There are few areas in medicine – other than perhaps in the sphere of health economics – in which benefit to the individual comes at the risk of population-level harm. Getting this balance right is a key responsibility of those advocating for improved management both of time-sensitive infections such as pneumonia, and of the body’s life-threatening syndromic response to infections, sepsis. In both medical conditions –the former being the cause of around half of cases of the latter – the mainstay of therapy lies in the identification and control of the infecting organism, including with antimicrobials.
Herein of course lies the conundrum. If we err too much on the side of antimicrobial prescribing hesitancy, we will cause lives to be lost through inaction. If, conversely, we overtreat for fear of harm or retribution or simply through diagnostic zeal (an accusation which has been levelled at some commissioning incentives at home and abroad), we will certainly contribute to the growing threat of antimicrobial resistance (AMR).
With almost 250,000 episodes of pneumonia in the UK each year, and with a similar number of people developing sepsis each year (the true number being unknown and contested but high), the quantum of the potential burden on healthcare resource consumption and on AMR is vast. Both conditions preferentially affect the very young and the old and frail. Whilst in the latter group improvements in dialogue with patients and their families might prevent inappropriate and often futile intervention toward the end of natural life, the reality is that the impact of this strategy alone in terms of mitigating the rise of AMR will be small. Nonetheless, this needs to be part of a bigger picture where antimicrobials are not prescribed unnecessarily or for too long. It is inevitable that a majority of patients with pneumonia and with sepsis will receive antimicrobials but also worth stressing that the majority of chest infections are viral and require no specific treatment.
We should recognise that our public are more concerned about whether they need urgent assessment for antimicrobials, and whether or not they need a trip to hospital, than they are about whether or not they satisfy technical diagnostic criteria for pneumonia or sepsis. Further, such formal diagnostic tools and treatment guidelines can be difficult to implement with precision in a busy, resource-constrained NHS. Responsible health education of our public and empowerment to access healthcare sensibly is important, but so too is the understanding that pragmatic, operational guidelines for the recognition and management of these conditions should rightly sit alongside and support academic output. As you read this, the Academy of Medical Royal Colleges is working on new operational guidelines to support health professionals in the risk stratification and management of people with suspected sepsis and it is solutions such as these that will help clinicians to make time-sensitive but responsible decisions.
We’ve made huge progress in recent decades in supporting clinical decision-making with better diagnostic strategies underpinned by new definitions, and these definitions will continue to iterate over time as our understanding of infection, clinical risk and our body’s response to infection improves. Pattern recognition strategies applied to large patient-level datasets will, we hope, in time yield a move toward customised care and a greater understanding of therapies likely to be helpful (and at what time) for individual patients. Whilst this opportunity might be more targeted toward immunomodulation than antimicrobial therapy, it will certainly aid therapeutic precision and may well lead to more judicious use of antimicrobials.
So, what can we do right now?
It is time for a sea change in the way we talk about infection management. To accept that time-sensitive infection can be life-threatening, but that in development of strategies to mitigate this there lies responsibility to carefully consider not only AMR but also infection prevention and control (IPC). To consider these three as the ‘pillars’ of infections management and to involve all stakeholders in the conversation.
The state of the art of diagnostics technology allows us to integrate it closer to the patient, but these opportunities are being missed or delayed in today’s NHS. Real-time (within a few hours) decision making supported by rapid biomarker assays for differentiation of infectious versus non-infectious inflammation, pathogen identification and susceptibility testing, pre-symptomatic detection of sepsis and risk stratification, is increasingly possible and constantly improving. The challenge is to determine how best to utilise these tools in a clinical- and cost-effective manner, and how best to integrate (or not) the ever-expanding choice of novel diagnostics and monitors.
At a clinical level, sepsis and pneumonia sit with the deteriorating patient and must be prioritised responsibly and with due attention to clinical judgment. At a policy level, they must sit with AMR and IPC as the three pillars of infections management and be considered together.
Professor Mervyn Singer, and Dr Ron Daniels BEM will be speaking at our ‘Into Clinical Practice: Pneumonia’ conference, taking place 6 April 2022. See the full list of speakers and register your place here.