Overuse of antibiotics: Can viral vaccinations help stem the tide?

Antibiotics have been the cornerstone of modern medicine for the past 80 years and are one of the most common drugs prescribed in healthcare systems worldwide. However, overuse of antibiotics is driving the development and spread of antimicrobial resistance (AMR), compromising the utility of antibiotics to treat and prevent infections. Antibiotic exposure can alter a host's microbiome, thereby increasing the risk of adverse drug events and infections from opportunistic pathogens. If strategies are not implemented to control antibiotic overuse, adverse health and economic impacts are likely, with the burden of AMR disproportionally affecting low and middle-income countries. Within the United Kingdom, there has been a reported 32% rise in the total number of bloodstream infections (BSI) caused by bacteria resistant to one or more key antibiotics from 2014 to 2018. Over 2000 deaths annually are attributable to resistant infections in the United Kingdom. Therefore, to maintain the efficacy of available antibiotics and ensure the continuity of safe and effective healthcare, the U.K. government has continued to push for the optimisation of antibiotic use. Since 2014, progress in the U.K. has been promising, with an estimated 9% reduction in total healthcare antibiotic prescriptions. The majority of this reduction is a result of a drop in primary care antibiotic prescribing, where approximately three-quarters of total U.K. prescribing takes place. Implementation of several antibiotic stewardship interventions, including educational tools, campaigns, and financial incentives, has contributed to the reduction in antibiotic prescribing in primary care. While, for example, lower levels of amoxicillin prescribing in primary care are associated with lower levels of resistance against amoxicillin and trimethoprim among urinary specimens, this does not necessarily result in a reduction in resistance against antibiotics that are almost exclusively used in the hospital setting. Moreover, within England, the reported number of macrolide-resistant BSI for Gram-positive bacteria increased between 2014 and 2018, even though prescribing for macrolides decreased in both hospitals and primary care. Sustained or increased resistance in the absence of antibiotic exposure could be a result of multiple factors, including resistance genes imposing a negligible fitness cost, continued use of other antibiotics that are co-selecting for resistance, or lagged effects of antibiotic reductions. In secondary care, antibiotic prescribing is on the rise in England, with a 3% increase in prescriptions since 2014. Antibiotic stewardship programmes such as the Combined Sepsis and AMR Commissioning for Quality and Innovation (CQUIN) have improved prescribing practice within secondary care, with more prescriptions reviewed within 72 hr and reduced use of last-resort antibiotics. However, only around 25% of the trusts met their target reduction in total antibiotic use from 2017 to 2019. A recent study suggests that antibiotic prescribing in NHS hospitals in England could be safely reduced by up to one third. Greater understanding of behaviours hindering progress are needed to optimise antibiotic prescribing. With the threat of AMR being overlooked within the current Severe Acute Respiratory Syndrome coronavirus 2 (SARS-CoV-2) pandemic, ensuring sustainability and efficacy of antibiotic stewardship programmes will be essential to secure the appropriate use of antibiotics within healthcare. In England, the number of antibiotic prescriptions in primary care has dropped dramatically after implementation of the lockdown end of March. While there were more antibiotic prescriptions in March 2020 than in March 2019 (2%), during April–July 2020, there were 1.4 million prescriptions less than in the same period the year before, a reduction of 14% (https://openprescribing.net/bnf/050101/). This decline was especially marked for penicillin with a reduction of 25% (1.1 million prescriptions). Reductions are likely a result of strict social isolation measures that have decreased transmission of other communicable diseases in Received: 29 June 2020 Revised: 16 October 2020 Accepted: 3 November 2020