CHAPTER 12 SUMMARY OF RECOMMENDATIONS
A major threat
12.1 This enquiry has
been an alarming experience, which leaves us convinced that resistance
to antibiotics and other anti-infective agents constitutes a major
threat to public health, and ought to be recognised as such more
widely than it is at present (see above, paragraph 11.1).
Prudent use in human medicine
12.2 With a view to
encouraging more prudent use of antimicrobials, health authorities
should step up continuing professional development of doctors
in the area of prescribing, especially by prescribing audit and
feedback; by educational outreach; and, for GPs, by education
in communication skills and other ways to avoid prescribing on
demand (paragraphs 11.7 and 11.12).
12.3 The Government
and the health authorities must do more to educate the public
about the proper use of antimicrobials. In particular, we recommend
a campaign targeted at mothers of young children. Nothing must
be done to deter people from visiting their GP promptly, or from
taking their medicine when necessary; but the evidence that unnecessary
antibiotics not only have public health consequences, but also
increase the risk to the individual patient that any subsequent
infection will involve a more resistant strain, should be presented
to the public (paragraphs 11.13-14).
12.4 We also recommend
that—
(i) The Education Committee
of the General Medical Council and the medical Royal Colleges
should review the evidence that undergraduate curricula give insufficient
emphasis to infectious diseases and antimicrobial therapy, and
the Royal Colleges should increase the attention paid to antimicrobial
therapy in their programmes of postgraduate education and vocational
training (paragraph 11.6);
(ii) Industry and the grant-giving
bodies should give priority to work on rapid affordable systems
for diagnosis and susceptibility testing; where promising developments
emerge, they should be quick to move them towards the market (paragraph
11.8);
(iii) The Medicines Control
Agency should consider whether the drug licensing system could
be used more effectively to encourage prudent use in the interest
of public health (paragraph 11.9);
(iv) The Government and the
ABPI must maintain their firm stand against over-the-counter antibiotics.
The Government should engage in active diplomacy to ensure that,
should the issue be raised in the EU Council of Ministers, their
position is understood and their allies are in place; and, in
the long term, to induce those Member States which are currently
more relaxed about over-the-counter antibiotics to introduce more
controls (paragraph 11.11);
(v) The NHS should work with
the relevant professional bodies to see that courses of antibiotics
are defined according to the best available current information
(paragraph 11.15);
(vi) While the new guidelines
from the Department of Health, recommending more rapid diagnostic
tests and more stringent infection control in cases of suspected
MDR-TB, are welcome, the Department must find the necessary resources
(paragraph 11.16);
(vii) Those responsible for
the NHS Information Technology Strategy should consider the contrast
between the excellent data on GP prescribing, captured by both
the Prescription Pricing Authorities and GPs themselves, and the
lack of data on antimicrobial use in hospitals. All hospitals
should install computer systems for patient-specific prescribing
information at ward level (paragraph 11.17);
and we commend the work of the WHO,
through its Division of Emerging and other Communicable Diseases
Surveillance and Control, to equip professionals and regulators
in the developing world to respond appropriately to pharmaceutical
promotions (paragraph 11.10).
Prudent use in animals
12.5 There is a continuing
threat to human health from imprudent use of antibiotics in animals
(paragraph 11.18).
12.6 Antibiotic growth
promoters such as virginiamycin, which belong to classes of antimicrobial
agent used (or proposed to be used) in man and are therefore most
likely to contribute to resistance in human medicine, should be
phased out, preferably by voluntary agreement between the professions
and industries concerned, but by legislation if necessary (paragraph
11.20).
12.7 The veterinary
profession must address the problem of over-use of fluoroquinolones
and other potent agents of importance to human medicine by introducing
rapidly a Code of Practice on when and how such compounds should
be prescribed (paragraph 11.21).
12.8 We also recommend
that—
(i) MAFF and the new
Food Standards Agency should consider the need to improve surveillance
of resistance patterns in animals (paragraph 11.22);
(ii) Departmental and Agency
boundaries must not be allowed to prevent the Government from
getting a grip on the whole of the issue of resistance, in the
interests of public health. A single multi-disciplinary Government
committee to oversee all aspects of antibiotic use, as recommended
by the Swann report, should now be established (paragraph 11.23);
(iii) MAFF should consider
the evidence of Dr Coles which suggests that resistance in
worms and scab pose a threat to the British sheep farming industry
(paragraph 11.24).
Infection control
12.9 Purchasers and
commissioning agencies for hospital services should put infection
control and basic hygiene where they belong, at the heart of good
hospital management and practice, and should redirect resources
accordingly; such a policy will pay for itself quite quickly.
The NHS Executive should assure themselves that every NHS hospital
is covered by a properly trained infection control team, as recommended
in the Cooke Report (paragraph 11.26).
