How to measure and monitor antimicrobial consumption and resistanceMedición y monitorización del consumo de antibióticos y resistencias bacterianas

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Abstract

Collateral damage caused by antibiotic use includes resistance, which could be reduced if the global inappropriate use of antibiotics, especially in low-income countries, could be prevented. Surveillance of antimicrobial consumption can identify and target practice areas for quality improvement, both in the community and in healthcare institutions. The defined daily dose, the usual adult dose of an antimicrobial for treating one patient for one day, has been considered useful for measuring antimicrobial prescribing trends within a hospital. Various denominators from hospital activity including beds, admissions and discharges have been used to obtain some standard ratios for comparing antibiotic consumption between hospitals and countries. Laboratory information systems in Clinical Microbiology Services are the primary resource for preparing cumulative reports on susceptibility testing results. This information is useful for planning empirical treatment and for adopting infection control measures. Among the supranational initiatives on resistance surveillance, the EARS-Net provides information about trends on antimicrobial resistance in Europe. Resistance is the consequence of the selective pressure of antibiotics, although in some cases these agents also promote resistance by favouring the emergence of mutations that are subsequently selected. Multiple studies have shown a relationship between antimicrobial use and emergence or resistance. While in some cases a decrease in antibiotic use was associated with a reduction in resistance rates, in many other situations this has not been the case, due to co-resistance and/or the low biological cost of the resistance mechanisms involved. New antimicrobial agents are urgently needed, which coupled with infection control measures will help to control the current problem of antimicrobial resistance.

Resumen

El daño colateral más importante derivado del uso de los antibióticos es la aparición de resistencias bacterianas. La prescripción inadecuada de los antibióticos está íntimamente relacionada con este efecto, observado globalmente a nivel mundial, pero principalmente en países con recursos económicos limitados. La estrecha vigilancia del consumo de los antibióticos puede ser de gran ayuda para identificar cuáles son los problemas relacionados con la prescripción de estos fármacos e introducir las estrategias necesarias para evitarlos, tanto en el ámbito ambulatorio como en el hospitalario. La dosis diaria definida, referida a la dosis usual de un antimicrobiano concreto, destinada al tratamiento diario de un paciente, se ha considerado útil para el estudio de las tendencias de consumo de los antibióticos en el hospital. Esta unidad se ha introducido en diversas fórmulas que incluyen diversos denominadores correspondientes a la actividad hospita laria, entre ellos el número de camas, ingresos y altas. Todo ello, con el objetivo de obtener una serie de indicadores estandarizados que se utilizan para efectuar comparaciones sobre el uso de antibióticos entre distintos hospitales y países. Los sistemas de información del laboratorio son las fuentes primarias de datos para la preparación de informes acumulados de sensibilidad. Esta información es útil para planificar tratamientos empíricos y adoptar medidas de control de infección. Entre las iniciativas supranacionales de vigilancia de la resistencia, la red EARS-Net proporciona información acerca de las tendencias de resistencia en Europa. La resistencia es consecuencia de la presión selectiva de los antimicrobianos, aunque en ocasiones estos agentes también promueven la resistencia al favorecer la aparición de mutaciones seleccionadas posteriormente. Múltiples estudios indican la relación entre el uso de antimicrobianos y la aparición de resistencias. Aunque en algunos casos una disminución del uso de un antimicrobiano se asocia a una reducción en las tasas de resistencia a este, en muchas otras situaciones no sucede así, debido a la corresistencia o al bajo coste biológico del mecanismo implicado. Son necesarios nuevos antimicrobianos, que junto con medidas de control de infección ayudarán a paliar el problema de la resistencia.

Introduction

Antibiotics have increased life expectancy. Self-medication occurs in many countries where antibiotics are classified as prescription-only medicines. Currently, microbial resistance to treatment with antibiotics constitutes an important public health problem, especially in the hospital environment. In this environment we find significant complexity and density of antibiotic use.

Surveillance of antimicrobial resistance can identify trends in resistance patterns and novel resistances. Antimicrobial stewardship initiatives and infection control programmes play an important role in decreasing inappropriate use and halting the dissemination of resistance. Education of professionals and the public should focus on changing behaviour rather than exclusively increasing knowledge, as the latter could have a paradoxical effect by increasing demand and prescription. Behaviour change should target all prescribers, including veterinarians, since microbes know no boundaries between animals and humans and are capable of exchanging resistance genes.1 This section is focused on certain aspects related to measures of antimicrobial consumption and bacterial resistance.

Section snippets

Ways of measuring antimicrobial consumption

A European Commission press release dated November 17, 2011 outlined an action plan against bacterial resistance to last-line antibiotics, comprising 12 specific measures to be implemented in the next five years.2 Two of the measures aim to heighten awareness regarding the appropriate use of antimicrobials and to strengthen surveillance systems of bacterial resistance and antimicrobial consumption in medicine.

In order to promote rational use and to avoid the development of resistance,

Evolution of human consumption of antimicrobial agents

Although most antimicrobials are prescribed in the community,27 microorganisms isolated from hospital infections usually show more resistant profiles than microorganisms from community infections,28 due to the fact that the proportion of patients receiving antimicrobial agents is much higher in hospitals than in the community,29 and for this reason the exerted selective pressure is much higher in hospitals.

In order to see the evolution of antibiotic consumption in the European Union, we will

Measuring bacterial resistance

Data to measure resistance to antimicrobial agents are first obtained at Clinical Microbiology services, based on cumulative tabulated susceptibility testing results of isolates from individual patients. In Spain and many other countries, this is most often achieved using the laboratory information system (LIS), or susceptibility testing system software. The free Windows-based WHONET software (http://www.who.int/drugresistance/whonetsoftware/en) can also interact with susceptibility test

Antibiotic pressure and the development of bacterial resistance

It is currently accepted that exposure to antibiotics does not directly determine the appearance of resistance in bacteria; it instead causes selective pressure on susceptible bacteria, allowing the proliferation of resistant organisms from pre-existing resistant subpopulations. Antibiotics should be considered, in general terms, as selective agents in a “natural” (Darwinian) process of survival of the fittest. Mutants may appear spontaneously because of mutations generated during DNA

Antibiotic restriction without recovery of bacterial activity

The impact of the use of antimicrobials on resistance to antimicrobials has been tested in some studies.52., 53., 54. Gottesman et al. in Israel53 assessed the impact of the restriction of ciprofloxacin use on the resistance profiles of Escherichia coli from urine isolated in the community. After the intervention, a significant reduction (>40%) in quinolone consumption during the studied period was observed, which was associated with a significant decrease (25%) in the isolation of E. coli

Impact of new antibiotic incorporations in bacterial resistance

The evolution of antimicrobial resistance and a dearth of new antibiotics in the pipeline raise the possibility of untreatable multi-drug resistant (MDR) infections. Recently, there have been some cases of extreme drug-resistant (XDR) bacteria, also known as “superbugs”, which will become more and more common. The WHO recently identified antimicrobial resistance as one of the three greatest threats to human health.58

Why does antibiotic resistance happen? The answer is complex. Levy's theory59

Conflicts of interest

The authors declare that they have no conflicts of interest.

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