Antibiotic prescribing and use are complex processes under the influence of socio-economic and socio-cultural drivers. Human beings have a dynamic and evolving relationship with antibiotics at the biological and sociological level. Biologically, the emergence of antibiotic resistance is potentiated by exposure to antibiotics, through their consumption by humans and animals, and through the environment (e.g., agricultural use and human, animal and manufacturing waste). In the last thirty years, there have been increasing efforts to optimise antibiotic use in human populations and, as part of a One Health approach, in farming, fisheries, agriculture and the environment. Following WHO guidelines, every country is encouraged to have a National Action Plan which identifies specific objectives for optimising antibiotic use in humans, and across a One Health agenda. These efforts are supported by a growing body of evidence indicating where gains have been made and where further work is needed. Despite these efforts, suboptimal antibiotic use remains a major concern.
The social drivers for antibiotic resistance
Discovered in 1928 and mass-produced during the Second World War, antibiotics were touted as wonder drugs that were going to cure heretofore incurable and deadly diseases. Though resistance to them developed very rapidly, the original aura of wonder drugs has not been tarnished in the collective psyche. The overreliance and false confidence in antibiotics to always save the day remains. Despite the growing evidence and efforts of scientists, clinicians, and campaigners the overarching sentiment is that there will be more antibiotics developed and the risk of using existing antibiotics to treat the present patient outweighs any future harm associated with their use. This is a fallacy, as the antibiotic pipeline is not as free-flowing as anticipated with little incentive for big pharma to invest in antibiotic drug discovery and development. Despite this, the call for more research and development for new drugs is the loudest voice in the antibiotic resistance research field, with much of the initial drug discovery research conducted using public funding through research grants. Though a necessary investment, this alone will not solve the problem of antibiotic resistance. Unless we understand the sociocultural and behavioural drivers for antibiotic use and develop contextually fit, equitable and sustainable strategies to address them, no amount of new antibiotics will cut the tide of emerging antibiotic resistance and its spread through populations.
Human beings operate within social norms and rules which moderate behaviours. Healthcare is a microcosm of human cultures and behaviours, complete with its own tribes, social norms, and microcultures. Research has demonstrated that hierarchies within healthcare across professional divides, specialism, and levels of seniority influence antibiotic use and prescribing, despite evidence-based recommendations. One of the failures of our work to date has been to not recognise this when developing strategies to influence antibiotic prescribing practices. Successful strategies will only work if we understand who the opinion leaders are within specialities, professions, and organisations. Furthermore, we need to understand that clinicians like to practice autonomously and value their own expertise and experience and that of colleagues they consider to be their peers. To influence behaviours, diplomacy is as critical as having a robust evidence base to support one’s arguments. We need to co-develop strategies with peers from the specialities, organisations and professions whose antibiotic prescribing behaviours we want to change and or optimise. We need to understand the language of risk which will resonate with the target audience. It may not always be sufficient, or even appropriate to talk about the threat of antibiotic resistance, which is a negative message. First, we must identify what risks and outcomes matter to our colleagues and how the threat of antibiotic resistance would influence these risks and outcomes. That is where the conversation about antibiotic resistance should always start.
Achieving equity in global health is central to tackling antibiotic resistance
When developing solutions to tackle antibiotic resistance, we often overlook the contextual needs, behavioural drivers, and the stakeholders who need to be involved. This is critical, particularly in collaborations between high-income countries (HICs) and low-and middle-income countries (LMICs). The threat of antibiotic resistance is greatest where there are fewest resources. Solutions invented with research funding in HICs cannot be airlifted to LMICs. What is needed is a thorough and thoughtful consideration of the resource limitations and needs in each setting. This means fostering more equitable research partnerships between HICs and LMICs, built on mutual trust and respect, to enable bilateral learning and knowledge exchange. Infectious disease and antibiotic resistance do not recognise or respect cultural or geographic boundaries. To truly have a chance at stemming the tide of antibiotic resistance, we also need to break through the cultural and geographic boundaries which are influencing the flow of resources and knowledge between the global North and the Global South.
