In this century, one of the most serious threats to public health is the increasing levels of antibiotic resistance worldwide. It was revealed in the latest report released by the World Health Organisation (2018) based on the new data gathered by the Global Antimicrobial Resistance Surveillance System earlier this year. According to the World Health Organisation (2015), antimicrobial resistance (AMR) refers to the ability of microbes to resist the effect of the drug from working against it. Antimicrobial resistance occurs when a microbe changes in a way that reduces or eliminates the effects of drugs, chemicals or other agents designed to cure or prevent infections. There are many ways in which bacteria develop resistance to antimicrobial agent such as developing an ability to neutralise the antibiotic, using efflux systems to prevent the drug from reaching its intracellular target, modifying the drug’s target site, producing an alternative metabolic pathway to bypass the action of the drug, acquiring resistance through genetic mutation or by acquiring resistance genes from other organisms (Tenover, 2006). As a result, standard medical treatments become inefficacious and infections persist, increasing the risk of spread to others. Over the previous years, the overuse, underuse, and misuse of antimicrobials increased the number and strains of resistant organisms. Notable examples include methicillin-resistant Staphylococcus aureus (MRSA) or the golden staph, Neisseria gonorrhoea, vancomycin-resistant Enterococcus (VRE), multi-drug-resistant Mycobacterium tuberculosis (MDR-TB) and carbapenem-resistant Enterobacteriaceae (CRE) gut bacteria (World Health Organisation, 2015).
Fig. 1. How Antibiotic Resistance Happens
From “Antibiotic/ Antimicrobial Resistance” by CDC, 2015 (https://www.cdc.gov/drugresistance/about.html)
Antimicrobial resistance is a major public health problem brought about by the inappropriate use of antibiotics. It poses a serious challenge to the health care system, not only because of the disease burden that comes with it but also because of its economic implications. The previously treatable infectious diseases may become incurable or more difficult to treat causing patients’ greater susceptibility to infections and the need to use more medications with serious adverse effects. The success of major surgery and cancer chemotherapy would be compromised without the availability of effective antibiotics. Furthermore, AMR leads to prolonged hospital stay, increased mortality, high risk of spread of the infection and increased medical costs due to longer duration of illness, additional tests and use of more expensive drugs (Australian Commission on Safety and Quality in Health Care, 2017; World Health Organisation, 2018).
In 2017, the data collected by the Antimicrobial Use and Resistance in Australia (AURA) surveillance program provided a comprehensive and integrated overview of the patterns and trends of AMR and antimicrobial use throughout Australia. In the community, high use of antibiotics was noted in 45% of the Australian population was supplied by at least one systemic antibiotic through the Pharmaceutical Benefits Scheme/Repatriation Pharmaceutical Benefits Scheme between the 1st of January and 31st of December 2015. Many antimicrobial prescriptions are unnecessary because antimicrobials are frequently used to treat infections for which they provide little or no benefit. Among the member countries of the Organisation for Economic Co-operation and Development, Australia’s antimicrobial prescribing rate is the eighth highest. In the hospital setting, the use of antibiotics has continued to decline since the peak usage rate in 2010 but there was a 2.1% decrease in 2015 compared with 2014. In 2015, among the participating facilities in the National Antimicrobial Prescribing Survey (NAPS), 21.9% of the hospital prescriptions were assessed as inappropriate, and 23.3% were non-compliant with guidelines, compared with 23.0% and 24.3% respectively in 2014. Additionally, in the context of surgical prophylaxis and pneumonia, almost 40% of cefalexin prescriptions were inappropriate in NAPS contributor hospitals.
Resistant microbes spread easily in the general community especially in hospitals and aged care homes. A recent document published by Australian Commission on Safety and Quality in Health Care in 2017, provided a summary of the data collected from the passive and targeted AMR programs that contribute to the Antimicrobial Use and Resistance in Australia (AURA) Surveillance System. Key issues identified includes the following: there was a noticeable increase in rates of fluoroquinolone resistance in Escherichia coli from blood cultures and Shigella sonnei between 2014 and 2015; among gram-negative bacteria, rates of resistance in the community remain relatively stable compared with 2014, and are low by world standards; in Enterobacteriaceae, fluoroquinolone-resistant Escherichia coli and extended-spectrum ? lactamase-producing (ESBL) E. coli are an increasing problem in community infections, and such strains are often multidrug-resistant; Australia has one of the highest rates of vancomycin resistance in Enterococcus faecium in the world and it will be extremely challenging to reverse the incidence of VRE in Australia; for Mycobacterium tuberculosis, the overall resistance rates have not changed significantly in the past decade, the rate of multi-drug resistance is low but has been gradually increasing (1.9% in 2015), and extremely drug-resistant strains are occasionally found but remain rare; Community-onset infections caused by strains of MRSA are will likely to fail treatment with the usual ?-lactams used by community practitioners, resulting in hospitalisation for treatment with parenteral antimicrobials, therefore more patients will be treated with vancomycin and related agents, generating increasing selection pressure for other multidrug-resistant pathogens such as VRE; until now, no country has found effective interventions to control the spread of CA-MRSA, hence, effort in this area is considered a priority since it poses a challenge to health care.
