Antimicrobial resistance poses a major global threat as no new class of antibiotics has been introduced in decades and bacteria are developing resistance faster than new drugs can be developed. Antibiotic overuse and misuse in healthcare, agriculture, and the environment contribute to the rise of resistant bacteria. In response, Ireland and many other countries have implemented national action plans to promote appropriate antibiotic use and strengthen surveillance of resistant infections through improved prescribing, infection control, and public education. Coordinated global efforts are needed to address the growing crisis of antimicrobial resistance.

1. Antimicrobial Resistance: A Major Cause for Concern
Antibiotic therapy has played a major role in the treatment of bacterial infectious diseases
and the entire world has benefited from one of the greatest medical advancements in history.
Although a large number of antibiotics exist, they fall into only a few classes with an even
more limited number of targets. No new class of antibiotic has been introduced over the last
two decades, and antimicrobial resistance is a major global threat.
Antibiotic Classification
1. –β-lactams (penicillin’s) –cell wall biosynthesis
2. –Glycopeptide (vancomycin) –cell wall biosynthesis
3. –Aminoglycosides (gentamycin) –protein synthesis
4. –Macrolides (erythromycin) –protein synthesis
5. –Quinolones (ciprofloxacin) –nucleic acid synthesis
6. –Sulfonamides (sulfamethoxazole) –folic acid metabolism
Cell Wall Synthesis Penicillins
Cephalosporins
Vancomycin
Beta-lactamase Inhibitors
Carbapenems
Aztreonam
Polymycin
Bacitracin
Protein Synthesis Inhibitors Inhibit 30s Subunit
Aminoglycosides (gentamicin)
Tetracyclines
Inhibit 50s Subunit
Macrolides
Chloramphenicol
Clindamycin
Linezolid
Streptogramins
DNA Synthesis Inhibitors Fluoroquinolones
Metronidazole
RNA synthesis Inhibitors Rifampin
Mycolic Acid synthesis inhibitors Isoniazid
Folic Acid synthesis inhibitors Sulfonamides
Trimethoprim

2. https://meducation.net/resources/63520-Antibiotics-summar

3. No new class of antibiotic has been introduced over the last two decades.
Antibiotics an overviewavailable at https://www.khanacademy.org/science/health-and-medicine/current-issues-in-health-
and-medicine/antibiotics-and-antibiotic-resistance/a/antibiotics-an-overview. Accessed 12 November 2018
Antimicrobial resistance is one of the biggest healthcare challenges of the 21st century.
Rapidly emerging resistant bacteria threaten the extraordinary health benefits that have
been achieved with antibiotics and many of the practices of modern medicine on which we
have come to rely. The crisis is global, reflecting the worldwide overuse of these drugs and
the lack of development of new antibiotic agents by pharmaceutical companies to address
the challenge. A growing number of infections such as pneumonia, tuberculosis, gonorrhoea,
and salmonellosis are becoming harder to treat as the antibiotics used to treat them become
less effective. Antibiotic resistance leads to longer hospital stays, higher medical costs and
increased mortality. It is estimated globally that more than 700,000 people die each year as
a result of microbial resistance.
WHO defines antimicrobial resistance as a microorganism's resistance to an antimicrobial
drug that was once able to treat an infection by that microorganism. Resistance is a property
of the microbe itself, not the person or other organism infected by a microbe.
CDC (2013) published an analysis outlining the top 18 antibiotic-resistant threats and
announced that the human race is now in the “post-antibiotic era.”
Urgent Threats
 Clostridium difficile
 Carbapenem-resistant Enterobacteriaceae (CRE)
 Drug-resistant Neisseria gonorrhoeae
Serious Threats
 Multidrug-resistant Acinetobacter
 Drug-resistant Campylobacter

