23rd June 2021

To celebrate our 50th anniversary, we’re inviting a select number of experts to share what they see as being the 21st-century solutions to one of the biggest and most complex challenges of our generation: antimicrobial resistance. In this post, Debra Goff explores the future of of antibiotic stewardship...

We are one year into the global COVID-19 pandemic. What if you could have done something to contribute to the prevention of COVID-19 would you have done it? I think every person would say YES! You now have an opportunity to make a meaningful difference to stop a global slow moving pandemic called antibiotic or antimicrobial resistance (AMR). Unlike COVID-19 that hit hard and fast, AMR has been occurring slowly over several years. AMR didn’t hit hard and fast yet 700,000 people worldwide die from AMR infections each year. If we stay the course experts predict 10 million people will die from AMR by 2050. AMR undermines the whole the medicine. AMR needs a grass roots effort to move the needle with respect to preserving antibiotics for our children’s children. We must learn how to use antibiotics in humans and animals in a way that doesn’t worsen AMR. COVID-19 showed we know how to react quickly to an infectious disease. We must band together globally and have move quickly to slowdown AMR.

The word stewardship means caring for or overseeing something worth protecting. The term antibiotic stewardship refers to overseeing the appropriate use of antibiotics in humans, animals and the environment to decrease AMR and preserve antibiotic effectiveness worldwide. Antibiotics are a precious resource that can save your life and therefore antibiotics are worth protecting. Unfortunately the world has overused antibiotics for decades and I see people with untreatable antibiotic resistant infections that result in death. If we want a future free from the fear of untreatable infections we ALL need to become “stewards” of antibiotics. This includes healthcare providers who overprescribe antibiotics, consumers who pressure doctors for antibiotics, and veterinarians and farmers who overuse antibiotics in animals. The overuse of antibiotics in livestock production significantly contributes to AMR.  Fast food restaurants are some of America’s largest meat buyers. They play an instrumental role in pushing meat producers to use antibiotics responsibly. Consumers want restaurants to serve meat raised without the routine use of antibiotics and therefore we now have a scorecard comparing fast food restaurants use of antibiotics.

People have the power to make a difference in AMR by choosing to shop at grocery stores selling antibiotic free chicken and meat or eating at restaurants that serve antibiotic free chicken and meat.

According to the Centers for Disease Control and Prevention (CDC), at least 2.8 million antibiotic-resistant infections occur each year in the US, killing at least 35,000 people. That equals 7,670 AMR infections per day, many of which are preventable. Antibiotics are the most prescribed medicine in the world. High-income countries like the US have access to all antibiotics and therefore have excessive antibiotic use. In U.S. hospitals, nearly 60% of patients receive antibiotics during their stays. Despite national guidelines for the appropriate use of antibiotics, data obtained in 2015 from 190 US hospitals identified 56% of antibiotic prescriptions examined were inappropriate, either the wrong dose, wrong duration or wrong drug. In an effort to improve the appropriate use of antibiotics in hospitals, antibiotic stewardship programs are now required in US hospitals. However, most antibiotics are prescribed in the outpatient setting. The CDC found 30% of outpatient antibiotic prescriptions are unnecessary. Many people pressure doctors to prescribe antibiotics even when they don’t need them. Doctors often prescribe antibiotics to please the patient and to avoid negative reviews on social media.  AMR did not occur overnight and therefore it is difficult to quickly change the antibiotic prescribing behavior of physicians. The overuse of antibiotics must stop and antibiotic stewardship programs are designed to do just that. I am frequently asked why I am so passionate about antibiotic stewardship. I am passionate about antibiotic stewardship because I have seen people in hospitals across six continents suffer and die from AMR. I have worked in hospitals in low- middle-income countries (LMIC) that have no access to effective antibiotics. The indiscriminate use of antibiotics that are often prescribed “just-in-case” there might be an infection was the title of my TedX talk on AMR. I have also seen first hand the impact of people who are committed to slowing the spread of AMR. It may be the security guard at the entrance of the hospital in India who made sure you used alcohol hand gel to clean your hands before entering the hospital, or the neonatology nurse in Vietnam who showed the new mom how to wash her hands properly to prevent her newborn from acquiring an AMR infection or the pharmacist in South Africa who taught taxi drivers that antibiotics do not work for colds. They understand that the whole of medicine and the future health of our children’s children depend on access to effective antibiotics.

In contrast to the excess use of antibiotics in high-income countries, LMIC have problems of lack of access to antibiotics. In LMIC’s, more people die from lack of access to antibiotics than AMR. There are patients who need antibiotics and have no access to a doctor or antibiotics. This lack of access to doctors is why antibiotics can be purchased over-the-counter in many countries without prescriptions. Targeted educational campaigns to inform the public on when an antibiotic may be necessary and when antibiotics are not be needed is important. Community pharmacists in low-middle income countries (LMIC) can play an important role in helping patients to make good antibiotic decisions.

AMR is a crisis now and requires individuals to engage in some form of action. I like using the Train the Trainer approach. I teach 4 South African pharmacists antibiotic stewardship activities, and they teach 4 additional people who then teach 4 others. This grassroots hands on approach can be duplicated to rapidly tackle AMR. Society cannot sit back hoping world leaders will solve the spread of AMR. AMR policies are necessary but individual people hold the key to making a difference in AMR. Malala Yousafzai showed the world how one person can make a difference. At the age of 17 she was awarded The Nobel Peace Prize for her activism for the rights of girls to have an education. AMR needs more Malala’s.

Dr. Goff is an Infectious Disease Specialist pharmacist, global antibiotic stewardship expert and founding member of the Antibiotic Stewardship Program (ASP) at The Ohio State University (OSU) Wexner Medical Center (OSUWMC) and Professor of Pharmacy Practice in the College of Pharmacy in Columbus Ohio USA.

Dr. Goff is a TEDx speaker on antibiotics “just in case” there’s infection. She founded the OSU-South Africa Train-the-Trainer Antibiotic Stewardship Pharmacist Mentoring Program in 2012. She received the 2019 OSU Distinguished International Outreach and Engagement Award for her ongoing work in South Africa. She has worked in hospitals across six continents implementing antibiotic stewardship programs. Dr. Goff is one of twenty-five global experts selected by the World Health Organization (WHO) to implement stewardship programs in low-middle income countries (LMIC). She is a consultant to the Centers for Disease Control and Prevention (CDC) on neonatal antibiotic stewardship in LMICs. She has over 150 publications and lectures nationally and internationally. She uses Twitter (@idpharmd) to increase global engagement, educate and increase awareness of antibiotic resistance.

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Initial response from BSAC

Dr Goff’s blog addresses the overuse and inappropriate use of antimicrobials in human medicine and animal husbandry. It also highlights the conflict between excess and access.

There are a number of conundrums relating to antimicrobial resistance and the use of antimicrobials agents. These emphasise the global nature of the AMR problem and also the inequalities in healthcare provision in different settings.

  • Worldwide, more antimicrobials are administered to well animals than to unwell humans
  • More people die due to lack of access to essential antimicrobials than due to antimicrobial excess.
  • Yet, we see the burden of antimicrobial resistance increasing relentlessly as more people are infected with resistant organisms and this is driven by overuse.

The blog emphasises that we need coordinated global action to combat these issues. Climate change is an often used comparator for global action. Utilising concepts such as the comparison of antimicrobial exposure of meat products to influence public opinion could prove important. Should we label food products with the ‘antibiotic footprint’ in the same way that we consider the carbon footprint of actions we take?

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