Antibiotic resistance continues to rise

"Antibiotic resistance continues to rise," BBC News reports as, despite warnings, the number of antibiotic prescriptions in the UK continues to soar, as do new cases of resistant bacteria.

Other news reports take different slants on the story, with The Daily Telegraph blaming the rise on hospitals and out of hours GPs.

The news follows the publication of a new report by Public Health England on the English surveillance programme for antimicrobial utilisation and resistance (ESPAUR), which reports the change in antibiotic prescribing and resistance over recent years.

The report highlights a number of key findings, including a year on year increase in antibiotic prescribing in England, with the majority of antibiotic prescribing taking place in general practice. There also seems to be variation across the UK, with areas with higher antibiotic prescribing also having higher rates of resistant infections.

Public Health England hopes this report will enable general practices and hospitals to compare their data with regional and national trends. They could then see if their rates are higher than other areas, and investigate why and if they can reduce these. This will also provide a baseline measure from which to track changes in both prescribing and resistance in England.

What is antimicrobial resistance?

Antimicrobial resistance is a global health threat.

Antimicrobials are drugs used to treat an infectious organism, and include antibiotics (used to treat bacteria), antivirals (for viruses), antifungals (for fungal infections) and antiparasitics (for parasites).

When antimicrobials are no longer effective against infections they were previously effective against, this is called antimicrobial resistance. Regular exposure to antimicrobials prompts the bacteria or other organisms to change and adapt to be able to survive these drugs.

As the report says, the problem has been around for decades, but in the past it was seen as less of a problem as new antibiotics were regularly being developed.

However, nowadays fewer new antibiotics are being developed, meaning we have fewer options and stronger and stronger drugs in our antibiotics armoury have to be used to treat common infections once they become resistant. This means we are now facing a possible future situation where we will be without effective antibiotics.

What does the report say about current antimicrobial resistance in England?

The report highlights the following:

There has been an increase in the number of bloodstream infections between 2010 and 2013, and an increase in the number of cases where resistance was identified. For example, during this three-year period the number of bloodstream infections caused by E. coli increased by 12%.
The proportion of E. coli bacteria with resistance to antibiotics increased between 2001 and 2006-07 and then decreased, but has risen again between 2010 and 2013. Roughly around one in five infections involving E. coli bacteria in 2013 were resistant to a commonly used antibiotic (ciprofloxacin), an 18% increase from 2010. Around 1 in 10 infections were resistant to the stronger antibiotics (third-generation cephalosporins and gentamicin), a 27-28% increase.
Looking across England there is variation in resistance, with ciprofloxacin resistance ranging from 25% in London to 12% in Cumbria, Northumberland and Tyne and Wear. Cephalosporin resistance ranged from 15% in London to 6% in Devon, Cornwall and the Isles of Scilly, and gentamicin resistance ranged from 15% in London to 5% in Durham, Darlington and Tees.
There have been increases in bloodstream infections caused by some bacteria (K. pneumoniae), while others (S. pneumoniae and Pseudomonas) have shown a decline. With all infections there appears to be a notable variation in resistance rates in different geographical regions.
A particular focus was looking at antibacterial resistance to carbapenems – very strong antibiotics widely considered to be "antibiotics of last resort". The data indicates these antibiotics currently remain effective for the treatment of more than 98% of blood infections caused by E. coli or K. pneumonia. But, as the report says, this should not lead to complacency. Despite the small proportion of bacteria resistant to carbapenems, there has still been a year on year increase in the number of bacteria able to produce enzymes capable of destroying this antibiotic.

What does the report say about current antimicrobial prescribing in England?

