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Preparation for a post-antibiotic era must start now


Attitudes towards infection control throughout the NHS have witnessed a profound cultural shift over the past five years.

This has gone from a general acceptance that, for a host of reasons, the vast majority of healthcare associated infections (HCAIs) were unavoidable, to an awareness that this is not so and a belief that accessing healthcare is not necessarily linked to acquiring an infection.

This emerging attitude also maintains that preventing exposure to infections isn’t the sole responsibility of the infection control team but is a component of all healthcare practice. It is now widely accepted that infection prevention is the proper business of each and every one of the 1.3 million people employed in both clinical and non-clinical roles in the NHS. They are all accountable for ensuring that patients, visitors and other employees are kept safe and are not exposed to infection.

We no longer feel it is sensible or acceptable to assume only 10-15 per cent of HCAIs can be prevented. We now aim higher, to where we accept that only a very small proportion of HCAIs are unavoidable.

The Department of Health’s Towards Cleaner Hospitals and Lower Rates of Infection programme has played a seminal role in bringing about this transformation. In NHS trusts where this new attitude is growing strong, there is a bounce among practitioners as they witness the successes of this programme in reducing MRSA and C difficile infections.

Spurred on to even greater efforts to improve hospital cleanliness and adherence to hand hygiene, and with the implementation of a constellation of evidence based infection prevention and control measures, it really does seem like the NHS has turned a corner and is now winning its struggle against infection.

This battle is far from won, however, and it is becoming increasingly difficult to keep chipping away at the prevalence of HCAIs. In the EU, more than 4.5 million people acquire an HCAI every year, 37,000 of whom die as a direct result. The cost of treating these infections is enormous and, as this annual rate of infection results in 16 million extra days of hospitalisation, the impact on healthcare systems is severe.

In England, an estimated 300,000 patients acquire an HCAI each year, costing more than £1bn - equivalent to the annual running costs of eight NHS hospitals. In addition, infections cost the NHS massive reputational damage.

Although HCAIs are associated with serious disability and death, most patients who acquire one are effectively treated with antibiotic therapy and recover. Storm clouds are gathering, however, as an increasing number of bacteria are becoming resistant to the antibiotics used to treat these infections.

Antimicrobial resistance is not new. Within just a few years after it came into use to treat serious staphylococcal infections in the 1940s, benzylpenicillin was rendered almost useless, as a virulent penicillin resistant strain of Staphylococcus aureus spread in the 1950s throughout hospitals and communities in many countries throughout the world.

With no other antibiotics then available to treat this resistant strain, salvation from this contagious onslaught was slow. After almost a decade of terrible vulnerability, new antibiotics engineered to destroy this resistant strain were introduced in the 1960s and brought it under control.

This was a sharp and frightening reminder to a world newly accustomed to antibiotic protection that mutating and recombining micro-organisms, resistant to antimicrobials, would constantly emerge.

Since this first experience with antimicrobial resistance, there have been many serious outbreaks throughout the world from a range of resistant bacteria that cause serious HCAIs.

Although an increasing number of micro-organisms are developing resistance, the number of antimicrobials in the pipeline for multidrug resistant pathogens is decreasing - and a pandemic may be gathering. Recent studies have identified patients in India, Pakistan and the UK who have become infected with new strains of Gram negative bacteria belonging to the family Enterobacteriaceac, such as Escherichia coli and Klebsiella pneumoniae. They contain a new gene known as NDM-1, which makes them resistant to the group of powerful antibiotics that are reserved for the treatment of patients with serious HCAIs and other infections caused by multidrug resistant Gram negative bacteria.

When these antibiotics fail, there is nothing left and the only hope is that the patient’s immune system will be strong enough to allow recovery. Even more frightening is that the NDM-1 gene can and does easily jump from one member of this large bacterial family to another, making them equally resistant to these last line antibiotics.

If antibiotic treatment fails on a grand scale because of the extreme antimicrobial resistance, the only protection left in a post antibiotic era will be the highest imaginable quality of evidence based infection prevention and control practice. Anticipating any eventuality, it’s time we all upped our game and moved quickly to a higher level of excellence in practice.

Robert Pratt is emeritus professor of nursing, Richard Wells Research Centre, Thames Valley University


Readers' comments (6)

  • Is it not possible that the current trend toward 'Superhospitals' is contributing to our problems?
    Even if hospital staff are spot-on with their infection control, patient visitors very often go onto the ward either before or after visiting the shopping mall in these hospitals, coming into contact with each other and passing infections on.
    In the past, infection control was easier because healthcare for an area was spread across three or four hospitals and if one of them had an outbreak it was isolated while the others took the strain.
    With the single superhospital for an area this is no longer possible.
    Maybe we should look again at what backup we have and possibly reintroduce specialist Infectious Diseases hospitals for highly contagious patients?

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  • At the same time as the 'upped game and quick move to a higher level of excellence in practice' as recommended by Robert Pratt, the wider world of the 'general public' needs to be enthused somehow into upping THEIR preparations for a post-antibiotic era. How this is to be achieved remains to be seen, but excellent hand hygiene would be a start. (Where was it that supermarket trolley handles were found to be contaminated with several types of potentially harmful bacteria.....?)

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  • not gonna change until people and professionals consider people's susceptibility. its not just about the bugs

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  • why does the photograph show someone using a bar of soap when this is contrary to handwashing policies?
    (sorry, couldn't resist the opportunity to be pedantic!)

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  • Richard White

    The post-antibiotic era will require changes to attitudes, practices and knowledge. One aspect that must be embraced is the appropriate use of antiseptics.

    We have been aware of the 'crisis' of antibiotic resistance for decades! Yes, decades. Whilst physicians and surgeons appear to have been the main culprits, the solution lies in the hands of all heathcare professionals. I really would like to see the nursing profession lead the way forward with this vital initiative.

    Richard White.

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  • Richard...

    Further to physicians and surgeons being the culprits. May I add, inapropriate Gp prescibing over decades and patients not completing their course. All of which have contributed to resistance.

    Thank you for a very thought provoking article. I do hope the nursing profession reads it, takes "the bull by the horns" and leads the way forward.

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