why ‘diversity
matters’ when it comes to antibiotics and highlighted a systematic review of various studies that suggest that “at low levels of baseline resistance, ‘clinical cycling’ of different antibiotics reduced the total incidence of resistant infections substantially.” “We still rely too heavily on a small number
of antibiotics,” he pointed out – highlighting some key findings from the English surveillance programme for antimicrobial utilisation and resistance (ESPAUR). The 2014 report found that 66 antibiotics were prescribed across general practice and hospitals in England, yet just 3 penicillins account for 44% of all antibiotic use in hospitals. A lack of diversity of antibiotic prescribing is driving resistance. Prof. Wilcox commented that computer-
assisted decision-making could help develop smarter ways of driving diverse antibiotic prescribing. He added that there is a lot we can already do to tackle the problem of antibiotic resistance – from antibiotic duration, and
dosage, to de-escalation. “The evidence shows that shorter duration of
antibiotics is as good as longer duration and, of course, shorter duration will be associated with less selection pressure for resistance. There are some exceptions, but we should be acting on the evidence that is available,” he concluded.
Underdosing of antibiotics Another key theme explored at the two-day IPC conference was the risk posed by underdosing of antibiotics, which results in bacteria being exposed to sub-therapeutic concentrations. This is a key factor in driving resistance, warned Ruth Dando, Head of Nursing Theatres, Critical Care and Anaesthetics, at Barking Havering and Redbridge University Hospitals Trust. She commented that failure to ensure the full dose of an intravenous antibiotic administration leads to treatment failure as a direct worst case scenario, with longer term dangerous consequences through AMR and the development of drug resistance infections. She explained under dosing occurs as a
result of residual fluid, containing the active drug, remaining trapped in the tubing of administration sets, which is disposed of at the end of the infusion and not administered to the patient. Between 20% and 40% of the dose may be subsequently lost. With 1 in 3 NHS patients being on antimicrobials at any given time, every wasted dose has an associated cost, which can quickly accumulate into substantial financial losses. She went on to highlight the role of flushing.
When referencing line flushing in relation to residual volume of antibiotics, it is important to highlight that this relates to the need to flush the administration set tubing (including the drip chamber), she explained. This is the only way that the full dose will be delivered. Often it is thought that this routinely happens, but this is usually referencing flushing the needle- free extension (octopus) or vascular access device, further downstream, which is routine in clinical practice. She emphasised that this does not produce the same results and leads to underdosing. She added that underdosing can be seen as a double-edged sword as incorrect disposal of remnants of antibiotics in unflushed lines contributes to environmental contamination, which is regarded as a strong driver of antimicrobial resistance. “When I first started my career in nursing,
Figure 1: Award categories and criteria for antimicrobial evaluation, Source: NHS England 20
www.clinicalservicesjournal.com I November 2024
many things were different, including the way we delivered antibiotics and intravenous fluids and medication - we used a Burrette system. This enabled the line to be rinsed after the infusion, ensuring the patient received the total prescribed
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