Antimicrobial resistance: how you can make a difference
Feeling daunted by the AMR crisis? Here's how your daily practice can help turn the tide
Feeling daunted by the AMR crisis? Here's how your daily practice can help turn the tide
- While AMR is 'inevitable', its speed is accelerated by excessive, inappropriate and unnecessary use of antimicrobial treatments
- Helping people improve their health and prevent long-term conditions will ultimately decrease reliance on antibiotics, say experts
- Nurses should only be taking specimens when clinically indicated, not 'just in case'
With estimates suggesting that antimicrobial resistance (AMR) will kill ten million people a year globally by 2050 – more than cancer and diabetes combined – can individual nurses do anything to help turn the tide?
The magnitude of the problem can leave healthcare professionals feeling helpless, agrees RCN professional lead on infection prevention and control Rose Gallagher. ‘It can be very hard for people to relate to the information about what’s likely to happen if we do nothing,’ she says. ‘But for those of us who work in this specialty, and seeing the dangers on a daily base, it’s very real.’
Excessive, inappropriate use
The Health and Social Care Select Committee’s report on AMR, published in October 2018, says that while resistance is inevitable, its speed is accelerated by excessive, inappropriate and unnecessary use of antimicrobial treatments. ‘Although only 10% of sore throats benefit from antibiotic treatment, as most are viral, antibiotics are still prescribed in 60% of cases,’ says the report.
For Ms Gallagher, AMR has similarities with climate change, in that it presents an opportunity for individuals to make a difference. ‘They are two of the greatest threats to our health that we’ve faced for a long time,’ she says. ‘But they’re also the biggest opportunities we have to improve our health globally. By taking action to mitigate them, even in a small way, we can contribute significantly.’
‘It doesn’t begin and end in hospitals. There are conversations you can have with patients, carers and families about how to prevent infections’
Rose Gallagher, RCN professional lead on infection prevention and control
One of the key ways nurses can reduce unnecessary or inappropriate use of antibiotics is by helping people to live healthier lives, she believes. ‘As nurses, we have a unique role in advising and supporting people. We’re also the glue that binds everything together. We coordinate and deliver care, act as a conduit for information, are present in every care setting and very visible.’
Improving health through initiatives such as smoking cessation, promoting healthier diets and encouraging mobility helps to reduce the likelihood of conditions such as chronic obstructive pulmonary disease (COPD) and diabetes. ‘And by their nature, long-term conditions increase contact with healthcare and the risks associated with a predisposition to infection, having to take medications and surgery,’ she says.
Dispelling anti-vaccine myths
Preventing infection is critical. ‘It doesn’t begin and end in hospitals,’ says Ms Gallagher. ‘There are lots of conversations you can have with patients, carers and families about how they might be able to prevent infections.’
Reminding them about vaccinations is another aspect. ‘That’s one of the pieces of armour we have and we need to use it,’ she says. ‘Listen to people’s concerns, dispelling any myths they may have heard from the anti-vax lobby. We’ve not seen the impact of potentially fatal diseases, such as measles, because vaccines have been so effective.’
What nurses can do right now
- Make sure that patients are up to date with the appropriate vaccinations, including flu, pneumococcal and shingles for those aged 65 and over
- Remember the five Rs: the Right antibiotic for the Right indication, the Right dose, the Right route and for the Right duration, says Jodie Allan, antimicrobial nurse specialist at NHS Grampian. ‘It’s a good thing to have going through your mind, every time you dispense an antibiotic’
- Use patient-friendly information during consultations to improve communication and the confidence to self-care, without always resorting to antibiotics. The Royal College of General Practitioners’ (RCGP) TARGET antibiotic toolkit includes leaflets on treating UTIs and respiratory tract infections. ‘They include safety-netting advice too – what to do if things don’t improve,’ says antimicrobial stewardship nurse Jo McEwen, of NHS Tayside. ‘They minimise the use of antibiotics, without compromising on patient safety’
- For patients who are asked to provide specimens at home, including urine or sputum, provide advice on how to collect them properly, explaining its importance to securing an accurate diagnosis
- If you’re revalidating, consider using antibiotic resistance or antimicrobial stewardship as an area for reflection, suggests RCN professional lead on infection prevention and control Rose Gallagher. ‘Become familiar with your employer’s policies and procedures, research any articles and reflect on what it means for your own practice’
- Don’t get caught up worrying about the bigger strategic picture, says Ms Gallagher. ‘The bottom line is what does it mean on a day-to-day basis to you, for your patients, where you work. That will be different for everyone. Make sure you’re confident about the core principles of how infection can be prevented, and how you can support communities to live healthier lives’
Specimens only when indicated
Nurses also play a central part in collecting specimens, including urine and sputum. ‘We should only be taking specimens that are clinically indicated, and not “just in case”, following up on the results in a timely way,’ says Ms Gallagher. ‘The quality of specimens is really important in being able to interpret results and make a decision about whether a patient needs antibiotics.’
