AMR – failing to join up the dots

 

If anyone is attending the Chief Pharmacists conference and listening to Dame Sally Davies would you ask her a question for me. “Why is there not an antiseptic guardian program?”

Antiseptics are very important. Most surgical infections are caused by bacteria that are lurking on or within the skin. The solution that you apply to the skin is very important to reduce the chance of a surgical site infection. These infections can be deep and very dangerous or superficial and very annoying, sometimes appearing days after discharge from hospital. They all require the use of an antibiotic. I agree wholly with Dame Sally that unless we tackle antimicrobial resistance then routine operations will become more dangerous, however it is equally important that we tighten up the use of antiseptics to reduce surgical site infections to reduce the use of antibiotics. Even Lord Carter mentioned the need to reduce surgical site infections – it is an unnecessary waste of money and cause of suffering to patients.

The problem in the UK started over 10 years ago when we allowed, perhaps even supported, a workplace disinfectant (biocide) to be introduced and bypass both the medicines and biocide legislation. We played on the inadequacy or perhaps just the unwillingness of the Health and Safety Executive to get involved in the NHS and the blind side of the CQC to implement the existing biocidal products regulations. The MHRA battled to ensure appropriate labelling, but we know that few surgeons read the label. This failure was ignored by NHS England and even the RPS who, to this day, have consistently failed to clarify biocides and their legal position to members. It is perhaps sad to reflect that the use of workplace disinfectants (biocides) on patients in the NHS is now considered custom and practice.

We face a future is simple a rush to the bottom. Who can sell the cheapest antiseptics to the NHS. And when you don’t want to use workplace disinfectants – can you find the cheapest alternative. There are no new antiseptics coming into the UK market – what is the point of researching new products and getting a licence – being sterile, single use and evidence based – when austerity and apathy means that nobody will use them.

Let us reflect on what is actually happening. You can split the hospitals into four groups:

  • Using workplace disinfectants (biocides) in patient care
  • Using lower strength chlorhexidine off label where you might expect an excess of late onset superficial infections
  • Using aqueous povidone iodine (may be masquerading as povidone iodine alcoholic tincture) where you might expect an excess of both deep and superficial infections
  • Using a sterile, single use, evidence based, licensed medicine

If you want to overlay this with clinicians who like to use two layers of one over the other, those that use 70% alcohol you have a total hotch-potch.

So we find ourselves in a position where we do not have high quality research. Surveillance rarely goes outside the hospital to pick up late infections that would present to the GP and there are usually no feedback mechanisms. Many hospitals select the cheapest product that they can source. Some are happy to put the use of workplace disinfectants on their risk register and avoid telling patients what they are using. And the MHRA and CQC who acknowledged that gap in the implementation of the existing legislation within their memorandum of understanding have done nothing.

If you ask others you may find that NHS England believe it is a regulation issue and the CQC believe it is a hospital management issue. The RPS don’t believe it is a priority for them. So come on Sally – get a grip – and launch an antiseptic guardian program. At least get us some decent research.

Note: when I refer to biocides as workplace disinfectants it is because the legislation supporting the biocides fits under the Department of Works and Pensions and not the Department of Health and Social Care. The implementation responsibility sits with the Health and Safety Executive, but is delegated to the CQC in hospital premises.

Public Health England’s team recently published their research on antiseptics. They found that when subjecting certain bacteria to very low concentrations of a common antiseptic, the bacteria coped and became resistant to colistin and many other antibiotics. This is important research telling us that improper use of low strength antiseptics may influence bacterial resistance.

 

 

 

 

 

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