Interview with a Lead Pharmacist for Antimicrobial Resistance, UK Health Security Agency and Global AMR Lead, Commonwealth Pharmacist Association
Dr. Diane Ashiru-Oredope
In December 2021, the UCL PharmAlliance Medication Safety team were fortunate enough to meet with Dr. Diane Ashiru-Oredope - Pharmacist Lead for Antimicrobial Resistance and Stewardship and Healthcare Associated Infections (HCAI) at the UK Health Security Agency (UKHSA) and Global AMR Lead for the Commonwealth Pharmacists Association. The Medication Safety team collaborated with the UCL Fight the Fakes team to prepare questions which were then posed to Dr. Diane Ashiru-Oredope. It was a truly insightful and inspiring interview, which covered numerous topics - from the impact of the COVID-19 pandemic on antimicrobial resistance, to her day-to-day role.
1. Why is antimicrobial resistance a global health issue?
The World Health Organization (WHO) declared antimicrobial resistance (AMR) as one of the top 10 global public health threats against humanity, making it a major global health issue. AMR is concerning due to the speed at which it can spread, which is accelerated because of open borders, with people travelling often for business or leisure reasons, as well as the fact that it is possible for resistance to spread between humans (and note that as we see now with SARS-Cov-2 virus, healthy people can carry resistant bacteria and pass it on to others). Transmission of resistance from animals to humans can also occur.
High rates of resistance against antibiotics frequently used to treat common infections have been observed worldwide. For example, the rate of resistance to ciprofloxacin, an antibiotic commonly used to treat urinary tract infections, varied from 8.4% to 92.9% in countries reporting to the Global Antimicrobial Resistance and Use Surveillance System (GLASS). There are also high rates of drug resistance reported for fungi, viruses and parasites globally.
A report released in 2016 predicted that AMR could cause 10 million deaths each year by 2050 if adequate action is not taken. Inaction can also cause a significant economic burden, as it is estimated that AMR could cost 100 trillion dollars (also by 2050) if it is not controlled. Challenges in tackling AMR include lack of sanitation and clean water in some areas of the world, which can cause increased instances of microbial infections.
The misuse and overuse of antimicrobials to treat infections are also important drivers of AMR, as it allows mechanisms of resistance to spread more easily. There is also a limited pipeline of new antimicrobials, with the last discovery of a new class of antimicrobials being more than 30 years ago. Antimicrobials being developed today are combinations of existing classes. In 2020, WHO revealed that “none of the 43 antibiotics that are currently in clinical development sufficiently address the problem of drug resistance in the world’s most dangerous bacteria”.
In addition, highly resistant infections called ‘superbugs’ are on the rise, a common one being methicillin-resistant Staphylococcus aureus (MRSA). These infections are resistant to several types of antimicrobials, making them even more difficult to treat. In relation to the pandemic we are currently facing, the COVID-19 pandemic has shown us a real-life experience of what infections can do when untreatable.
2. Has the COVID-19 pandemic affected antimicrobial resistance in any way (both positively and negatively)?
In England, there is the English Surveillance Programme for Antimicrobial Utilisation and Resistance (ESPAUR) - an annual report which includes data on antibiotic prescribing and resistance, as well as antimicrobial stewardship. The ESPAUR report 2021 (data to end-2020) showed that the overall incidence of infection dropped between 2019 and 2020. This can be attributed to the fact that people stayed at home more often during this time and measures such as social distancing and masks were in place, making infections less likely to spread. There were also lower rates of antimicrobial prescribing.
In contrast, the proportion of bloodstream infections resistant to one or more antibiotics has increased, suggesting we are likely to see a rise in antibiotic-resistant infections as pandemic-related restrictions are discontinued. People are mixing more now in England and many places have opened up, so we have to be alert and continue to exercise caution. There have been challenges in maintaining many antimicrobial stewardship activities including audits and quality improvement activities, especially in hospitals, where resource has been allocated to dealing with the acute impact of COVID-19.
However, in a recent survey of infection pharmacists, some positive impacts were noted, including the use of technology to support meetings, for example virtual ward rounds have become possible, as well as the acceptance of biomarker tests (e.g., procalcitonin). We are also seeing primary care general practitioners (GPs) continue to access and utilise antimicrobial stewardship resources.
