Alison Holmes

Understanding the mechanisms and drivers of antimicrobial resistance

To combat the threat to human health and biosecurity from antimicrobial resistance, an understanding of its mechanisms and drivers is needed. Emergence of antimicrobial resistance in microorganisms is a natural phenomenon, yet antimicrobial resistance selection has been driven by antimicrobial exposure in health care, agriculture, and the environment. Onward transmission is affected by standards of infection control, sanitation, access to clean water, access to assured quality antimicrobials and diagnostics, travel, and migration. Strategies to reduce antimicrobial resistance by removing antimicrobial selective pressure alone rely upon resistance imparting a fitness cost, an effect not always apparent. Minimising resistance should therefore be considered comprehensively, by resistance mechanism, microorganism, antimicrobial drug, host, and context; parallel to new drug discovery, broad ranging, multidisciplinary research is needed across these five levels, interlinked across the health-care, agriculture, and environment sectors. Intelligent, integrated approaches, mindful of potential unintended results, are needed to ensure sustained, worldwide access to effective antimicrobials.

Antimicrobial resistance : a global view from the 2013 World Healthcare-Associated Infections Forum

Antimicrobial resistance (AMR) is now a global threat. Its emergence rests on antimicrobial overuse in humans and food-producing animals; globalization and suboptimal infection control facilitate its spread. While aggressive measures in some countries have led to the containment of some resistant gram-positive organisms, extensively resistant gram-negative organisms such as carbapenem-resistant enterobacteriaceae and pan-resistant Acinetobacter spp. continue their rapid spread. Antimicrobial conservation/stewardship programs have seen some measure of success in reducing antimicrobial overuse in humans, but their reach is limited to acute-care settings in high-income countries. Outside the European Union, there is scant or no oversight of antimicrobial administration to food-producing animals, while evidence mounts that this administration leads directly to resistant human infections. Both horizontal and vertical infection control measures can interrupt transmission among humans, but many of these are costly and essentially limited to high-income countries as well. Novel antimicrobials are urgently needed; in recent decades pharmaceutical companies have largely abandoned antimicrobial discovery and development given their high costs and low yield. Against this backdrop, international and cross-disciplinary collaboration appears to be taking root in earnest, although specific strategies still need defining. Educational programs targeting both antimicrobial prescribers and consumers must be further developed and supported. The general public must continue to be made aware of the current scale of AMR’s threat, and must perceive antimicrobials as they are: a non-renewable and endangered resource.

Understanding the Determinants of Antimicrobial Prescribing Within Hospitals: The Role of “Prescribing Etiquette”

Prescribing etiquette is an important determinant of antimicrobial prescribing behaviors. Prescribing etiquette recognizes clinical decision-making autonomy and the role of hierarchy in influencing practice. Existing clinical groups and clinical leadership should be utilized to influence antimicrobial prescribing behaviors.

Is health care getting safer

Despite numerous initiatives to improve patient safety, we have little idea whether they have worked. Charles Vincent and colleagues argue that we need to develop systematic measures

Systematic Review of Antimicrobial Drug Prescribing in Hospitals

Standardizing methods and reporting could improve interventions that reduce Clostridium difficile–associated diarrhea and antimicrobial drug resistance.

Behavior change strategies to influence antimicrobial prescribing in acute care: a systematic review.

BACKGROUND Antimicrobial use in acute care is widely reported to be suboptimal. Inappropriate use of antimicrobials is a major contributing factor to the emergence of multidrug resistance and health care-associated infection. Addressing prescribing behavior is a key component of antimicrobial stewardship. METHODS We performed a novel systematic review of both qualitative and quantitative literature on antimicrobial prescribing behavior in acute care. We assessed the extent to which behavioral sciences and social marketing were used and whether this could be related to the effectiveness of reported outcomes. MEDLINE, Excerpta Medica Database (EMBASE), Applied Social Sciences Index and Abstracts (ASSIA), Business Source Complete, The Cochrane Library, PsychInfo, Database of Abstracts of Reviews of Effectiveness (DARE) and Health Management Information Consortium (HMIC) were searched for studies undertaken during the period January 1999-April 2011 and published in English. RESULTS Five qualitative and 5 quantitative studies met the quality criteria. Qualitative studies highlight the predominant influence of social norms, attitudes, and beliefs on antimicrobial prescribing behavior. Quantitative studies reporting interventions to optimize antimicrobial prescribing behavior do not use theoretical science or primary research to inform the design and choice of the interventions deployed. CONCLUSIONS Despite qualitative evidence demonstrating the impact of behavioral determinants and social norms on prescribing, these influences are not given due consideration in the design and evaluation of interventions. To ensure a better understanding of prescribing behaviors and to improve the quality of interventions and research in this area, the incorporation and application of behavioral sciences supported by appropriate multidisciplinary collaboration is recommended.