12.10 The NHS should
set itself targets for controlling MRSA in hospitals, and publish
its achievements (paragraph 11.27).
12.11 The NHS should
draw up national standards and guidelines for community infection
control management, along the lines of the Cooke Report for hospitals.
These should include a requirement that every district health
authority should have at least one community infection control
nurse (paragraph 11.28).
12.12 Those responsible
for the review of the Public Health (Control of Disease) Act 1984
should consider Dr Mayon-White's evidence as to shortcomings
of the provisions for compulsory medical examination and detention
in hospital, and the case for a more humane regime, and for extending
the legislation to provide also for supervised treatment at home
(paragraph 11.29).
Surveillance
12.13 The Government
should engage constructively with the efforts of the BSAC and
the PHLS to put resistance surveillance on a more strategic and
comprehensive footing, and should find additional resources. NHS
Trusts and universities should examine their priorities in the
resourcing of their microbiological laboratories (paragraph 11.37).
12.14 The Department
of Health must reconsider the cuts in the Departmental subvention
for the PHLS (paragraph 11.32).
12.15 We also recommend
that—
(i) The NHS R&D Directorate
should support microbiological surveillance among the population
at large, with a view to improving denominator information, as
a legitimate call on the NHS R&D Budget. The MRC and the medical
charities should also be prepared to support such work (paragraph
11.31);
(ii) Those responsible for
the review of the notification provisions of the 1984 Act should
consider the proposals of our witnesses for reporting of diseases
by causative organism, and for mandatory reporting of certain
resistances. The NHS must face the resource implications of any
increase in the burden of reporting placed on hospital laboratories;
and the level of feedback from the PHLS must be correspondingly
improved (paragraph 11.33);
(iii) Health Ministers should
set a deadline for full compatibility of definitions and data-collection
between the PHLS and its analogues in Scotland and Northern Ireland
(paragraph 11.34);
(iv) Those responsible for
the NHS Information Technology Strategy should consider the scope
for IT to facilitate surveillance (paragraph 11.35);
(v) The NHS should examine
the ICARE Project run by the US Centers for Communicable Disease
Control and Prevention (CDC), and consider the possibility of
setting up something similar, possibly in partnership with CDC
(paragraph 11.36);
(vi) The failure of clinical
academic microbiology to attract recruits and fill senior posts
must be addressed by the NHS, the HEFCs and the heads of medical
schools. This seems to be a special case of a more general problem
concerning the pressures placed on clinical academic medicine
by the conflicting demands of the Research Assessment Exercise
and the ever-growing burdens of teaching, service provision and
administration; we have expressed concern about this before, and
we do so again (paragraph 11.38).
New drug development
12.16 The Government
should respond positively to the EU proposal for an "orphan
drug" regime, and should seek to ensure that the scheme gives
the pharmaceutical industry a real incentive to work on novel
treatments for problem diseases, particularly diseases of the
world's poor such as malaria (paragraph 11.40).
Vaccines
12.17 We commend the
establishment of the Edward Jenner Institute. The numerous agencies
committed to research into effective vaccines must keep up the
good work (paragraph 11.41).
Antiviral drugs
12.18 As new antivirals
reach the market, the NHS must ensure that they are used prudently
from the start, and that changes in susceptibility are monitored
(paragraph 11.42). The PHLS reference laboratory for antiviral
resistance must be adequately resourced (paragraph 11.43).
International
12.19 The Government's
exemplary support for the WHO Division of Emerging Diseases should
be maintained, and the United Kingdom Government's example should
encourage other nations and agencies to contribute to this vital
work. We endorse the resolution on this subject which is to be
considered by the World Health Assembly in May; we hope that the
Assembly will pass it. The United Kingdom's good record of support
for malaria research, and for the efforts of the WHO to help poor
countries to combat this disease, must be maintained by the Government
and the grant-awarding bodies (paragraphs 11.45-46).
Resources for research and data-collection
12.20 Grant-awarding
bodies and the NHS Executive should reconsider the important public
health issues surrounding antimicrobial research and give such
research an enhanced priority. This is a particularly suitable
area of activity for the NHS R&D Strategy. We challenge the
research community to come forward with proposals for antimicrobial
research which will fully justify support from the grant-awarding
bodies (paragraphs 11.48-49).
Information technology
12.21 The NHS Executive
must work towards the goal of compatible and interconnected IT
for every GP, every hospital ward and infection control team,
and every clinical microbiology laboratory. They must accept the
considerable cost involved; and they must give a strong lead from
the centre to ensure compatibility (paragraph 11.51).
A national strategy
12.22 The Government
should develop a strategy to safeguard the effectiveness of antimicrobials
along the lines recommended in this report; they should back it
with resources; and they should set themselves and the Health
Services challenging targets for real improvement (paragraph 11.54).
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