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2. Background

The worldwide threat from antimicrobial resistant organisms is increasing. The consequences of this for society as a whole are potentially very serious. Various threats to health are posed by antimicrobial resistance:

• Some infections may become untreatable
• Empirical antimicrobial treatment may become increasingly ineffective, and thus time may be lost in treating critically ill patients
• Length of hospital stay, antimicrobial use, morbidity, mortality and overall costs to all involved may be increased
• Less effective, more toxic, and/or more expensive alternative medications may be required ⁴
• Other interventions e.g. organ transplantation, cytotoxic therapy for cancer, hip replacements, may prove increasingly ineffective should prophylactic and empirical antimicrobial therapy fail
• The reduced ability to control bacterial infection will impede progress in the development of innovative medical procedures.

The development of antimicrobial resistance is a complex evolutionary process. The major factor is exposure to antimicrobial agents but there are, however, other drivers for resistance including other drugs and environmental factors. Certain prescribing practices are likely to exacerbate the development of antimicrobial resistance ⁵. The association between antimicrobial prescribing and the emergence of resistance is not straightforward; once resistance has developed, removal of the agent selecting for resistance will not necessarily result in the disappearance of resistant strains. However, prudent prescribing using agents less likely to select for resistance can delay the emergence of resistant strains ⁶. It is hard to prove that changing practice, including prudent antimicrobial prescribing, reduces the emergence of resistance, but it is certain that failure to change will worsen the current situation.

It is known that a significant proportion of current antimicrobial usage in hospitals is not 'prudent' ⁷; this is mainly an issue of excessive use (use of an antimicrobial where not necessary or prolonged courses), or inappropriate choice of (or incorrect dosing of) antimicrobial agent for treatment or prevention of the relevant infection. Prudent prescribing of antimicrobials may prevent, or at least slow the rate of, the development of drug resistant strains ^{8, 9} - for example, the Scottish Intercollegiate Guidelines Network SIGN 88 document, Management of Suspected Bacterial Urinary Tract Infection in Adults, has defined criteria where it is inappropriate to use antimicrobials for this condition ¹⁰. Promoting good prescribing practice is an ongoing process requiring continuing vigilance. It will be greatly enhanced by developing better information systems about resistance patterns, and improved and more consistent dissemination of current and future information to those who need it most urgently, namely prescribers at the point of writing prescriptions.

In addition to the selection of resistant bacteria by antimicrobial treatment, spread of infection in hospital is encouraged by other factors such as poor hygiene, crowded environments, transfers of potentially or actually infected patients between wards in hospitals, and the fact that hospitals, care homes and other healthcare settings can act as a significant reservoir of resistant bacteria. It is imperative that NHS Boards institute, audit and regularly review policies and procedures that promote prudent antimicrobial prescribing and minimise the incidence of antimicrobial resistance (and the attendant patient morbidity and mortality). This will also reduce the increasing risks of litigation when patients acquire resistant infections during healthcare.

There is significant public, political and professional concern about the emerging and apparently increasing problem of Clostridium difficile associated disease. This is not an issue of antimicrobial resistance, but its emergence and the precipitation of illness in patients may well be directly related to all the prudent prescribing factors cited as contributing to the overall resistance problem. It is clear to the Group that the interventions proposed to alleviate antimicrobial resistance could also contribute significantly to the prevention and control of C.difficile associated disease.

There is clearly an issue for use of antimicrobials in 'out of hospital' care as well as within hospitals; infection with resistant organisms in the community is most likely to arise in those recently treated with antimicrobial medications ^11-15, and it is increasingly recognised that many cases of Clostridium difficile are generated in community settings.

The Ministerial Action Plan Preventing Infections Acquired While Receiving Healthcare¹⁶ published in 2002 included actions relating to antimicrobial resistance; these were included in the overarching work programme of the Ministerial Healthcare Associated Infection ( HAI) Task Force ¹⁷ formed as a result of the Action Plan. The HAI Task Force has produced a raft of policies and supporting documents complementary to the antimicrobial resistance issues, including the Code of Practice for the Local Management of Hygiene and HAI³, hand hygiene initiatives, extensive education and training resources in infection prevention and control, a National Cleaning Services Specification ¹⁸, and changes to organisational structures. It is the primary aim of these strategies that they will lead to a reduction in the magnitude of this important public health problem.

