Antibiotic resistance is of considerable and growing concern in both human and veterinary medicine. In 2010, the World Health Organization (WHO) reported that over the past 70 years the use and misuse of antimicrobials has led to a 'relentless rise' in the number and types of resistant microorganisms. As a consequence it is estimated that over 25,000 human patients die in Europe every year due to infections caused by resistant bacteria. This startling figure has led WHO to publicly state their fear that we may be moving into a post-antibiotic era, with the organisation adopting the tagline 'No action today, no cure tomorrow'.

The evidence that overprescribing and inappropriate usage are generally the main drivers of increased resistance to antimicrobials is overwhelming. Enforcement of prescribing protocols is heavily dependent upon responsible clinician behaviour, and the concept of 'one medicine' places a growing responsibility on the veterinary profession to consider how they use antimicrobials. Multidrug-resistant pathogens are resulting in pressure to use, and sometimes misuse, drugs that are of critical importance in human medicine, creating a conflict between veterinary medicine, human medicine, government bodies and public health personnel. The European Commission is currently reflecting on its management of the risks of antimicrobial resistance. Specifically, it has called for views on how to improve the use of antimicrobials in veterinary practice, and has indicated that the concept of restricted use is being considered.

The threat of reduced efficacy of antimicrobials and the possibility of restrictive legislation limiting a veterinary surgeon's ability to prescribe antimicrobials for animals under his/her care are both very real. In his annual report for 2008, the chief medical officer, Sir Liam Donaldson, suggested that veterinarians should be banned from prescribing certain classes of antibiotic, including fluoroquinolones and some cephalosporins in order to maintain their efficacy in humans. Such a policy would have far-reaching implications for veterinarians and for the health and welfare of our patients. To argue against such a ban, it is important that we continue to use antimicrobials responsibly and have data available to carry out risk analysis. Rather than trying to focus blame on others, veterinary and human medicine must admit that they both play a role in antimicrobial resistance and both must work to limit this problem. Ultimately, resistance to an antibiotic means that drug becomes less and less useful, leaving clinicians, human or veterinary, with fewer therapeutic options.

Over recent years there has been a cultural change in the way that organisations tackle infection prevention and control and the priority that they are afforded. Many staff and infection control teams have identified the development of a culture of senior management leadership and engagement as the most important action to be taken. NHS Trusts that demonstrate strong leadership and ward management are underpinned by robust performance monitoring, see the greatest reduction in infection rates (greater than 80%). Standardised infection-control practices and adherence to recommended antibiotic-usage guidelines are two major areas of focus if we are to slow the development of antimicrobial resistance. Strict adherence to the fundamentals of aseptic technique and environmental cleaning remain kingpins underlying any strategy, although antibiotic stewardship is also widely recognised as an essential component in limiting the development of antibiotic resistance. Stewardship can be interpreted as responsible caretaking; the concept is based on the premise that we don't own resources, but are managers of them and hence are responsible to future generations for their condition.

Accepted as a vital component of any infection control strategy, stewardship comprises a package of measures designed to provide effective, safe and economic use of antimicrobials whilst also limiting the development of resistance. Changes in antimicrobial use are paralleled by changes in the presence of resistance and a current trend in human medicine has been to limit the usage of fluoroquinolones and cephalosporins. The subsequent effect has been a direct correlation between a reduction in usage and a lower incidence of microbial resistance to these antibiotics. At present the NHS views this type of antibiotic stewardship as an essential strategy in limiting the spread of resistance.

The benefits of good infection-control practice are team based, and rely upon all team members having similar standards of understanding and knowledge. The aim is to create a disciplined culture in which all members of staff are encouraged to challenge poor practice. The development of an organisational culture from the top down is essential as the actions of a single individual have a significant impact on the entire unit. Strict adherence to infection prevention and control measures, including the use of hand-washing measures, are fundamental, although universal compliance is challenging. For example despite reported compliance rates of 80–90%, studies routinely fail to document hand hygiene compliance rates exceeding 40%. Empowering the nursing team is vital; a positive correlation between nursing input and compliance with prescription guidelines has been reported. Instilling a sense of pride within the team helps ensure that both environmental cleanliness and antibiotic stewardship measures are adhered to. Nurses take huge pride in their levels of patient care and outbreaks of infection really hurt them. This pride often makes them ideal stewards who should be empowered to challenge poor prescribing practice or failure to follow hygiene measures.

The Surgical Site Infection Surveillance Service (SSISS) was established in 1997. The scheme encourages hospitals (both NHS and private) to use surveillance to improve the quality of patient care by enabling them to collect and analyse data on surgical site infections (SSIs). This has required the development of a standardisation approach to the categorisation of SSIs including guidelines on post-discharge surveillance in order to provide better estimates of the risk of SSI following surgery. Evidence has indicated that if NHS Trusts apply passive systems for finding cases of SSI, rather than active methods, the likely result is poor case ascertainment and underestimation of the rate of SSI. This emphasises the importance of ensuring that a hospital's data collection methods are robust to enable reliable inter-hospital comparisons to be made. In the medical field between 12% and 84% of SSIs are detected after patients have been discharged from the hospital. This figure is likely to be higher in veterinary practice due to shorter postoperative hospitalisation times. Since July 2008, NHS Trusts have been required to undertake some post-discharge surveillance, this change increasing the number of SSIs detected by 40% overall. At least two studies have shown that most SSIs become evident within 21 days of surgery and hence at Northwest Surgeons we survey the owners of surgical cases 4–6 weeks postoperatively. In addition clients are educated regarding proper incision care, symptoms of SSI and the need to report such symptoms directly to the hospital.

The NHS reports considerable variation in rates of SSI between hospitals. However, reductions in rates have been observed in hospitals participating in SSISS, and the benchmark rate of SSI in orthopaedic surgery has reduced significantly since surveillance became mandatory in 2004. Collecting and feeding back data on rates of SSI to the surgical team has been reported to help contribute to reductions in rates of infection, the publishing of data instilling a degree of pride within the unit.

Since the discovery of antibiotics, resistance has developed with the introduction of every new agent or antibiotic group currently available. Current antibiotic usage strategies are aimed at delaying the inevitable spread of antimicrobial resistance in the hope that new pharmaceutical developments solve the problem long term. However, these advances may never come. Current proposals are nothing new, rather the principles remain but they need to be followed. To effectively prevent and control resistance, a marriage of infection control and antimicrobial management is essential. Organisational culture and individual behaviours have a significant impact on the success of interventions and consequently we all have an important role to play. Relatively small interventions can, if combined with global good practice, produce significant improvements.

References

1.  Arias C, Murray B. Antibiotic-resistant bugs in the 21st century - a clinical super-challenge. New England Journal of Medicine 2009;360:439–443.

2.  Donaldson L. 150 years of the Annual Report of the Chief Medical Officer: On the state of public health. www.dh.gov.uk, 2008.

3.  Dellit T, Owens R, et al. Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America guidelines for developing an institutional program to enhance antimicrobial stewardship. Clinical Infectious Diseases 2007;44(2):159–177.

4.  Wayne A, McCarthy R, et al. Therapeutic antibiotic use patterns in dogs: observations from a veterinary teaching hospital. Journal of Small Animal Practice 2011;52(6):310–318.

5.  Protocol for the Surveillance of Surgical Site Infection. Surgical Site Infection Surveillance Service. Health Protection Agency; Version 5 April 2011: www.hpa.org.uk

6.  Sixth report of the mandatory surveillance of surgical site infection in orthopaedic surgery April 2004 to March 2010. Health Protection Agency: www.hpa.org.uk