4.  Fluconazole-resistant Candida (a fungus)
 Extended spectrum beta-lactamase-producing Enterobacteriaceae (ESBLs)
 Vancomycin-resistant Enterococci (VRE)
 Multidrug-resistant Pseudomonas aeruginosa
 Drug-resistant nontyphoidal Salmonella
 Drug-resistant Salmonella Typhimurium
 Drug-resistant Shigella
 Methicillin-resistant Staphylococcus aureus (MRSA)
 Drug-resistant Streptococcus pneumoniae
 Drug-resistant tuberculosis
Concerning Threats
 Vancomycin-resistant Staphylococcus aureus (VRSA)
 Erythromycin-resistant Group A Streptococcus
 Clindamycin-resistant Group B Streptococcus
Practices contributing to misuse of antibiotics and antimicrobial resistance include:
Inappropriate specimen selectionand collection; inappropriate clinicaltests and failure to use
stains and smears, cultures and susceptibility tests: use of antibiotics with no clinical
indication (example viral infections): use of broad spectrum antibiotics when not indicated:
inappropriate choice of empiric antibiotics. Empiric therapy is a medical term referring to the
initiation of treatment against an anticipated and likely cause of infection prior to
determination of a firm diagnosis.
Other causes are: uncontrolled sale of antibiotics in some countries where they can be
obtained over the counter without a prescription, potentially resulting in antibiotics being
used when not indicated: antibiotic use in livestock feed at low doses for growth promotion
is known to lead to increased levels of resistance: releasing large quantities of antibiotics into
the environment during pharmaceutical manufacturing through inadequate wastewater
treatment increases the risk that antibiotic-resistant strains will develop and spread (WHO,
2014)
Several International studies have demonstrated that patterns of antibiotic usage greatly
affect the number of resistant organisms which develop. Overuse of broad-spectrum
antibiotics, such as second- and third-generation Cephalosporin’s, generate resistant strains.
The resistant strains arise either by mutation and selection or by genetic exchange in which
sensitive organisms receive the genetic material from the resistant organisms and the part of
DNA carries with it the information of mode of inducing resistance against one or multiple
antimicrobial agents. Incorrectly prescribed antibiotics contribute to the promotion of
resistant bacteria. Studies have shown that treatment indication, choice of agent, or duration
of antibiotic therapy is incorrect in 30% to 50% of cases. (CDC, 2013, Luyt et al. 2014).
In 2016 Doctor Nuala O’ Connor, ICGP Lead for HCAI Infection Control and Antimicrobial
Resistance stated that “Ireland is in the top third of antibiotic consumption in the EU. GPs in
Ireland prescribe too many broad-spectrum antibiotics, far more than countries who are
achieving low levels of antibiotic resistance and are using more targeted, narrow spectrum
antibiotics. Residents of Irish nursing homes are more than twice as likely to be on antibiotics

5. as in any other European country. Almost 40% of antibiotics used in nursing homes and long-
stay facilities in 2013 were prescribed on a purely preventative basis. We are reducing the
number of antibiotic prescriptions especially for those under the age of 16 and we are also
reducing broad-spectrum antibiotics. But we have a long way to go”.
WHO’s secretariat (2015) described the following ways to help stop antibiotic resistance.
Doctors, nurses, veterinarians and other health care prescribers should not prescribe or
dispense antibiotics unless they are absolutely necessary and have made every effort to test
and confirm which antibiotic is required.
Patients should take antibiotics only when prescribed and should always complete the full
prescription, even if they feel better, because stopping treatment early promotes the growth
of drug-resistant bacteria.
Farmers and those working in the agriculture sector should ensure that antibiotics given to
animals are used only to control or treat infectious diseases andunder veterinary supervision.
Misuse of antibiotics in livestock, aquaculture and crops is a key factor contributing to
antibiotic resistance and its spread into the environment, food chain and humans. Clean and
uncrowded conditions and vaccination of animals can reduce the need to use antibiotics.
Governmentsrequire robust national action plans to tackleantibiotic resistance.Criticalsteps
are improved surveillance of antibiotic-resistant infections, regulation of the appropriate use
of quality medicines, and education about the dangers of overuse. Countries seeking donor
help to strengthen their health systems need guidance to ensure essential antibiotics are
affordable, reach the people who really need them, and are used responsibly.
Industry needs to move fasterand more aggressivelytoresearch and develop new antibiotics,
but we also have to implement new ways of stimulating research and development. We are
currently in a race between drug development and bacterial evolution.
In amove to find a solution to the crisis,a GlobalActionPlan on Antimicrobial Resistance was
adopted by all countries in 2015, through decisions of the WHO World Health Assembly, the
FAO Conference and the World Health Organisation for Animal Health.
The Global Action Plan outlines five objectives to tackle the resistance:
 Improve awareness and understanding of antimicrobial resistance
 Strengthen knowledge through surveillance and research
 Reduce the incidence of infection
 Optimise the use of antimicrobial agents
 Develop the economic casefor sustainableinvestment that takes account of the needs
of all countries, and increase investment in new medicines, diagnostic tools, vaccines
and other interventions.
The Council of the European Union called on all its Member States to have a national action
plan in place by mid-2017 againstantibiotic resistancebased on the One Health approach and
in line with the objectives of the Global Action Plan.