Often specimens are collected by the patient at home. ‘It’s vital that they understand what can go wrong, if a specimen hasn’t been collected in the right way,’ she says.
‘Inappropriate sampling can lead to inappropriate prescriptions of antibiotics’
Jo McEwen, antimicrobial stewardship nurse, NHS Tayside
Antimicrobial stewardship nurse Jo McEwen, of NHS Tayside, agrees, saying samples must be justified. ‘We need to make sure that they are within the presenting signs, symptoms and context of a patient’s illness,’ she says. ‘Given we all carry bacteria, inappropriate sampling can lead to inappropriate prescriptions of antibiotics.’
As part of her work, Ms McEwen developed an award-winning education programme, which challenged eight community hospitals to pause before reaching for antibiotics to treat older patients with suspected urinary tract infections (UTIs). Rather than testing routinely, staff considered whether the individual patient had signs of an infection, such as a raised temperature, as well as any pain, their frequency or urge of urination, and any new or worsening confusion.
If there’s just one sign, now staff watch, wait, promote hydration and look at personal and toilet hygiene. As a result, the numbers of inappropriate urine samples being sent to laboratories for testing has decreased by 29%.
Antibiotics: the facts
- Inappropriate use of medicines worsens drug resistance, says the World Health Organization (WHO), with overuse, underuse and misuse all contributing to the problem
- WHO lists AMR as one of the ten global health threats in 2019, along with vaccine hesitancy (reluctance or refusal to accept vaccination)
- According to government figures, at any one time one in three patients in hospitals in England is on an antibiotic
- AMR infections currently claim at least 50,000 lives each year across Europe and the US alone, and 700,000 lives globally, according to the select committee’s Antimicrobial Report
- By 2050, it is estimated that AMR will kill 10 million people a year globally
- No new classes of antibiotics have been discovered for decades. The select committee report cites pharmaceutical companies’ concerns about profitability as a reason for limited investment in their development
Encourage patient awareness
For Ms McEwen, nurses have a primary role in safely and effectively administering medicines. ‘Often nurses have a responsibility to clinically assess patients too and this can influence the decision to prescribe antibiotics or not,’ she says. In Scotland, nurses are the second highest prescribers of antibiotics (only doctors prescribe more), with evidence demonstrating they are complying with policies on first-line antibiotic treatment.
Anecdotally, she thinks there is a shift in patients’ attitudes towards antibiotics. ‘Public health campaigns are helping to plant the seed in people’s minds that they may not need a prescription for antibiotics, which is fantastic,’ she says.
‘They are starting to be more mindful now and I feel there is more awareness.’ Often people want antibiotics because their lives are so busy and they think a prescription will hasten recovery, she says. ‘But our bodies are very well equipped to deal with self-limiting infections and antibiotics have little, if any, impact.’
As nurses are at the front line of patient care, they are fundamental in improving antibiotic use in hospital and care settings, helping to reduce resistance, believes Jodie Allan, antimicrobial nurse specialist at NHS Grampian. ‘We’re the largest workforce and the majority of our day is spent with patients and their families,’ she says. ‘We’re constantly reviewing at every contact.’
‘We need to educate the public too not to presume they will be given antibiotics or pressurise for them’
Jodie Allan, antimicrobial nurse specialist at NHS Grampian
Key questions include checking how long someone has been taking an antibiotic for and why they’ve been prescribed in the first place; whether the person is clinically improving or getting worse; and looking at their microbiology results.
‘We can also remind patients not to miss doses, to complete the entire course and not stockpile medicines or give them to others,’ she says. ‘I’ve had conversations with people who’ve said they have a strip of antibiotics in their cupboard, and do I think they should take them. Patients feel better, so they stop taking the antibiotic and then keep them for the next time they’re not well. This lack of education is what’s driving resistance.’
As part of her newly created role, she has been involved in an antibiotic awareness campaign, based at the local Aberdeen football stadium. ‘We were targeting all ages. We had a questionnaire and some people knew a lot and others very little. It was a very mixed bag,’ says Ms Allan. ‘Public engagement is high up on our agenda.’
They are also using social media to relay important messages. ‘It’s about constantly keeping it in people’s thoughts. We need to educate the public too not to presume they will be given antibiotics or pressurise for them. If the expert advice is that you don’t need them, accept that decision.’
Lynne Pearce is a health journalist