CONTROLLING ANTIMICROBIAL RESISTANCE

Perceptions of antimicrobial use

Even though physicians are aware of the harmful effects of over-prescribing antimicrobial agents and of their own role in this practice, still they continue to over-prescribe. In part this may be to ensure patient satisfaction - to provide a "quick fix" - or to avoid the need for explanations about why a prescription is not in the patient's best interest.

To overcome this problem, it is always better;

* Improve the public's perception about the risks/benefits of microorganisms and the risk/benefits of antimicrobial therapy, by targeting parents of children and patient and other consumers by media compaigns and educational programs.

* To Improve physicians' perceptions about the risk/benefits of microorganisms and the risk/benefits of antimicrobial therapy.

* Guidelines are to be considered to be useful for the clinical diagnosis of infection and the indications for treatment. It was felt that to change perceptions, feedback should be given to physicians about their prescribing behaviour while at the same time a support system would be in place to make expertise available to individual practitioners and small hospitals.

* Establish a surveillance system permitting timely acquisition and analysis of local, regional, and/or national data concerning antimicrobial resistance in human pathogens. The specific organisms and the methodology should be determined by an expert working group.

* Establish a system within acute care hospitals to identify at admission and throughout hospitalization, as needed, patients at high risk of harbouring antibiotic-resistant bacteria. These patients should then be screened for the presence of antibiotic-resistant organisms.

* Create an expert working group to establish national laboratory standards for the detection of antimicrobial-resistant bacteria. These standards will include sample collection and transport, the use of appropriate selective media, identification and antimicrobial susceptibility testing techniques, reporting and molecular biology techniques used for molecular epidemiology. These standards will include recommendations concerning proficiency testing and training.

* Determine the scope of antimicrobial resistance and antimicrobial usage in long-term care facilities through either a pilot study involving selected long-term care facilities or through a sentinel system of long-term care facilities. The pilot would be used to study the epidemiology of antimicrobial resistance, antimicrobial use and other related issues.

* Establish a national surveillance system to monitor antibiotic resistance and antimicrobial use in the agrifood and aquaculture sectors.

* Make notifiable at the regional and national levels certain infections due to antimicrobial-resistant microorganisms. An expert working group should establish the list of microorganisms and the case definitions for the purpose of surveillance. 

Detecting Antimicrobial Resistance

The role of the microbiology laboratory is crucial in the detection and surveillance of antimicrobial resistance. The laboratory is ideally placed not only to interpret results for individual physicians but also to analyze the data it obtains so that trends in disease and in patterns of resistance can be ascertained and information passed on. It was felt that at present the links between diagnostic laboratories, public health personnel and health care professionals are not as strong as they should be. As well, there is no established information system to allow sharing of information betwen the various partners. A lack of resources and commitment is seen to be at the root of these deficiencies. A further barrier is the lack of national standards for laboratory proficiency as well as for detection of antimicrobial resistance.

Detection and surveillane were considered in relation to the community, acute care hospitals, long-term care facilities and the agriculture and animal food industry.

In the community

* identifying key populations within the community that would be targeted for surveillance, for example preschool children in day-care centres

* determining the main purpose of surveillance, and how to build on existing programs and exchange information

* establishing local antimicrobial resistance committees

Acute care institutional settings

* implementing hospital-based programs to screen for patients who are likely to introduce antimicrobial-resistant organisms into the hospital

* exploring ways of tracking overall incidence of antimicrobial resistance

* developing national standards for laboratory identification, testing and reporting of microorganisms

* providing feedback to local, regional and national stakeholders on trends in antimicrobial resistance

* linking information on antimicrobial use with information on resistence patterns

Long-term care facilities

* obtaining data on antimicrobial use and resistance in long-term care facilities, given the absence of such data at present

* identifying the barriers to detecting resistance, including lack of on-site laboratory facilities, differences in interpretation of laboratory reports, lack of accountability on issues of infection and infection control

* developing strategies to prevent the development of antibiotic resistance, the most important of which would be a recognised infrastructure in infection prevention and control.