The report highlights the following trends in antimicrobial prescribing:

Between 2010 and 2013, total antibiotic prescribing increased by 6% – general practice prescribing increased 4%, prescribing to hospital inpatients increased by 12%, and other community prescriptions (such as by dentists, out of hours prescribers, nurses, and other non-medical prescribers) increased by 32%.
In 2013, 27.4 out of every 1,000 inhabitants in England were taking a prescribed dose of antibiotics each day, with 79% of these prescriptions occurring in general practice, 15% in hospital and 6% being other community prescriptions (predominantly dentists).
The highest combined general practice and hospital antibiotic prescriptions were in Merseyside, with 30.4 per 1,000 inhabitants per day taking antibiotics, more than 30% higher than Thames Valley, with the lowest prescription rates (22.8 per 1,000 inhabitants per day). The highest prescription rate from general practice alone was Durham, Darlington and Tees (26.5 per 1,000 inhabitants per day), which was more than 40% higher than London (18.9 per 1,000 inhabitants per day). It was suggested the lower GP prescribing in London may reflect different healthcare access and delivery in the capital, where there may be a shift in prescribing to local hospitals and private healthcare providers.
Overall, the antibiotic use per 1,000 inhabitants per day is thought to be an underestimate of total consumption, as it does not include private prescriptions, which are not recorded as part of ESPAUR at present. The reasons for the increase in consumption are unknown, but may represent changes in the number of patients presenting to medical care with infections requiring antibiotics, or it could be overprescribing of antibiotics by doctors (or dentists). The report says the increase in other community prescriptions needs to be explored to assess whether general practice prescribing is being displaced to out of hours treatment centres.
In 2013, 66 different antibiotics were prescribed in both general practice and hospital settings, with a top 15 of these antibiotics accounting for 98% of GP prescriptions and 88% of hospitals. These top antibiotics include penicillins, tetracyclines and macrolides (such as erythromycin). Over the past four years, prescribing of penicillins has increased by 3% and macrolides by 6%.
Generally, in general practice the prescription of broad spectrum antibiotics (that are less specific to particular bacteria and cover a wide range of different bacteria) has decreased over recent years, while in hospital the prescription of broad spectrum antibiotics has increased.
Comparing the UK with other EU countries, we are said to be in the mid-range for community prescriptions of antimicrobials. But for antibiotics prescribing in hospitals, the UK had rates that were more than twice the average (median) in the EU. However, this may relate at least in part to different prescribing and recording of prescription practices in UK hospitals.

What is being done to help?

As the report highlights, antibiotic prescribing and antibiotic resistance are inextricably linked, and overuse and incorrect use of antibiotics are major drivers of resistance.

The Chief Medical Officer for England highlighted the problem of antimicrobial resistance in the 2013 annual report, which led to the UK cross-government five-year (2013-18) antimicrobial resistance strategy.

This is the first report from the English surveillance programme for antimicrobial utilisation and resistance (ESPAUR). Their key aims are to develop surveillance systems to measure both antimicrobial prescribing and resistance, and to measure the impact of antimicrobial prescribing on antimicrobial resistance and patient and public safety.

The data in this report provides national and regional surveillance of antibiotic resistance and antibiotic use trends from 2010 to 2013. Public Health England cautions these are just single snapshots of data, so will require further investigation. They say further validation and exploration of the findings is needed.

The report highlighted that when comparing the maps of antibiotic prescribing and resistance across regions, areas with high prescribing in general have higher resistance levels. Primary and secondary care organisations are advised to audit their own prescription data to compare with regional and national trends.

Knowledge that their consumption is higher than national trends, and assessment of the reasons for this, should help them develop strategies to improve their prescribing as needed.

This information will provide a baseline measure from which to track changes in both prescribing and resistance in England.

What can I do to help?

People can help cut antibiotic (or wider antimicrobial) resistance by recognising that many common infections, such as coughs, colds and stomach upsets, are often viral infections that will go away after a short period without treatment ("self-limiting" infections). These infections do not need an antibiotic prescription as they will have no effect.

If you are prescribed an antibiotic (or other antimicrobial), it is also important to make sure you take the full course as prescribed, even if you feel better before you finish the course.

This will reduce the chances of the organisms being exposed to the drug but then surviving, allowing them to develop resistance if they encounter it again.

It will also increase the chances of you getting better, as by not taking a full course you may find the infection comes back and requires further antibiotic prescriptions, which further increases the chances of resistant organisms developing.