Do smartphone applications in healthcare require a governance and legal framework? It depends on the application!

The fast pace of technological improvement and the rapid development and adoption of healthcare applications present crucial challenges for clinicians, users and policy makers. Some of the most pressing dilemmas include the need to ensure the safety of applications and establish their cost-effectiveness while engaging patients and users to optimize their integration into health decision-making. Healthcare organizations need to consider the risk of fragmenting clinical practice within the organization as a result of too many apps being developed or used, as well as mechanisms for app integration into the wider electronic health records through development of governance framework for their use. The impact of app use on the interactions between clinicians and patients needs to be explored, together with the skills required for both groups to benefit from the use of apps. Although healthcare and academic institutions should support the improvements offered by technological advances, they must strive to do so within robust governance frameworks, after sound evaluation of clinical outcomes and examination of potential unintended consequences.

Clinical and molecular epidemiology of ciprofloxacin-susceptible MRSA encoding PVL in England and Wales

We aimed to enhance our case ascertainment of meticillin-resistant Staphylococcus aureus encoding Panton-Valentine leucocidin (PVL-MRSA), determine the patient demographic, risk factor and disease associations, and define the clonal diversity amongst isolates referred to the UK Health Protection Agency’s Staphylococcus Reference Unit. PVL-MRSA collected during 2005–6 from community-based and hospitalised patients located across England and Wales were identified by polymerase chain reaction (PCR). Representative geographically and temporally unrelated isolates were characterised via toxin gene profiling, SCCmec, spa and agr typing, multilocus sequence typing (MLST) and minimum inhibitory concentration (MIC) determinations. PVL-MRSA were identified from 275 patients. Affected individuals were <1 to 95 years of age (mean 30, median 27 years). Forty-five isolates were from 18 household or community-based clusters and 23 isolates were from outbreaks in healthcare settings. Overall, 58% (n = 161) had skin and soft tissue infections and 9% (n = 25) presented with or developed more serious disease, including eight patients (3%) with necrotising pneumonia, five of whom subsequently died. PVL-MRSA were genetically diverse and harboured SCCmecIV or VT/VII. Representatives of MLST clonal complexes (CCs) 8, 30 and 80 were identified the most often. The 275 PVL-MRSA included internationally disseminated community-associated MRSA (CA-MRSA) strains, as well as other minor lineages, and were associated with typical risk factors and disease presentations.

International cooperation to improve access to and sustain effectiveness of antimicrobials

Securing access to effective antimicrobials is one of the greatest challenges today. Until now, efforts to address this issue have been isolated and uncoordinated, with little focus on sustainable and international solutions. Global collective action is necessary to improve access to life-saving antimicrobials, conserving them, and ensuring continued innovation. Access, conservation, and innovation are beneficial when achieved independently, but much more effective and sustainable if implemented in concert within and across countries. WHO alone will not be able to drive these actions. It will require a multisector response (including the health, agriculture, and veterinary sectors), global coordination, and financing mechanisms with sufficient mandates, authority, resources, and power. Fortunately, securing access to effective antimicrobials has finally gained a place on the global political agenda, and we call on policy makers to develop, endorse, and finance new global institutional arrangements that can ensure robust implementation and bold collective action.

Advances in electronic surveillance for healthcare- associated infections in the 21st Century: a systematic review

BACKGROUND Traditional methodologies for healthcare-associated infection (HCAI) surveillance can be resource intensive and time consuming. As a consequence, surveillance is often limited to specific organisms or conditions. Various electronic databases exist within the healthcare setting and may be utilized to perform HCAI surveillance. AIM To assess the utility of electronic surveillance systems for monitoring and detecting HCAI. METHODS A systematic review of published literature on surveillance of HCAI was performed. Databases were searched for studies published between January 2000 and December 2011. Search terms were divided into infection, surveillance and data management terms, and combined using Boolean operators. Studies were included for review if they demonstrated or proposed the use of electronic systems for HCAI surveillance. FINDINGS In total, 44 studies met the inclusion criteria. For the majority of studies, emphasis was on the linkage of electronic databases to provide automated methods for monitoring infections in specific clinical settings. Twenty-one studies assessed the performance of their method with traditional surveillance methodologies or a manual reference method. Where sensitivity and specificity were calculated, these varied depending on the organism or condition being surveyed and the data sources employed. CONCLUSIONS The implementation of electronic surveillance was found to be feasible in many settings, with several systems fully integrated into hospital information systems and routine surveillance practices. The results of this review suggest that electronic surveillance systems should be developed to maximize the efficacy of abundant electronic data sources existing within hospitals.