The Scottish strategic approach to antimicrobial resistance

In 2002, the Scottish Executive (now the Scottish Executive) produced the Antimicrobial Resistance Strategy and Scottish Action Plan¹. The three key elements of this strategy were:

• Surveillance: to monitor and provide data on resistant organisms, associated morbidity, and antimicrobial usage
• Prudent antimicrobial use: to reduce unnecessary and inappropriate exposure of micro-organisms to antimicrobials in clinical practice
• Infection prevention and control: both in general and with a specific focus on antimicrobial resistant organisms.

In response, one strand of the HAI Task Force work programme was the publication Antimicrobial Prescribing Policy and Practice in Scotland: recommendations for good antimicrobial practice in acute hospitals ( APP&P) in 2005 ². This document detailed the practical steps to be taken by acute hospitals to improve the quality of antimicrobial prescribing and thus reduce the risk of resistance. These are presented under six key areas:

• Establishing lines of responsibility and accountability in NHS Boards;
• Defining structures and responsibility for multidisciplinary and generic undergraduate and postgraduate training relating to antimicrobial prescribing;
• Defining the minimum dataset requirements and standard procedures for collecting information related to antimicrobial resistance patterns;
• Defining the minimum dataset requirements and procedures for collecting information related to antimicrobial consumption and quality of prescribing;
• Defining the key areas for acute hospital policy and recommendations for audit; and
• Defining and developing performance indicators.

There has been some progress since publication of APP&P in implementing these recommendations; however it is clear that to sustain and enhance this progress, further work is necessary. Specifically, there is an urgent need in the short term to contain and then reduce the spread of antimicrobial resistant organisms as part of the broad agenda for the HAI Task Force and for NHSScotland.

There are specific and significant public concerns about the risk of acquiring antimicrobial resistant organisms - the so-called 'super bugs' - and C. difficile while in hospital, either as a patient or as a visitor. Whatever the evidence from surveillance, this risk is popularly perceived as being on the increase. Public involvement is already well embedded within the HAI Task Force strategy to reduce the prevalence of HAIs. To help allay these fears, further work is required to educate the public in order to promote their knowledge of (and involvement with) hospital and 'out of hospital' care, infection control and prevention, and antimicrobial management. Much is being done by the HAI Task Force Public Involvement Communications Team ¹⁷. The Chief Medical and Nursing Officers have jointly issued 'Five Top Tips' to help engage patients and visitors in preventing infections ¹⁹.

Also in 2005, the Care Commission published A Review of Cleanliness, Hygiene and Infection Control in Care Homes for Older People²⁰ which confirms that, in order to prevent and reduce infections, older people in care homes must have a clean and safe environment, where staff receive regular infection control and prevention training.

International Examples of Good Practice

In 1998 the European Union made recommendations in response to the threat of antimicrobial resistance ²¹. These recommendations emphasised that:

• Antimicrobial resistance is a major European and global problem
• Prudent use of antimicrobials should be promoted
• Member states should set up surveillance systems for antimicrobial resistance
• Member states should collect data on the supply and consumption of antimicrobial agents.

In relation to this, certain European countries (Denmark, Sweden, Netherlands and others), now have national agencies which produce annual reports detailing the incidence of antimicrobial resistance, trends in antimicrobial usage for humans and animals, and studies examining the links between antimicrobial use and antimicrobial resistance ^22-24. These reports are disseminated widely and help ensure that appropriate action is taken where indicated. For example, in Sweden, colonisation and carriage as well as actual infection with Meticillin Resistant Staphylococcus aureus ( MRSA) is now reported (mandatory by legislation) and areas of high or increasing incidence are identified, investigated and appropriate action taken ²³. Sweden, Denmark and the Netherlands tend to have a lower incidence of antimicrobial resistance; however, it is not proven that these measures alone are responsible for the observed lower prevalence, as each of these countries have implemented additional policies to control the spread of resistance. It is also important to note that these countries introduced measures when the incidence and prevalence of resistance (particularly in the case of MRSA) was low. Implementation of similar measures in Scotland may not necessarily have the same magnitude of beneficial effect, as we already experience a comparatively high level of antimicrobial resistance ²⁵.

In May 2005 the European Centre for Disease Prevention and Control ( ECDC) was established under the direction of the European Parliament and Council ²⁶. With respect to antimicrobial resistance, this organisation aims to:

• Identify and maintain networks of microbiological reference laboratories
• Develop epidemiological surveillance to identify and assess emerging threats to human health from communicable diseases
• Communicate objective, reliable and easily accessible information to the public and decision makers on communicable diseases relevant to health.

The ECDC has stated in its annual epidemiological report for 2007 that "The most important disease threat in Europe is posed by micro-organisms that have become resistant to antibiotics... Each year approximately three million people in the European Union catch a healthcare-associated infection, of whom approximately 50 000 die".²⁷

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