Antimicrobials have enabled huge advances in modern medicine. Without them, routine surgery such as hip replacements and immunosuppressive treatments, including chemotherapy and transplants, would be difficult, if not impossible.
Over the past 50 years, many antimicrobials have been produced (National Institute for Health and Care Excellence (NICE), 2016). However, their widespread misuse has led to the development of resistance in bacteria, fungi, viruses and parasites. The development of new antimicrobials is slow and expensive, and when new drugs are produced it is only a matter of time before resistance to them emerges.
Infection with resistant organisms increases mortality, duration of illness, length of stay in hospital and cost (World Health Organization (WHO), 2018). Microorganisms may develop multiple resistances to antimicrobials, becoming all but impossible to treat (WHO, 2018). Five years ago, the WHO (2014) raised concerns about the magnitude of the problem of antimicrobial resistance and its implications for modern health care, highlighting the alarming possibility of the return to an age where minor infections can kill.
Why has resistance developed
Resistance is a natural process that allows the microorganism to adapt to environmental changes and survive (Michael et al, 2014). On exposure to antimicrobials, organisms may mutate to block the action of the antimicrobial, the resistance genes are then inherited by their offspring and may be transferred to other unrelated microorganisms. Resistant strains multiply and spread, and the resistant infection can be transmitted to individuals who have never been exposed to the antibiotic (Centers for Disease Control and Prevention (CDC), 2017).
Resistance has arisen through overuse of antibiotics, often for minor infections that are self-limiting and may be viral in origin. Overlong prophylaxis and therapy, especially with broad-spectrum antibiotics, are contributory factors, as is the use of antibiotics as growth promoters in farm animals destined to enter the food chain.
What is antimicrobial stewardship
It is unlikely that resistance will ever be eradicated. Instead, we need to conserve the use of present antimicrobials and slow down the emergence of resistance to new drugs through antimicrobial stewardship (AMS).
A key factor in AMS is to reduce usage: with this in mind, the Government has set a target of reducing inappropriate antimicrobial prescribing in England by 50% by 2020 (HM Government, 2016). Other factors include (NICE, 2015; CDC, 2017):
The prevention of infection is also crucial, as fewer infections mean fewer exposures to antimicrobials and reduced opportunity for multiresistant organisms to spread.
What can nurses do?
Guidelines for AMS to date have called for a multidisciplinary approach (NICE, 2015; CDC, 2017). However, very little mention is made of the role of the nurse. Fisher et al (2018) and Olans et al (2016) argue that nurses are an underused workforce in antimicrobial stewardship. Many nurses are now becoming qualified to prescribe, meaning that they have a key role in managing antimicrobial resistance (Ladenheim, 2018). Not all nurses will go on to prescribe, however, they will be involved in various antimicrobial stewardship activities (Courtenay et al, 2018).
Aside from preparing, administering and monitoring the effects of antimicrobials, nurses are involved in coordinating care, clinical assessment, taking specimens, monitoring patient progress and reporting adverse events, all of which offer opportunities to influence antimicrobial prescribing.
The most prominent role of nurses in AMS has traditionally been in infection prevention and control (IPC), where they often initiate measures such as isolation and screening. In addition, nurses are trusted professionals who are in the ideal position to educate patients and the public about the importance of AMS as part of health-promotion activities (Olans et al, 2016).
Challenges
There are, however, challenges in nurses becoming involved in AMS: they may assume that it is a prescribing issue and, if they are not prescribers, they may not see the relevance to their practice (Ladenheim, 2018). Other barriers include hierarchical structures and lack of co-operation by prescribers (Fisher et al, 2018).
Lack of education is also an issue, Olans et al (2016) suggested that, although undergraduate nurses are taught microbiology and pharmacology, their education in AMS is lacking. This is supported by Castro-Sanchez et al (2016), who found that only 36% of undergraduate healthcare programmes addressed AMS adequately. Education about AMS is crucial for all health professionals including nurses (Olans et al, 2016).
Looking ahead
With this in mind, Courtenay et al (2018) have developed AMS competencies for undergraduates and the Nursing and Midwifery Council (NMC) has included AMS in the new standards for pre-registration nursing (NMC, 2018). Nurse educators need to promote AMS as part of undergraduate programmes to empower the next generation of nurses to take greater ownership of this issue and help to preserve antimicrobials for use now and in the future.
Antimicrobial resistance threatens modern health care. Nurses are ideally placed to influence decisions in relation to antimicrobial prescribing and to promote patient and public awareness of this issue, so their engagement with local AMS programmes is crucial.
Education is a key factor in empowering nurses to take responsibility for AMS and nurse educators must incorporate AMS in preregistration nursing programmes to ensure that antimicrobials use is preserved for future generations.