By Samrina Bhatti, MRPharmS, PGDipGPP, Manager, Centre for Health Solutions
The growth of antimicrobial resistance (AMR) is widely acknowledged as an urgent public health challenge, causing at least 700,000 deaths globally every year.1 AMR also presents serious financial threats in healthcare costs and productivity losses.2 Although COVID-19 is caused by the SARS-CoV-2 virus, a growing body of international evidence shows that the global threat of AMR is worsening due to the fact that many patients with COVID-19 symptoms are being prescribed antibiotics partly due to uncertainty about the pathology of the infection; and as a precaution in preventing and treating secondary bacterial infections.3
In June 2020, the World Health Organisation (WHO) noted that surveillance data from countries that monitor and report on AMR, reveals a worrying increase in the number of resistant bacterial infections. The WHO raised concerns that this trend is being fuelled further by the inappropriate use of antibiotics during the COVID-19 pandemic.4 Consequently, the WHO has issued guidance advising against providing antibiotic therapy or prophylaxis to patients with mild COVID-19 or with suspected or confirmed moderate COVID-19 illness unless clearly clinically indicated.5
What steps has the UK government taken?
For many years the UK government has played a central role in working to improve AMR. In July 2014, it commissioned a seminal two-year ‘Review on Antimicrobial Resistance’, to evaluate the problem and propose actions to tackle it internationally. The May 2016 report ‘Tackling drug-resistant infections globally: Final report and recommendations’, identified the steps needed to fix both supply and demand problems, including extending the usefulness of existing products and reducing the urgency to develop new ones. It recommended that governments should be held accountable for building a global coalition for affirmative action.6
The UK government’s response included investments in improving laboratory capacity, international surveillance systems and a global AMR innovation fund. It also funded the development of innovative diagnostic tools and initiatives making full use of diagnostics to drive appropriate prescribing in the NHS. It committed to implement the recommendations in the AMR Review and to develop financing systems that would reinvigorate both early-stage R&D and, by working through the UN and other international fora, to support action on AMR.7
In 2019, the UK government published a new five-year action plan and 20-year vision to contain and control AMR by 2040, building on the UK’s previous 5-year AMR strategy (2013 to 2018). The requirements in the new strategy include:
- reducing UK antimicrobial use in humans by 15 per cent by 2020
- reducing the number of drug-resistant infections by 10 per cent by 2025
- reporting on the percentage of antibiotic prescriptions supported by use of a diagnostics test or decision support tool by 20248
In 2020, the UK became the first country to announce a new payment strategy to incentivise companies to develop new antibiotics. The UK will pay companies via a subscription-style model for antimicrobials based primarily on a health technology assessment of their overall value to the NHS, as opposed to the volumes used. Consequently the government expects the NHS to have access to new drugs when needed, and companies to have more certainty about investment returns.9
How can healthcare professionals tackle the global AMR challenge?
Healthcare professionals have an important role in antimicrobial stewardship and medicines optimisation, including focussing on individual areas of practice to lower the antimicrobial burden. Becoming an Antibiotic Guardian, can help staff understand the actions they can take.10
AMR local prescribing information is publically available in the UK via the Public Health England ‘fingertips’ tool. The data helps raise awareness of antibiotic prescribing and facilitates the development of local action plans. The data is openly accessible to healthcare staff, commissioners, and directors of public health, academics and the public to compare the situation in their local area to the national picture.11
As a member of the pharmacy team for one of the twelve Commonwealth Partnerships for Antimicrobial Stewardship (CwPAMS). I have seen first-hand the contributions made globally to this important agenda. CwPAMS are helping to build capacity for antimicrobial stewardship in four African commonwealth countries. The Commonwealth Pharmacists Association (CPA) have supported their profession through developing initiatives including establishing a ‘Telegram’ online support group and a COVID-19 resource toolkit and webinars to signpost relevant materials directly to the pharmacy workforce.12
How are digital technologies being used to address the AMR challenge?
Timely advice and adherence to infection control practices can avoid the need for antimicrobial therapies altogether. Advancements in digital technologies that help prevent, diagnose, manage and control bacterial infections can reduce inappropriate antimicrobial prescribing. For example:
- Healthy.io who launched a digital, pharmacy first, test-and-treat service in 2019, available in many UK retail pharmacies. Subsequently, in 2020, Healthy.io have developed a digital home urine test to help diagnose urinary tract infections and deliver antibiotics, where indicated, to patients within a few hours13
- FebriDx, a point of care system developed to differentiate, rapidly, viral from bacterial infections using a fingerpick test. The system detects levels of viral proteins which then guides the appropriate management of the infection. This has now been adapted for COVID-19 identifying those patients who may need to be quarantined and/or require subsequent confirmatory testing14
- mobile apps are also being used internationally as an educational resource amongst healthcare professionals. Within the CwPAMS programme, an app, originally developed to bring together resources to support infection prevention and control and antimicrobial stewardship, now has a dedicated COVID-19 section added to the CwPAMS ‘Microguide app’ providing up to date guidance.15
What is the position of industry?
In January 2020 at the World Economic Forum (WEF) in Davos, a coalition of public and private sector organisations launched the ‘Investor Year of Action’ to galvanise global action on AMR. This recognised that the financial sector sits on the top of the investment chain and can positively change behaviour if it aligns with international standards and guidelines on AMR. During this year long initiative investors are encouraged to assess and integrate risks, opportunities and impact through an AMR lens when making decisions.16
The 2020 AMR Benchmark, hosted by the Access to Medicine Foundation, which aims to guide and incentivise pharma companies to do more to tackle drug-resistance, was also launched at the 2020 WEF.17 This Benchmark evaluates 30 pharma companies with a major stake in the anti-infectives space and found that some positive signs of improvement in how companies are tackling AMR, particularly stewardship and sharing surveillance information. While it found pockets of good practice, the review concluded that the pace of change does not match the scale of the AMR challenge. Critically, the R&D pipeline remains small; and despite rising AMR rates, pipelines include few novel candidates. There is also a lack of efforts to supply older, still useful, antibiotics to low- and middle-income countries.18
The Benchmark report notes the importance of clear priorities and external incentives, such as those offered by civil society or public health agencies. While research grants and other ‘push’ incentives for R&D have stimulated small- and medium-sized companies (SMEs) to develop innovative antimicrobials, a number are at risk of going bankrupt and increasing public and private investments will be needed to guarantee the global supply of any antibiotics emerging from the pipeline.19 Here again, the impact of COVID-19 on the R&D pipelines is becoming increasingly evident and there is a real risk that the race to find a vaccine and treatments for COVID-19 will undermine progress on new antibiotics further.20
Recently, a new AMR Action Fund, launched on 9 July 2020, has stepped in to save the collapsing antibiotic pipeline, using $1 billion funding from 20 leading biopharma companies. This ground-breaking partnership is focussed on urgent public health needs and aims to bring two to four new antibiotics to patients by 2030.21
The need for a global response to AMR is now firmly on the agenda of most government’s, and the above initiatives demonstrate the increased priority now being given to tackle AMR. The urgency to embed an effective approach has become even more apparent especially as the progress so far is at risk of being undermined by the scale and impact of the COVID-19 pandemic.
One positive is that the pandemic has emphasised still further the need for technology to be able to differentiate between viral and bacterial infections and ensure that checks and balances are in place to improve the stewardship of antibiotic prescribing, including using the wealth of prescribing and diagnostic data to underpin decision making. The importance of new technologies in empowering patients to self-care and understand when to use antibiotics is also critical to tackling AMR. Now, more than ever, is the time to take action on AMR, to reduce current and future public health threats.