Global, co-ordinated stewardship18/05/17Health
Professor Dilip Nathwani delivered the keynote speech at ECCMID 2017 on the role of stewardship in combatting antimicrobial resistance
Antimicrobial resistance (AMR) is emerging as one of the key international health challenges of the 21st Century. At the 27th European Congress of Clinical Microbiology and Infectious Diseases (ECCMID), the topic of AMR dominated conversations among the high-level stakeholders who are at the forefront of the fight against resistant bacteria.
The keynote speech at the event was delivered by Professor Dilip Nathwani, the president of the British Society for Antimicrobial Chemotherapy and chair of the European Study Group on Antibiotic Policies, who was awarded an OBE in 2015 for services to the treatment of infectious diseases. Nathwani opened by discussing the recent United Nations high-level meeting on antimicrobial resistance. While he welcomed the discussions and the resulting recommendation that countries develop national action plans, he expressed some disappointment that no specific goals or targets were set; without these, he argued, it will be difficult to quantify success.
Nathwani emphasised the need for a comprehensive global approach to combatting AMR, which takes into account the prescribing of antibiotic drugs in both a hospital and community setting, as well as other areas of impact, such as agriculture and aquatics, sanitation, and poverty. Describing the enormity of the challenge the global healthcare community is facing, Nathwani said: “We have to deal with overuse as well as inappropriate use. We are working with healthcare systems across the world that are pluralistic. We need to look at the behavioural determinants of how we actually influence the prescribing landscape, [because] there are many actors within this complex interplay: patients, pharmaceutical companies, community prescribers, community health workers, regulators and so on.”
Different cultures, different landscapes
One of the biggest challenges in creating this global approach, the professor explained, is the fact that many countries are divided by resources, income, and healthcare capabilities. “If you look at the countries that many of us come from,” Nathwani said, referring to the attendees of the conference, “stewardship is variable but we generally have reasonable microbiological support, even if sometimes we don’t use it appropriately. But those lower to middle income countries have a very different cultural and political landscape. Broken taxation systems offer very poor funding and infrastructure of public hospitals, sanitation, and microbiological support.”
One aspect of the problem of which the global community mustn’t lose sight, Nathwani warned, is the importance of providing access to vulnerable populations in developing countries, although this presents its own set of complications: “A large number of the population do not have access to simple, effective antibiotics. Unfortunately, it is that access, when you make it available to certain communities, that often will be abused and lead to excess. […] The onus is on each and every one of us to manage that complex balance and struggle between ensuring access, which many parts of the world do not have, against managing excess.”
There are a number of potential solutions here. Nathwani spoke of antibiotics which have been used in the past but have fallen out of regular use, such as chloramphenicol. Because they are not in regular use, these drugs remain effective against bacteria which have grown resistant to commonplace antibiotics, and so a long term solution may involve a cycle of antibiotics which does not allow bacteria to build resistance.
On financial investment, the professor argued that stewardship efforts would no doubt prove cost effective in the long term, but financial evaluations of the value of intervention had not fully demonstrated this to be the case. “Those [evaluations] are focused around antimicrobial costs, but if you bring about changes in practice you have to implement them, and that’s actually potentially quite costly. We need to do thorough economic analysis.” Further, continuing on his theme of a global approach, he added: “The majority of studies are from North America and Europe, so we need health economic data about the cost effectiveness of stewardship interventions from Asia and Africa and we should encourage colleagues from these parts of the world to undertake some of these studies.”
The challenge in co-ordinating practice around the globe is that the concept of stewardship does not necessarily translate between healthcare systems across countries. The only way to ensure that the concept can be understood across national boundaries, and even between various healthcare disciplines, is to ensure that the methodology is translatable and that goals are clearly defined. Nathwani suggested that focusing on the impact that combatting AMR could have on each discipline is the best way to reform prescribing practices. For example, a clinician is not interested in costs, but in patient outcomes and safety, and so to explain to an orthopaedic surgeon that stewardship can optimise a patient’s outcome, or to a hospital chief executive that the hospital will be safer through Nathwani’s methods, is a more resonant message than discussing the concept of “resistance”.
