Antimicrobial resistance (AMR) is considered by the UN as ‘one of the top 10 global public health threats facing humanity’, causing around 12,000 deaths a year in the UK – the same number as breast cancer.

The Scottish parliament held its very first debate on the matter last month, and the Health Secretary outlined the importance of stewardship and surveillance in dealing with the global health crisis.

Donald Morrison has spent most of his career as a public health microbiologist before moving to focus specifically on antibiotic resistant pathogens in the environment. He spoke to healthandcare.scot about the importance of taking a One Health approach and what we can do to help here in Scotland.

For the first 21 years of his career as a microbiologist, Dr Morrison says hospital and clinician use of antibiotics was the main concern of those in the antimicrobial resistance realm; only in the early 1990s was the scale of the problem in farms was found. And it was even later – just at the beginning of this century - when risks in the environment were exposed.

A One Health approach that considers antibiotic use and exposure in humans and animals, and now the environment, together – as part of what Dr Morrison calls a three-legged stool – is critical to dealing with the challenge:

“In my work for the first five to ten years, it was just one leg of that stool we were focused on: clinical use,” the Edinburgh Napier lecturer told healthandcare.scot.

“So it's only when we came across a new antibiotic resistant pathogen in 1987/88 that we hadn't seen before, and we asked “where did this come from?”  that we found the use of antibiotics on farms.

“So that kind of focused down to the second leg of the stool, we've got to think not just in the human medicine, but to think of animal medicine.

“And then for 10,15, 20 years of my career, we were just dealing two legs of that One Health stool. Then it opened up that the environment has now been shown to enhance resistance in a new system we hadn’t seen before.

“Unless you look at what all of them are contributing, we won't be able to deal with the AMR threat.”

The long lasting and profound effects of AMR cannot be overstated: infections could become harder to treat and surgeries could become less safe, which the review on antimicrobial resistance estimates could contribute to as many as 10 million deaths by 2050.

From 2022, the “Keep Antibiotics Working” public awareness campaign in Scotland (which runs in November-December each year to coincide with World Antibiotic Awareness Week) will be redesigned to emphasise this multi-sectoral approach to containing and controlling antimicrobial resistance, including the importance of correct pharmaceutical disposal.

Dr Morrison has been working with the One Health Breakthrough Partnership, a group in the north of Scotland that seeks to tackle environmental pharmaceutical contamination.

One initiative the group has fought for is for pharmacists to hand out disposal bags alongside people’s prescriptions, to make it easier for patients to discard of unused drugs safely.

However, antibiotics that are taken by people also pose a risk. People excrete around 70% of a consumed antibiotic on average, which then enters wastewater and increases antibiotic concentration within in the environment.

Avoiding unnecessary prescriptions of antibiotics would contribute to lowering the antibiotic concentration found in environmental sources, says Dr Morrison.

At least five antibiotic resistance pathogens that are currently causing problems in hospitals have originated from the environment, showing the importance of tackling over-prescription:

“A dominant one is reducing the use of antibiotics. Of course, we do need to use them, but there is overuse of them, and this is for unnecessary treatment,” says Dr Morrison.

“That [minimising over-prescription] would then reduce the concentration of antibiotics in the environment that is then selected for them. So that is an important stand for every nation to address.”

Antibiotic use in Scotland has fallen by 17.1% in the last five years according to a recent report by ARHAI Scotland. People’s increased abilities to practice self-care for minor infections, improved hand hygiene, and desire to protect the NHS ‘may have contributed’, says the organisation.

For infections that do require antibiotics, proper surveillance must be in place – something Dr Morrison says is a key aspect of his work.

Humza Yousaf told parliament last month that officials are looking into how Scotland could implement a “once-for-Scotland electronic surveillance system for infection, which could support patients and staff on the front line of infection control and underpin our important AMR work”.

Dr Morrison says such a standardised surveillance system, that is uniform for researchers, vets and clinicians, is key:

“It has got to be a uniform system so that we are given the same data as vets and clinicians, and it is harmonised.

“So that's where the electronic surveillance system, which would be monitoring these three areas of the One Health on the data, will be compatible. That's an area where I feel it's important to make it a One Health System.”

The pandemic has affected research efforts across the world, and microbiology research has been no different. Dr Morrison says their own work within this has also been impacted, and that the departure of two PhD students, caused by covid-19 related factors, has restricted his research output over the last two years.

Scottish Labour are calling for the Scottish Funding Council to review domestic and global funding streams available to Scottish universities and research groups that focus on antimicrobial resistance to safeguard this important stream of research.

Maree Todd, Scotland’s Public Health Minister, told parliament that “we cannot afford to be complacent”, adding that ministerial colleagues have written to the UK government several times to call for AMR to be included in all UK free trade agreements moving forward.

Read more: Pandemic sees sharp fall in antibiotic use; SMC backs antimicrobials pilot; Dentists' key role in reducing antibiotics

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