Context
A summary of the key issues
Antimicrobial resistance
Antimicrobial resistance (AMR) is a global threat causing 1.3 million deaths in 2019 with projections of 10 million by 2050.(Murray 2022) Resistance arises because targeted prescribing is difficult. The wrong drug, the wrong dose, and antibiotic use in non-bacterial infections all cause future harm. But prescribing the wrong antibiotic in the face of predictable or proven resistance (so-called ‘bug-drug’ mismatches) leaves the infection untreated and causes immediate harm.
The right antibiotic depends on integrated and timely information.
Integrated knowledge of prior treatment and resistance but patient's digital health records are fragmented. This is a logistical problem in large cities such as London with multiple secondary and specialist care providers and a mobile population. In 2016-17, nearly 4 million patients received care from two or more different hospital trusts resulting in 11 million hospital attendances with breaks in the continuity of electronic health records.(Warren 2020)
Timely knowledge of current resistance is needed, but microbiology testing takes hours to days. Most tests involve culturing and inspecing samples (blood, urine, etc). A recent audit at UCLH showed time to proven resistance is 2 days 22 hours with results available in only 30% of patients. Modern predictive algorithms work in silico to predict resistance(Yelin 2019) but such algorithms have never been deployed at scale.
Two populations are at particular risk: those living with cancer, and those living in care homes.
Living with cancer
Chemo- and immune-therapy weaken immune systems during cancer treatment, increasing infection risk. As cancer treatments improve, patients now die more often from causes other than cancer. Among younger patients, infection is the leading cause of non-cancer death.(Zaorsky 2017) Cancer care relies on protocolised broad spectrum antibiotics that when introduced 50 years ago more than halved mortality.(Schimpff 1971) But now preventable deaths loom as AMR grows.(Teillant 2015)
Living in care
Care home residents face heightened infection risks due to age-related immune decline, multiple comorbidities, and communal living. Infections like influenza, urinary tract infections, and gastroenteritis are endemic, frequently causing severe illness requiring hospital treatment. Outbreaks spread rapidly, often forcing home closures and preventing residents from seeing relatives, as seen during COVID-19.(Krutikov 2021) Infection rates are 3-5 times higher than community-dwelling older adults and care home residents receive antibiotics at twice the rate of those living independently.
Use of the wrong antibiotics in both populations create reservoirs of future anti-microbial resistance harming the wider community.
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