To overcome the geographical boundaries, closer co-operation will be necessary, he continued: “If we work closer together around education, training, research, stewardship programmes, we will achieve so much and ensure that there are different models of delivering stewardship as opposed to one. It’s about adoption and adaptation to bring about the transformational change that we require in the healthcare system and the patient populations. We need to adapt to be geographically specific, resource specific and culturally specific if we are to really bring about the solution that we need.”
There are several different approaches currently being taken by countries around the world that could be adapted for use in others, where those solutions are compatible with healthcare systems. The primary approach is the development of regulatory legislation, which has been employed with great success in some areas, as the professor outlined: “In Brazil and Mexico, they put in a restriction prohibiting the use of systemic antibiotics without prescription, which has shown evidence of the benefits of self-regulation. In India, the Red Line Campaign that requires prescriptions is a wonderful regulatory innovation. The challenge there is how to monitor its success. The Chinese approach – where you can be prosecuted if your performance in prescribing antibiotics is no good – has been incredibly successful. We’re exploring a range of potential ways to support legislation.”
The other proactive approach to stewardship that is currently being undertaken is that of accreditation, efforts which were led by Australia and have grown to include the US and Canada. However, because these efforts are only just getting underway, there is little data to demonstrate whether or not accreditation actually works, although the professor acknowledged that “there is some evidence to support that the accreditation approach has been quite successful in certain parts of the world”.
As well as the quantity of antibiotics being consumed, Nathwani warned, we must also understand the quality of diagnosis and prescribing to ensure that they are effective, although the challenge here is that once again there is insufficient data to monitor this accurately. However, Nathwani pointed to one tool which he thinks will begin to improve this situation: “CDDEP provides maps of surveillance of microbes as well as quantity of prescribing. It’s very useful and I think that is the way ahead in terms of informing around consumption of antibiotics linked to resistance. We also have point prevalence surveys that just look at quantity of prescribing. I think we need to look at quality of prescribing, but this kind of work is very instrumental in looking at the landscape.”
How can the data be used? The professor explained: “This kind of data will show you at a patient level what they have, what their prescribing was and whether they were compliant with guidelines. It tells you the quality of your landscape, your hospital, your ward, your country; but it also allows you to bring about some indicators from it, which you can use for some benchmarking across the globe around compliance.”
In improving the quality of prescription, Nathwani argued that it will require a deeper understanding of why antibiotics are badly prescribed in the first place. He suggested that there are a number of factors which contribute, such as a lack of knowledge, delay or lack of trust in results, patient demand, fear of clinical failure and others; practitioners may be hesitant to question the decisions of colleagues, for example, which can act as a barrier to broader change.
Having highlighted these areas in which greater efforts need to be undertaken and stewardship needs to be translated and implemented, Nathwani offered some vital solutions which he feels will alleviate some of the challenges the healthcare community is facing in the global battle against AMR. Perhaps the most fundamental aspect is the leadership which will drive and support a global overhaul in the use of antibiotics. “Global leaders,” Nathwani said, “are really a community that needs to collaborate and work together to ensure the delivery of effective stewardship. But when you talk about leadership, the local, clinical and multidisciplinary leadership is even more important.”
The professor offered an example of how global cultural differences must be understanding in engaging all relevant actors: “In certain parts of the world, the pharmacist leadership and the nurse leadership is as important as the medical leadership and we need to cultivate, to encourage and to support this leadership to achieve our ambitions. […] We recently did a large survey and found that the nurse has as important a role in many parts of Africa as the pharmacist.”
To achieve this synchronous leadership at all levels of medicine and care requires closer collaboration between actors. Nathwani argued: “We have to have toolkits for secondary care as well as primary care, which are really very supportive to ensure that general practitioners are equipped with the skillset that they require. The challenge here is for hospitals and communities to work together. I would ask you to tell me of any healthcare systems where the primary care and the hospital sector is connected to the extent that they learn, they practice and they evaluate together, but I think that many of you will not be able to answer.”