3. What has the UK Health Security Agency (UKHSA) implemented to tackle antimicrobial resistance?
The UKHSA is proactive in implementing the UK AMR strategy and leads on national surveillance of antimicrobial resistance, prescribing, and stewardship in England. The ESPAUR report is published annually. The UKHSA also highlight key behavioural change strategies and leads on public awareness campaigns such as Keep Antibiotics Working. We work in partnership with NHS England and NHS Improvement and other government organisations to tackle antimicrobial resistance.
There are also several Antimicrobial stewardship (AMS) activities that we lead on in the form of education and training opportunities for healthcare professionals (HCPs) and the public. For example, the Antibiotic Guardian campaign, where people can pledge to make better use of antibiotics to help tackle antimicrobial resistance. We currently have more than 147,000 pledges in more than 80 countries. It is a global support system. Antimicrobial stewardship for primary and secondary care is also provided by the UKHSA, examples of which are the TARGET Antibiotics toolkit for primary care and the ‘Treating Your Infection Respiratory Tract Infection (TYI-RTI)’ which includes information leaflets for patients. The latter is available in more than 20 languages so more people can benefit. These resources are also free of charge.
There are also online interactive and fun teaching materials on infections and AMR resistance and stewardship through the eBug website for educating children and young people, and the Antibiotic Guardian platform runs a ‘schools ambassadors’ campaign. Professionals in public health and healthcare provide teaching sessions in local schools around tackling AMR – largely supported by the excellent eBug materials.
The UKHSA leads World Antimicrobial Resistance Awareness Week for England, a campaign to raise awareness of AMR. The week runs from 18-24 November each year and this year focused on disseminating digital resources, including digital ‘sticky notes’, teleconference backgrounds, screensavers and promoting social media activity, including Twitter polls and videos from senior leads in partner organisations, pledging their ongoing support of tackling AMR.
Lastly, we publish data on AMR openly, and to my knowledge I believe England is still the only country which does so to a locality level (GP practice, CCG, hospital). The data published includes AMR and antibiotic prescribing data for Clinical Commissioning Groups (CCGs).
4. Can you tell us a bit more about your research/day to day work?
I have two roles, my main role is as the Lead Pharmacist for Antimicrobial Resistance, Stewardship and healthcare associated infections (HCAI) at UKHSA, I also have a role as the Global AMR lead for the Commonwealth Pharmacist Association (CPA). I am also an honorary lecturer at the UCL School of Pharmacy, and I am currently leading a UK wide evidence review on pharmaceutical public health on behalf of the 4 UK Chief Pharmaceutical Officers. I focus most of my time on AMS projects at UKHSA, such as developing a new stewardship workstream to consider surveillance for COVID-19 antivirals. I am also currently focused on developing the strategy and planning for the coming year, commenting and providing feedback on a range of documents including policy, guidance and Patient Group Directions (PGDs). It can be challenging but it is actually really fun, rewarding and I love my role. For my global AMR role, this week I have been on teleconferences with colleagues in Sierra Leone, Nigeria, Uganda and other African countries, to support AMS initiatives to tackle AMR. I have also been focused on the UK-wide pharmaceutical public health research, by drafting the final report and writing a presentation to the Chief Pharmaceutical Officer for England (Prof Keith Ridge) and the Pharmacy Advisory Group (PAG). Something else that I do is support and mentor trainee pharmacists as a General Pharmaceutical Council (GPhC) report found that Black trainee pharmacists perform less well in the registration assessments.
This week I have discussed clinical academic career pathways for pharmacists and met with colleagues at Imperial College London to collaborate on a Patient and Public Engagement Strategy on AMR and health inequalities. I've also had discussions around advanced clinical practice in public health for healthcare professionals, as well as meetings on AMR campaigns.
I also lecture/contribute to sessions at universities such as Schools of Pharmacies at UCL and Aston University. At Aston University, over the last few weeks I have been supporting one of their elective modules on AMR.
