War on ‘Bugs’: The Critical Yet Unrecognized Role of Nurses in Combating AMR

In 1945, Sir Alexander Fleming, physician and researcher who discovered penicillin, warned that “the person playing with penicillin treatment is morally responsible for the death of the man who finally succumbs to infection with the penicillin-resistant organism”. Today, we are witnesses to Fleming’s prediction rapidly unfolding as a global reality and disaster.

The introduction of antimicrobials has transformed public health. The discovery of penicillin and other antimicrobial medications, regarded as a modern-day therapeutic revolution, has vastly improved human survival from supposedly fatal infectious diseases. The general public has viewed antibiotics as “miracle drugs” that are able to cure even diseases like colds, bronchitis, and sinusitis for which they are usually ineffective. This perception changed society’s attitude towards the use of antibiotics. This prompted the practice of prescribing broad-spectrum antibiotics to conditions that do not necessarily need them. With the goal of soothing anxieties and meeting expectations of both the physician and the patient, broad-spectrum antibiotics undoubtedly became the easiest and first choice treatment for any condition.

The current abundance and the unprecedented abuse of the use of antibiotics are allowing resistant organisms to survive and thrive. The misuse and / or overuse of antibiotics has led us to an era of antibiotic resistance – a war on ‘superbugs’. To simply put it, we are victims of our own success.

The threat of antimicrobial resistance (AMR) is projected to intensify until 2050 leading to 10 million deaths annually and huge global economic losses. Any nurse or health care professional can attest to the fact that multidrug resistant organisms (MDRO) are a part of daily hospital reports. According to the World Health Organization (WHO), “the most critical group includes multidrug-resistant bacteria that pose a particular threat in hospitals, nursing homes, and among patients whose care requires devices such as ventilators and blood catheters. This includes Acinetobacter, Pseudomonas, and various Enterobacteriaceae (including Klebsiella, E. coli, Serratia, and Proteus), which can cause severe and often deadly infections such as bloodstream infections and pneumonia.”

To address the growing problem on AMR, the Philippines has committed to the 6-point policy package of Global Action on AMR introduced by WHO in 2011. In 2014, President Aquino created the Interagency Committee on AMR through Administrative Order No. 42 directing government agencies to formulate and implement a national action plan that will streamline efforts to combat AMR. Healthcare institutions then began establishing antibiotic stewardship programs (ASP) that implement inter-professional strategies to institute rational drug use – ensuring every patient gets the right antibiotic, at the right dose, administered by the right route, for the right duration. A growing body of knowledge suggests that antibiotic stewardship programs decrease incidence of antibiotic misuse, slow the development and spread of antibiotic resistance thus, improving patient outcomes.

Antimicrobial stewardship has been described as an interdisciplinary approach to minimizing the development of antimicrobial resistance through rational drug use. At present, key activities of antimicrobial stewardship such as (1) monitoring indication for antimicrobial treatment, (2) initiating prompt shift from intravenous to oral therapy, (3) monitoring duration, and drug allergies and side effects, (4) ensuring timely administration of antibiotics, and (5) following up missed doses have fallen in the hands of physicians and pharmacists. However, these activities are sometimes performed inconsistently due to time constraints and high workload.

Nurses are poised to collaborate with ASP implementers and contribute to the inter-professional management of antibiotics across varied healthcare settings as they are considered the primary healthcare providers responsible for reviewing medication orders and in administering these medications to patients. Nurses’ perspectives and engagement are crucial for the successful implementation of antibiotic stewardship programs. However, the extent to which nurses can contribute to these initiatives is often poorly understood. Nursing engagement in infection control has been existing since Florence Nightingale’s innovations in infection management. As frontline healthcare providers, nurses are in an ideal position to enhance ASP through multidisciplinary collaboration and cooperation.

In a review article, Edwards et al. (2011), suggests the following as potential contributions of nurses in antimicrobial management:

  • Additional support and training of nurses could ensure treatment is in line with microbiology results, and use of broad spectrum antimicrobials is limited where possible.
  • In collaboration with doctors and pharmacists, nurses can ensure antimicrobials are prescribed for appropriate duration.
  • Nurses can monitor IV antimicrobial prescriptions and engage physicians and pharmacists in discussion regarding de-escalation to oral therapy.
  • Through collaboration with doctors and pharmacists, nurses can ensure antimicrobials are prescribed for appropriate duration.
  • Through increasing nurse’s awareness and training in ASP, it is likely that they will improve antimicrobial administration practices/
  • Nurses could contribute through monitoring of blood results and working with physicians to ensure doses are in-line with recommended

As pharmacologic options for the treatment of infections decrease and the development of new antimicrobials is relatively slow and declining, it is crucial that other initiatives to reduce AMR are effectively implemented. It is imperative, then, for nurses to be informed about antibiotic resistance, antimicrobial stewardship, and other evidenced-based strategies on antibiotic management. Increasing awareness on antimicrobial management and its impact on patient outcomes may enhance antimicrobial therapy, monitoring, and administration.

Although not directly involved in prescribing medications, nurses can greatly influence decision making by (1) encouraging good medication compliance, (2) monitoring prescription decisions, and (3) reducing prescription errors. Antibiotic ward rounds can be established to provide a venue among nurses, physicians, and pharmacists to discuss antimicrobial treatment, indication, and duration. Thus, enhancing inter-professional antimicrobial management and promoting best practices.  Nursing engagement in ASP is empowering nurses to become more effective patient advocates and, could therefore be a time and cost-effective use of resources aimed at improving patient outcomes and quality of care.

Truth be told, the world is running out of antibiotics. And what better way to combat AMR than with the capacity to evolve much like these superbugs? The challenge remains. We must evolve in the way we treat and prevent infections if we are to thrive and survive this war on ‘bugs’. ###

 

References:

Antimicrobial Resistance Surveillance Reference Laboratory, Antimicrobial Resistance Surveillance Program 2013 Annual Report. Available from: Department of Health. [2014].

Antimicrobial Resistance Surveillance Reference Laboratory, Antimicrobial Resistance Surveillance Program 2014 Annual Report. Available from: Department of Health. [2015].

Edwards, R., Drumright, L., Kiernan, M., & Holmes, A. (2011). Covering more Territory to Fight Resistance: Considering Nurses’

Role in Antimicrobial Stewardship. Journal of Infection Prevention12(1), 6–10. http://doi.org/10.1177/1757177410389627

Manning, M. (2016). Antibiotic stewardship for staff nurses. American Nurse Today, 11(5).

Olans, R., Olans, R., Witt, D. (2017). Good Nursing is Good Antibiotic Stewardship. American Journal of Nursing, 117 (8), 58-63.

Republic of the Philippines 2014, Administrative Order No. 42: Creating an Inter-Agency Committee for the Formulation and Implementation of a National Plan to Combat Antimicrobial Resistance in the Philippines.

World Health Organization, 2011, Policy Package to Combat Antimicrobial Resistance.

World Health Organization, 2014, Antimicrobial Resistance Global Report on Surveillance.

World Health Organization, 2015, Action Agenda for Antimicrobial Resistance in the Western Pacific Region, WHO Press: World Health Organization 20, Avenue Appia – 1211 Geneva 27, Switzerland

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