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By Dr. Nehad Al Sharawi, Intensive Care Unit Consultant, Al Zahra Hospital Dubai and Dr. Mohaymen Abd El Ghany, Al Zahra Hospital Dubai, CEO
Since the discovery of penicillin by the Scottish scientist Alexander Fleming in 1928, antibiotics have been increasingly used to treat infections. Alongside with discovery of new antibiotics, microbial resistance appeared. The first strain of penicillin resistant staphylococcus was discovered in 1940. Currently, antimicrobial resistance has become a global health threat. According to United Kingdom statistics, antimicrobial resistance is expected to cause 300 million premature deaths by the year 2050 without action. This will be more than death caused by non-infectious diseases such as heart disease or cancer. In addition, antimicrobial resistance is expected to result in 100 trillion dollars loss in global economy by 2050.
New antimicrobial resistance mechanisms are emerging and spreading globally. This will lead to inability to treat common infections, which results in prolonged illness, increased cost and death. Without effective antimicrobial therapy, procedures such as major surgeries, organ transplantation or cancer chemotherapy become very high risk or even fatal.
Antimicrobial resistance occurs when microbes are exposed to antimicrobial drug. It happens through genetic alteration that renders the microbe resistant to the action of antimicrobial. This is a natural process, which is accelerated by the overuse and misuse of antibiotics. Up to 85 per cent of antibiotics have non-human use and up to 75 per cent have non-therapeutic use such as growth promoter. It is estimated that more than 50 per cent of antimicrobial prescription in hospitals is inappropriate.
Heker MT et al (2003) analysed the patterns of inappropriate antimicrobial prescription in 129 patients. He found that 33 per cent of unnecessary prescription was due to longer duration than required, 32 per cent due to treatment of non-infectious syndromes, and 16 per cent due to treatment of colonisation.
According to the Centre for Disease Dynamics, Economics and Policy (CDDEP) report in 2017, the prevalence of Extended Spectrum Beta-lactamase (ESBL) Escherichia coli (E coli) in the UAE is 48 per cent, which is close to that in the Kingdom of Saudi Arabia (KSA) which is 49 per cent. Carbapenem- resistant E coli prevalence in UAE is 2 per cent and KSA is 3 per cent, according to the same report. Antimicrobial Susceptibility and Multidrug Resistance in the Middle East (SMART) study showed that the prevalence of ESBL Klebsiella pneumoniae (K pneumoniae) is 25 per cent in KSA, 28 per cent in Lebanon, 52 per cent in UAE and 54 per cent in Jordan. At Al Zahra Hospital, Dubai (2018), the prevalence of ESBL E coli is 20 per cent, K pneumoniae ESBL is 17 per cent, and carbapenem-resistant K pneumoniae is 2 per cent.
In view of these alarming numbers of antimicrobial resistance and the few new effective antibiotics in the pipeline, the World Health Organization (WHO) has identified antimicrobial resistance as a major health threat and called for global action. To overcome the problem of antimicrobial resistance, we need to optimise the use of existing antimicrobials and to prevent the transmission of multi-drug resistant organisms. The first can be achieved through effective antimicrobial stewardship programme and the latter through effective infection control practices.
The Centre of Disease Control (CDC) has recommended four necessary actions to prevent antimicrobial resistance. These are:
Antimicrobial Stewardship Programme involves careful and responsible management of antimicrobials. This includes both pre-operative antibiotic prophylaxis and treatment of various infections. It also involves timely and optimal selection of antimicrobial that covers the most likely organisms involved, using the appropriate dose and duration and avoid treating non-infectious or non-bacterial syndromes with antibiotics.
The advantages of Antimicrobial Stewardship Programme include:
Any Antimicrobial Stewardship Programme has core elements. CDC has identified seven core elements for effective ASP which include: leadership commitment, accountability by appointing a single leader for the programme, presence of clinical pharmacist, implementing at least one recommended action or protocol, tracking antibiotic prescribing patterns and antibiograms, reporting information about antibiotic use and resistance to other healthcare workers and educating the prescriber, patient and family.
Antibiotic Stewardship Programme at Al Zahra Hospital Dubai started in the year 2017. It consists of a team leader who is a physician with an interest and expertise in infection diseases, clinical pharmacist, clinical microbiologist and infection control nurse. Daily prospective audits are performed on all cases that are prescribed antimicrobials. Data is collected and presented to the antimicrobial stewardship committee on regular basis. Several protocols are available to guide physicians on the optimal use of antimicrobials such as preoperative prophylactic antibiotics protocol, treatment of upper respiratory tract infection protocol, and treatment of infectious diarrhoea protocol. Continuous feedback is given to prescribers about their antimicrobial prescription patterns.
In conclusion, an optimal Antimicrobial Stewardship Programme requires multidisciplinary efforts to retain impact and sustainability. Leadership commitment, prescriber’s involvement and patients/family education will help to overcome the challenges associated with Antimicrobial Stewardship Programme.
Dr. Abdelghany will be one of the panellists at the “CEO and leadership panel: Establishing a culture of patient safety” on October 24, day one of the Patient Safety conference, at Patient Safety Middle East.