5. Out of the many global health issues, why was it important for you to focus on antimicrobial resistance?
My journey with antimicrobial resistance started when I was an AMR pharmacist in hospital, after which I got a role in the Health Protection Agency as it was then. AMR became more than a day job for me when I watched a documentary about an 11-year-old girl who got a simple scratch. She started to complain about hip pain, and soon after was admitted to hospital. She did not come out until 5 months later, and when she did, she was in a wheelchair, blind in one eye and had survived double lung transplants due to an untreatable infection. What had happened was that resistant organisms had caused an infection, and the doctors could not treat this infection, which meant the infection wreaked havoc on her body. I watched another documentary where another child had cut the cuticle of their finger, and due to a resistant infection, ended up having to have their finger cut off. At the time my children were very young, and I thought to myself this could happen to anyone, and realised AMR was something I wanted to help address. I wanted to do more to raise awareness and increase public engagement. One of the main things I focused on was the development of what is now called the Antibiotic Guardian campaign, as well as join the CPA, to support and learn from the CPA and other organisations as well as colleagues in other countries.
6. How do falsified and substandard medicines contribute to antimicrobial resistance?
The WHO in 2017 released a report on the burden of substandard and falsified Antimicrobials where their global analysis highlighted that 11% of antimicrobials contained subtherapeutic concentrations of active ingredient. Of course, these will not adequately treat an infection. This can lead to an increase in antimicrobial resistance. It is bad enough that we have effective medicines for which resistance develops, falsified and substandard antimicrobials pose an even greater risk of resistance developing and spreading. If infections cannot be treated adequately, it will lead to increased mortality rates, an increase in morbidity and increased risk of resistance spreading to other people.
7. What measures can be put in place in pharmacy practice to ensure the impact of antimicrobial resistance is reduced?
Infection prevention and control - pharmacy practice can put measures in place to prevent infections happening in the first place, reduce the risk of resistant organisms developing and reduce the need to use antimicrobials. Vaccination reduces the burden of infection, and so can reduce the risk of AMR, so pharmacies can provide vaccination services and/or promote vaccination
We can also optimise the use of antimicrobials. For example, if a patient presents with a self-limiting infection, we can give support without suggesting antimicrobials. Like I said before, there are resources such as the TARGET Antibiotics toolkit for primary care and the ‘Treating Your Infection Respiratory Tract Infection (TYI-RTI)’ which includes information leaflets for patients. We can inform patients how long infections will last for, when to worry or talk to a HCP, basically safety netting and giving self-care advice.
When patients come in with prescriptions, pharmacists should assess prescriptions for appropriateness and provide adequate counselling. The Pharmacy Antibiotic Checklist is a useful resource. We can assess how we are doing in terms of supporting tackling AMR by conducting audits and quality improvement projects.
Finally, we have a key role in raising awareness of AMR to the public and educating other healthcare professionals.
8. What can university students and student organisations such as PharmAlliance and Fight the Fakes do to raise awareness on antimicrobial resistance?
What you are doing right now. Educating yourselves on this important global health issue and engaging in discussions around AMR. Public engagement is another way to raise awareness on antimicrobial resistance - university students have a key role in lobbying within their university, for example through leading campaigns during World Antimicrobial Awareness Week. Students can also start simply with talking to family and friends, educating them on AMR and what we can do as individuals to mitigate its impact. Students can also organise activities such as workshops to ensure the engagement of their peers in tackling AMR. Some examples are Vaccination Champion and Antibiotic Guardian.
You can also raise awareness of AMR by posting on social media. Using the hashtags #AntibioticGuardian and #KeepAntibioticsWorking is encouraged, as we can see what excellent awareness activity you are engaging in throughout the year. I hope one day I may work alongside some of your readers in taking the fight forward together.
For more information on antimicrobial resistance, we recommend you watch this video explainer where Dr Diane Ashiru-Oredope explains what role microbes have on our planet, how antimicrobials work, what the origins of antimicrobial resistance are and more importantly, what can you do to help reduce it: https://www.youtube.com/watch?v=MENdrA8B0N4
Authors: Dorothea Tang, Nusayba Ali and Janice Wong
Acknowledgments: Yasna Nasrollahi and UCL Fight the Fakes