He went on to detail an example of this kind of system in practice: “It has been done in Vietnam. They combined infection prevention with data collection, and shared the data to bring about a change in practice. They used the regional networks in the country to ensure that the data, infection prevention and laboratory capacity was supported.” However, this is not always possible, particularly in those developing countries with weak public health infrastructure, where much healthcare is private. “How do those countries encourage private practitioners and primary pharmacists to dispense antibiotics appropriately? If we are to truly achieve success, we need to ensure that the structures and the processes are in place, and those will bring about improvement in the outcome.”
While a lack of resources has presented a serious challenge, there is also the additional complication that in some areas time and efforts are being wasted attempting to determine that minimising the use of antibiotic drugs will curb AMR, instead of concentrating on efforts to encourage practitioners to curb their use. Nathwani argued that further attempts to demonstrate this constitute wasted effort because it has already been definitively proved: “A recent Cochrane systematic review told us that we no longer need to do trials showing that lowering antibiotic use and appropriateness of use will help, will not increase mortality and will likely reduce lengths of stay in hospitals. Additional trials are like trying to do a trial of whether a parachute is going to prevent death; it’s not worth doing because we know what the information of a more systematic review shows.”
The Cochrane review also emphasises the value of effectively communicating the findings of such trials to those who need to take action in reducing their use of antibiotics. “It shows that communicating and feeding back experience, information and data to the people who write the prescriptions is truly effective. It’s no good just collecting data and then putting it in an email. You need to engage with clinicians to discuss the data. Anything restrictive or persuasive that enables clinical teams to prescribe more effectively in this systematic review offers a better chance of success than not doing so.”
“There’s no doubt,” he continued. “The evidence shows that if you comply with guidelines, if you de-escalate when you have a culture, if you review a patient with infection expertise, you get a reduction in mortality. Stewardship in these interventions is saving lives, and there is now very good evidence to support that.”
The need to co-ordinate between different disciplines goes beyond those which directly interact with antibiotic use, and Nathwani went on to explain: “Changing behaviour requires psychology as well as a whole bunch of other sciences and disciplines within medicine. We need to think about human factors. We need to think about change management. I’ve talked about culture as well as engagement, and a little bit about empowerment and stewardship.” Examples of stewardship which are already underway in some disciplines, he said, make a strong case for its viability in dealing with AMR more broadly in the future: “Faecal microbiota transplantation is going to change the way we use antibiotics. [Then there are] nebulised antibiotics that target healthcare-associated pneumonia. All of these are going to be very influential in driving stewardship into the next decade.”
The reason that significant interventions are now necessary to ensure behavioural change is that certain elements have been ignored, as Nathwani argued: “To bring somebody to appropriate prescribing, unless they have the motivation and you give them the opportunity and you give them the capability, the change in behaviour will not happen. It’s very simple, but for too long we haven’t paid attention to capability, motivation and opportunity to drive that behaviour change.”
There remains room for innovation, particularly in prescribing, an area in which the professor said that a game changer is still needed. “Is the laboratory going to bring about the clinical reassurance that our healthcare professionals need to deliver better prescribing?” he speculated. “How do we ensure that prevention, stewardship and diagnosis work in a truly integrated model to achieve what we want to achieve? […] Didactic education, what we’re doing just now, is perhaps not the optimal way. It’s one way, but we need to work with other solutions.” Web-based e-health learning is generally thought to be very helpful, he added.
True stewardship coalition
Concluding, Nathwani reiterated the importance of efforts to prevent rising levels of resistance in bacteria by reminding the audience that while it is easy to speak about the problem in medical terminology, AMR has a serious impact on the people who suffer from antibiotic resistance infections: “Whenever we think about AMR and we think about stewardship, let’s keep reminding ourselves of the human costs of these amazingly difficult to manage and sometimes, sadly, deadly infections.”
He summarised his view of the role stewardship can play in these efforts: “Structure and processes are not good enough unless you use the processes of implementation, and in a global context, that implementation needs to be adoption, followed by adaptation. That will really lead to transformation. Many of the countries, cultures and hospitals and communities across this world need to move from a state of dependency to a state of independence, but that should not be the final layer of success. To me, a true stewardship coalition is the interdependency nature of each and every one of us to achieve a success that we all desire.”
This article will feature in issue one of Pan European Networks: Health, due for publication in May.