6. To tackle the globalcrisis,in2017 the Irish government announced the country’s first National
Action Plan on Antimicrobial Resistance 2017-2020. Medical professionals warned that
epidemics of conditions such as tuberculosis (TB) and pneumonia could strike Ireland and
become untreatable as antibiotic resistance continues to increase. Dr Kieran Clarke of Alere
Ireland, a medical technology company, said 60% of antibiotics prescribed in Ireland may be
done so unnecessarily. “This level of prescription and consumption is unsustainable and will
almost certainly lead to a health crisis in Ireland, and indeed around the world if we do not
take steps to combat antibiotic resistance now.”
Minister for Health Simon Harris and Minister for Agriculture Michael Creed secured
government approval for Ireland’s action plan on antibiotic resistance in 2017. The goalof the
action plan is to ensure, for as long as possible, the availability of effective antibiotic
treatment options for both humans and animals,with safemedicines that are quality-assured,
used in a responsible way, and accessible to all who need them.
Antimicrobial stewardship is a systematic approach to optimising antimicrobial therapy,
through a variety of structures and interventions. It includes not only limiting inappropriate
use but also optimising antimicrobial selection, dosing, route, and duration of therapy to
maximise clinical cure, while limiting the unintended consequences, such as the emergence
of resistance, adverse drug events, and cost (HSE, 2017).
Prudent use of antibiotics, in both community and hospital practice, is a key component in
the prevention of antimicrobial resistance.
We all have a part to play in antimicrobial stewardship and preventing the misuse of
antibiotics. The key elements of antimicrobial stewardship are to:
 prescribe the right antibiotic, antiviral, antifungal for the patient - considering age,
medical conditions, pregnancy, or long-term care resident
 choose the right dose, duration, and route for the condition being treating
 cause the least amount of harm for the patient - consider drug interactions, allergy
and toxicity
 cause the least amount of harm to future patients by increasing antimicrobial drug
resistance
 do not prescribe for obvious self-limiting viral infections
 only use antibiotics for suspected bacterial infections
 promote use of immunisation to minimise infections
 practice good infection control to minimise the spread of infections (HSE, 2018)
An example of recent good practice in Ireland is the ‘South Doc Antimicrobial Prescribing
Improvement Initiative’ lead by Dr Nuala O’Connor (ICGP Lead for HCAI Infection Control and
Antimicrobial Resistance), Roisin Breen and Michael Carton (HSE Quality Improvement
Division) and Ina Mc Grath (Senior Primary Care Occupational Therapist, HSE South). The
initiative which embarked on a quality improvement journey in the winter of 2017/’18, to
influence a change in GP antibiotic prescribing patterns and influence patient’s perceptions
of antibiotics had a very good success rate. Antibiotics which should be avoided as a first line
in primary care and which had a 45% pre intervention prescription rate were reduced to
16.8% of all antibiotics prescribed. Co-Amoxiclav, a broad spectrum antibiotic which should

7. only be prescribed in special cases and which had accounted for 34% of all antibiotics
prescribed pre intervention, was reduced to 11.6%.
HSE antimicrobial prescribing guidelines provides best practice information and guidelines for
practitioners about antibiotic prescribing for different conditions and illnesses, drug
interactions and prescribing in children. Available at: www.antibioticprescribing.ie
12 Steps to Prevent Antimicrobial Resistance
Source: https://www.slideshare.net/doctorrao/antibiotics-misuse-of-antibiotics
Source: https://www.slideshare.net/lehnent/antibiotic-ireland-94909358
Author: Theresa Lowry-Lehnen
Clinical Nurse Practitioner and Associate Lecturer at Institute of Technology Carlow, Ireland

8. References
Centers for Disease Control and Prevention (2013). Office of Infectious Disease Antibiotic
resistance threats in the United States. Available at:
http://www.cdc.gov/drugresistance/threat-report-2013. Accessed November 10th, 2018.
Department of Health (2017). Ireland’s National Action Plan on Antimicrobial Resistance
2017-2020. (iNAP) Available at http://health.gov.ie/national-patient-safety-office/patient-
safety-surveillance/antimicrobial-resistance-amr/ Accessed 12 November 2018
Halpin, H. (2017) Explainer: What is Ireland doing to tackle antibiotic resistance? Available at
https://www.thejournal.ie/antimicrobial-antibiotic-resistance-ireland-3507819-
Jul2017/Accessed 12 November 2018.
HSE Guidelines (2013) ‘Keeping antibiotics effective is everyone’s responsibility’. HSE,
Ireland. Available at
https://www.hse.ie/eng/services/news/media/pressrel/newsarchive/2013archive/nov2013
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HSE (2018) Antibiotic prescribing guidelines (Revised version 2018). Available at
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Luyt CE, Brechot N, Trouillet JL, Chastre J. (2014). Antibiotic stewardship in the intensive
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O’Connor, N., Breen, R., Carton, M. (2017). South Doc Antimicrobial Prescribing
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