20th July 2021

The Journal of Antimicrobial of Chemotherapy (JAC) recently published on the Canadian antibiotic stewardship campaign ‘Using Antibiotics Wisely’. This national campaign did not have the desired effect of reducing antibiotic prescribing. Dr Oliver Van Hecke was disappointed, but not surprised. Here, he explains why…

The SARS-Cov-2 pandemic has highlighted the shortfalls in pandemic preparedness and heralds a warning for current global health issues such as antimicrobial resistance. This pandemic has highlighted the urgent need to address the inequalities, governance failures, and structurally generated ill health. The pandemic has also signalled the importance of clear, accurate and consistent messaging to achieve effective communication strategies.

Last week in JAC, the Canadian Using Antibiotics Wisely campaign (introduced in 2018) reported no significant change in short-term antibiotic prescribing patterns nationally for acute respiratory tract infections over the period January 2015 and December 2019. This finding was consistent across different age groups and antibiotic drug classes. Disappointing as this may be, I am not surprised. The material available in the Using Antibiotics Wisely campaign is good and ought to be useful. So why didn’t it work?

It is worth recollecting that there are several steppingstones to producing effective campaigns: campaign messages are firstly received by the intended audience; the message enhances the quality of prescribing and outcome expectations; the message then enables the respective audience to change their behaviour by using fewer antibiotics, or making a better antibiotic choice for an optimum duration; with no negative effect on patient outcomes; thereby reducing drug-resistant infections. Importantly, each step needs to be successfully implemented before moving to the next step. It is unlikely therefore that all of these steps are addressed in an education-focussed campaign. As the authors infer in their publication, the Using Antibiotics Wisely campaign was ‘designed as a passive educational intervention focused on knowledge sharing’ i.e. creating practical resources for clinicians to use during consultations.

Behavioural economics and social science research informs us that health-seeking behaviour, and subsequent antibiotic prescribing/use is complex and context specific. Therefore, to isolate the effects of information on outcomes that are inextricably influenced by social norms, economic and political conditions, health architecture etc. seems unrealistic, and within the timeframe of this study, premature. Unfortunately, this study did not include a process evaluation, so the lack of effect remains unexplained.

Yet, there are other critical issues that need to be addressed around antibiotic campaigns and optimising antibiotic prescribing/use.

First, there is no silver bullet. Multimodal interventions are needed and perhaps used in parallel. This includes clinical decision-support tools, point-of-care tests for common infection syndromes that are fit-for-purpose, cross-discipline team efforts to optimise antibiotic prescribing, educational/awareness campaigns, public health interventions focussed on infection prevention, vaccination etc. However, at present, our interventions are neatly siloed dividing our focus and energies.

Second, one of the fundamental steps of a successful campaign is to ensure that messages are received by the intended audience. For example, despite the efforts of traditional public-facing campaigns, public misconceptions about antibiotic use and antibiotic resistance persist. This is important to address because communities need to see campaign messages as relevant to them and accessible to shape health seeking behaviour. The Wellcome Trust’s report Reframing Resistance provides a useful framework to guide communication strategies that are personal to a target audience, accessible and in a format that encourages engagement. This includes how the content, format and delivery of the intervention(s) can create an enabling environment to enhance the desired outcome for that context. In some instances, this will mean moving away from traditional campaign strategies or deriving better evidence which is tailored to the target audience. Co-design of materials will be critical to ensure messages reach underserved populations.

Third, perhaps a more suitable outcome measure for education-focussed campaigns might be a measure of active engagement or sustained knowledge attainment with an effect on individual (prescribing) behaviour long-term. Measuring the success of campaigns like Using Antibiotics Wisely based on a reduction in antibiotic use (or consulting behaviour) is probably too optimistic bearing in mind that the decision to consult or prescribe an antibiotic is complex with many contextual influences, often dictated by social health determinants.

Oliver Van Hecke is a practising GP in East London and NIHR Clinical Lecturer at the Nuffield Department of Primary Care Health Sciences, University of Oxford. His research broadly focuses on ways to optimise antibiotic prescribing/use in high- and low-and-middle income countries, and reduce the impact of antimicrobial resistance. He is an Ordinary Member on the BSAC Council. His Twitter handle is @belgianimpi

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