The information on the estimated health and economic impact of drug resistance in Australia are limited. The Australian Institute of Health and Welfare released the latest Burden of Disease report in 2016 stating that “infections” caused 1.6% of the total disease burden, measured by disability-adjusted life years. Nonetheless, reports specifically focusing on resistant infections or their impact on the health of the population are lacking. The only published Australian estimates of AUD$250 million per year, to our understanding, are based on international data and are more than a decade old (Wozniak, Graves, ; Barnett, 2018).
In order to combat the antimicrobial resistance crisis worldwide, the World Health Organisation (2015) developed a global action plan on antimicrobial resistance and encourage everyone to act on it with utmost urgency. Its ultimate goal is to ensure, for as long as possible, that there is continuity of the ability to treat and prevent infectious diseases with efficacious and safe medicines that are quality-assured, used responsibly, and that is accessible to all who need them. To accomplish this goal, the global action plan on antimicrobial resistance sets out five strategic objectives: (1) to improve awareness and understanding of antimicrobial resistance by means of effective communication, education and training; (2) to strengthen knowledge and evidence base using surveillance and research; (3) reduction of the occurrence of infection through effective hygiene, sanitation and infection prevention measures; (4) optimization of the use of antimicrobial medicines in human and animal health; and (5) development of the economic case for sustainable investment that takes into consideration the needs of all countries and to encourage more investment in new medicines, diagnostic tools, vaccines and other interventions. Through the implementation of clearly identified actions by Member States, the Secretariat, and international and national partners across multiple sectors, the attainment of these objectives can be observed.
As a response to this global threat, Australia developed its own national strategy and implementation plan both of which align with the current global efforts to curb the effects of antimicrobial resistance. The Australian Government released its first National Antimicrobial Resistance Strategy 2015–2019 (the Strategy) in 2015 with the goal of minimising the development and spread of AMR and ensuring the continued availability of effective antimicrobials. The Strategy supports a One Health approach with seven common objectives across the human and animal health, agriculture, and food sectors namely: (1) to improve awareness and understanding of AMR, its consequences and actions to combat it, through effective communication, education, and training; (2) implementation of effective antimicrobial stewardship practices in human health and animal care settings to establish the appropriate and judicious prescribing, dispensing and administering of antimicrobials; (3) to develop integrated national surveillance; (4) improvement of infection control and prevention practices; (5) to develop a national AMR research agenda and promote investment in research and development of new products and approaches to prevent, detect and contain antimicrobial resistance; (6) to strengthen international partnerships and collaboration on regional and global efforts to respond to antimicrobial resistance; and (7) establishment of clear governance preparations at local, jurisdictional, national and international levels to ensure leadership, participation, and accountability for actions to combat antimicrobial resistance. In November 2016, the Implementation Plan (the Plan) to support the Strategy was released, that of which outlines specific focus areas for action, and includes a stocktake of activities being undertaken by stakeholders that contribute to the achievement of the objectives. In line with this, the Australian Government funded the Australian Commission on Safety and Quality in Health Care in order to establish and coordinate a national surveillance system for Antimicrobial Use and Resistance in Australia (AURA). The suite of reports from AURA 2017 includes data about organisms that have been determined to be a priority for Australia, the volume of antimicrobial use (AU), the appropriateness of antimicrobial prescribing, key emerging issues for antimicrobial resistance (AMR), and a comparison of Australia’s situation with other countries. Also, AURA 2017 provides more comprehensive data and analyses that, together with other AURA reports, better inform strategies to improve prescribing and prevent and contain AMR. Additionally, AURA now includes the National Alert System for Critical Antimicrobial Resistances (CARAlert), which allows the early detection of critical antimicrobial resistances and, over time, will provide information on the effectiveness of measures to promote appropriate AU and contain AMR. Moreover, the Australian government allocated $27 million funding and launched a new online resource for industry and the community, as part of Australia’s ongoing effort to help tackle the rise of AMR (Commonwealth of Australia, 2015; Australian Commission on Safety and Quality in Health Care, 2017)
Healthcare professionals such as pharmacists play an important role in the management and prevention of antimicrobial resistance. In the community setting, pharmacists can educate patients on the proper use and disposal of antibiotics, as well as, provision of safe alternatives to antibiotics, raise awareness about antimicrobial resistance and monitor patient compliance to ensure quality use of medicine. Additionally, pharmacists should encourage vaccination and advice people effective ways to boost their immune system to avoid and prevent the spread of infection. Pharmacists can also give advice on the most suitable use of antibiotics for patients in aged care facilities. In the hospital setting, pharmacists primarily lead the antimicrobial stewardship program. They liaise with other medical health professionals like doctors and nurses to help ensure that they follow the correct guidelines in prescribing and utilization of antibiotics to minimize inappropriate use, thereby controlling antimicrobial resistance.
In conclusion, antimicrobial resistance is a complex problem that requires coordinated action to control its emergence and spread. The government, policymakers, health professionals and members of the community must work together to reduce antimicrobial resistance and ensure the continued worldwide availability of effective antimicrobial treatment. This can be achieved by raising awareness, implementation, and monitoring of the robust global and national action plans with the ultimate goal of curbing antimicrobial resistance. Furthermore, the need for sufficient investment and research in developing new antimicrobials, vaccines, and diagnostic tools to detect resistant microorganisms should be prioritized to prevent the exhaustion of tools available to combat resistant microorganisms.