Internationally, policymakers, funders and organisations with a stake in global health need to develop expectations and targets for change that reflect the resource limitations of different countries. Funders need to identify strategies for more equitable distribution of research money between HICs and LMICs – currently, over 70% of global health research funding remains in HICs. This requires a shift not only in platitudes and pledging to greater diversity and equality reports, but a seismic change in how we fund research. Equity in funding means giving more resources to LMICs to be able to match what is available in HICs. Achieving the needed balance in funding and equity is dependent on building capacity and supporting in-country researchers to: 1) deliver sustainable research, 2) have equitable representation in research outputs, 3) track follow on career progression through further funding, setting up research teams and emerging leaders. These are measurable targets, which funders can build into a framework for evaluating equity. The above indicators can facilitate the development of a framework for equitable partnerships in global health and antibiotic resistance research. Furthermore, we as clinicians, researchers, and advocates in global health and antibiotic research should advocate for funders to commit to investing at least 50% of all publicly funded research over the next five years inequitable research partnerships. To champion this approach there needs to be greater representation of Global South scientists, experts, and researchers in a) identifying research priorities and gaps in global health and b) co-developing and leading funding calls and panels. This is where every one of us has a role to play, by speaking up for those not represented and making room for them by sharing our platform.
Esmita is the Research Lead for Practice, Design and Engineering at the NIHR Health Protection Research Unit for Healthcare Associated Infections and Antimicrobial Resistance within the faculty of Medicine at Imperial College London. She is an honorary Associate Professor at the University of Cape Town and a visiting Researcher at Haukeland University Hospital, Bergen Norway, and adjunct faculty at Amrita Institute of Medical Sciences, Kerala India, where she is involved in helping implement and investigate national antibiotic stewardship programmes. Her work in AMR has been recognised through the Academy of Medical Sciences UK-India AMR Visiting Professor award. She is an expert advisor to the Commonwealth Pharmacy Association and a Global Health Fellow with the Office of Chief Pharmaceutical Officer, England. She is involved in mentoring and supporting clinical pharmacists across different healthcare settings and economies in implementing antimicrobial stewardship interventions. Her doctoral thesis investigated antimicrobial stewardship across India, Norway, France, Burkina Faso and England.
After completing her post-graduate training in Cambridge University Hospitals and ten years of experience as a clinical pharmacist in hospitals, Esmita began her research career. She is an investigator in a NIHR Invention for Innovation award investigating the development and use of a point of care personalised clinical decision support tool for antimicrobial prescribing. In her academic career, the focus of her research has been behaviour change interventions in the field of antimicrobial stewardship and the application of social science research methods to develop contextually relevant solutions. She is co-investigator on the ESRC award (2017-2021): Optimising antibiotic use along surgical pathways: addressing antimicrobial resistance and improving clinical outcomes (in England, Scotland, Rwanda, India & South Africa). Esmita completed her Masters (MPharm Hons) in Pharmacy at University College London, her MSc in Infectious Diseases at LSHTM and her PhD from Imperial College London.
Initial response from BSAC
Esmita has summarised a few of the many global challenges that we face in addressing antimicrobial resistance. The ‘One Health’ approach definitely does not equate to a ‘one size fits all.’ As she explains, context is everything. This matters at a national level where initiatives to influence behaviours in one Region or country may not work in another. As was once said: ‘How can I possibly get colleagues in my own hospital to improve hand hygiene if they won’t even stop at a red traffic light on the way to work?’ It also matters at a local level, even down to an individual hospital, where one clinical team may have a very different culture and ways of working to another. Most clinicians will be very aware of this from their own experiences. We need to understand the differences that exist at these various levels to be able to adapt initiatives appropriately and be successful in implementing change.