Background

This framework addresses the need for action to tackle one of the greatest threats to national and global public health: Antimicrobial resistance.

“Antimicrobial Resistance (AMR) occurs when bacteria, viruses, fungi and parasites no longer respond to antimicrobial medicines. As a result of drug resistance, antibiotics and other antimicrobial medicines become ineffective and infections become difficult or impossible to treat, increasing the risk of disease spread, severe illness, disability and death.” (World Health Organization (2023a))

“Antimicrobial resistance (AMR) is one of the top global public health and development threats. It is estimated that bacterial AMR was directly responsible for 1.27 million global deaths in 2019 and contributed to 4.95 million deaths.” (Antimicrobial Resistance Collaborators (2022))

About antimicrobials

An antimicrobial is an agent that kills microorganisms (germs) or prevents their growth.

Antibiotics are a commonly used type of antimicrobial medicine and are critical for treating infections caused by bacteria. They were discovered in 1928 and quickly became essential for healthcare. They have had a profound impact on the treatment and prevention of infection, including enabling surgery, cancer care and other treatments. Antimicrobials have greatly increased our life span and have saved millions of lives.

They are also used in the care of animals and plants, and they are important to ensure food production and supply.

About antimicrobial resistance

Antimicrobial resistance (AMR) happens when a microorganism no longer responds to antibiotics or other antimicrobials which have previously been used to treat the infection.

Antibiotic use is the main cause of AMR. Some bacteria die when we use them, but some resistant bacteria can survive and even multiply. The overuse of antibiotics gives bacteria more chances to become resistant to them.

AMR is a major threat to public health and healthcare in the world today.

Infections are now becoming more difficult to treat and there is a real risk of infections being more easily spread to others. Some antibiotics that were previously used for first-line treatment of common infections (e.g. penicillin for S. aureus infections), are no longer effective. The UK is now seeing some microorganisms that now resistant to many drugs and cannot be treated by antibiotics that are commonly used as a last resort.

The reduced choice of antibiotics seriously weakens our ability to fight infections.

Ultimately, the rise in antimicrobial resistant organisms (often called “superbugs”) will result in untreatable infection and loss of life. It is estimated that by 2050, 10 million people will die every year due to infection with resistant bacteria. Bacterial resistance usually develops silently, often in the human gut following exposure to antibiotics for treatment of a suspected infection in the chest or urine.

Resistance only becomes apparent later when a further infection occurs, and everyday antibiotics no longer work. The WHO (2023b) described AMR as “… a multi-faceted global challenge known as a “silent pandemic”. It is considered one of the top ten global public health threats to humanity in the 21st century.

We need urgent action to preserve the antimicrobials we have available today, by optimising their prescription and avoiding unnecessary use.

The use of antimicrobials in Scotland

In 2023, almost a third of the Scottish population received at least one course of antibiotics prescribed in primary care (excluding dental care). This was more than four out of every five antibiotics - over 4 million items. Less than one in five were prescribed in hospitals (ARHAI Scotland 2024).

Prescribing antimicrobials when needed can save lives, prevent hospital admission and other complications. When used before some operations or other procedures, antimicrobials can prevent infections related to the procedure.

However, antimicrobials are frequently misused, e.g. in the treatment of coughs and colds or for treatment of a possible urinary tract infection when there are no symptoms. Reducing unnecessary antimicrobial use across all care settings is urgently required and is a major focus in the fight against AMR. There are national targets to reduce their use in Scotland.

From 2018 to 2021 there was a 2.5% year on year reduction in the use of antibiotics. But in 2022 use was 10% higher than in 2021. From 2022 to 2023, total antibiotic use in humans increased by 5.1%.

The reasons for this are not yet clear, but clinical practice has changed very much after the COVID-19 pandemic. There are less face-to-face consultations and an increasingly elderly population. This often requires the management of more than one condition at the same time. It is vital that staff in all care settings contribute to containing and reducing AMR risk by supporting all aspects of antimicrobial prescribing.

The environment, human food, animal health and human health are all interlinked and must be tackled jointly. This is recognised by the Scottish “One Health” approach to control AMR.

What is antimicrobial stewardship?

“Antimicrobial stewardship is a systematic approach to educate and support health care professionals to follow evidence-based guidelines for prescribing and administering antimicrobials. The education of the health workforce is of crucial importance, as they form the front line in safeguarding the effectiveness of antimicrobial medicines.” (World Health Organization (2024))

“Antimicrobial stewardship is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms” (Association for Professionals in Infection Control and Epidemiology (APIC) (2024))

Antimicrobial stewardship (AMS) involves actions to select an appropriate antimicrobial drug and optimise its dose and duration to cure an infection. The aim is to minimise toxic effects and avoid the rise of resistant organisms.

The core AMS principles include:

• knowing when to start (or avoid) an antimicrobial
• choosing an appropriate agent
• selecting an appropriate dose, route of administration and duration of therapy
• safely administering treatment.

After the diagnosis of an infection, the ongoing need for antimicrobials needs to be reviewed. Antimicrobial treatment needs to be either continued, changed or stopped.

Many other aspects of care play an important role and impact on the optimal use of antimicrobials. They also include:

• preventing infection through infection prevention and control practices, vaccination and other public health measures
• promptly and correctly recognising and diagnosing infection, while avoiding overdiagnosis of infection by requesting unnecessary microbiological tests
• safely disposing of unused antimicrobials to minimise further environmental impact.

All health and social care staff need to work together to provide the best possible care. This means working across different care pathways and care settings, wherever care is delivered.

Those we care for - and their families and carers - also play a crucial role. It is therefore important that they also have an awareness of the issues related to the use of antimicrobials and are included in decision-making.

Together we need to keep antimicrobials working for future generations.