Background: Infection is a widespread problem in UK hospitals, with around a third of all patients on normal wards, and two thirds of patients in intensive care on antimicrobials at any one time. Moreover, within hospitals half of those patients on antimicrobials are determined to have healthcare-associated infections, costing the National Health Service over £1billion per annum and representing a major cause of mortality. Superimpose on that the marked, and increasing, prevalence of antimicrobial resistance among the bacteria causing these infections, and the high profile currently attributed to the issue of antimicrobial resistance by the international community can, perhaps, be seen to be warranted.
Strategies to combat this rise in antimicrobial resistance have recently been put forward in international forums by the WHO, but also by the Centers for Disease Control and Prevention (CDC) in the US and by the Department of Health here in the UK in their 5-year plan which sets out their policies for this issue through to 2018. Inherent in all these strategies are three key, inter-related policy areas:
- Optimising ‘prudent’ antimicrobial use
- Improving surveillance
- Improving infection control
Developing novel therapeutics: The opportunities for engineering and physical sciences to contribute to this global issue are manifold, from chemical engineering in developing therapeutics, to structural engineers in hospital design, through to computer engineers developing data-warehousing and ‘Big Data’ analysis techniques to improve surveillance. Perhaps more difficult to achieve, yet no less a valuable target, is use of engineering expertise in pursuit of ‘prudent’ antimicrobial use. Achieving such prudent use, thereby preserving our current armamentarium of antimicrobials, can be seen to be even more necessary when one considers development of novel therapeutics frequently takes 10 or more years.
Considering this pursuit of ‘prudent’ antimicrobial use, an engineering solution would have to act to aid each encounter between a doctor and a patient with an infection to achieve a balance between ensuring cure of the patient, but help avoid unnecessary biological selective pressure towards antimicrobial resistance. Getting this balance may be thought to be easy for medical professionals by some, yet perhaps surprisingly, various studies have shown that up to half of all antimicrobial prescriptions are sub-optimal, including in the dose prescribed and the specific antimicrobial chosen. This then creates a research gap in which engineering and physical sciences expertise can generate and develop answers for real world translation.
At CBIT, and in collaboration with the National Institute for Health Research Health Protection Research Unit (NIHR HPRU) headed by Prof Alison Holmes, the vision for engineering solutions for antimicrobial resistance has been developed and is currently pursuing two avenues to aid ‘prudent’ antimicrobial use:
Rapid diagnostic using lab-on-chip technology: The first of these avenues is to bring the rapid diagnostic capabilities of lab-on-chip technology developed at CBIT team to bear on antimicrobial resistance. Implementing such a diagnostic platform into clinical care would revolutionise diagnostic pathways, which currently rely on culturing bacteria, a process than can take 24–48 hours. The lab-on-chip platform therefore has the potential to improve patient care whilst simultaneously improving antimicrobial use at the societal level by allowing more targeted antimicrobials to be used earlier.
Clinical Decision Support for Antimicrobial Prescribing: The second avenue being pursued is that of translating the artificial intelligence and machine learning expertise within the CBIT into the field of clinical decision support for antimicrobial prescribing. This further optimises ‘prudent’ antimicrobial prescribing, where the majority of prescriptions are made by doctors who are not experts in infectious diseases or microbiology, by providing a software solution to aid doctors in optimising antimicrobial prescribing for each individual patient.
An NIHR i4i project referred to as Enhanced, Personalised, Integrated Care for Infection Management at the Point Of Care (EPIC IMPOC) is currently ongoing to pursue this avenue.
Bridging the gap between Engineering, Medicine and the Natural Sciences in AMR: CBIT is also involved in a two-year EPSRC project (EMBRACE) which aims to bridge the gap between Engineering, Medicine and the Natural and Physical Sciences in antimicrobial resistance (AMR) research at Imperial College London.