Current accounts of antimicrobial resistance: stabilisation, individualisation and antibiotics as infrastructure

Consubstantialities of resistance: Labor process, (bio)materialities, and pathogenicity

As social science scholarship has historically documented, social structure and clinical practice are more commonly as contradictory or incoherent as they are often framed. The increasing emphasis on the rise of antimicrobial resistance (AMR) has drawn attention to how social realms of resistance are entrenched and interconnected through varied structural, political, clinical, biological, and ecological relations. In this study, set in São Paulo, Brazil, I sought to unpack relational consubstantialities of AMR within the healthcare labor process and their enfolded (bio)materialities and pathogenicity by drawing on a series of interviews with primary care-based health professionals, health services managers, and policymakers, completed between late 2021 and early 2023. Participants' accounts reveal how the reproduction of the labor process in primary care foregrounds (bio)material relations in which antimicrobial resistance finds timely and proper coextensive social conditions of reproduction. In their turn, the study results highlight how work intensification relates to economies of scarcity, teamwork coerciveness, AMR virulence and pathogenicity, destabilizing ecological (bio)materialities amid structural and clinical practice interrelations. Building on renewed materialisms of the political economy of health, I propose an approach to complexify understandings of relational interconnectedness of resistance by instilling relational tension lines of objects against their pragmatic reification in health interventions and theory.

Cultures of Activity, Cultivating Resistance

The problem of antimicrobial resistance (AMR) is often viewed through biomedical and/or behavioral lenses, with the underlying economic principles and "headwinds" shaping resistance less visible. In this paper, we focus on how healthcare funding models structure the ways AMR is perceived and addressed as an institutional priority. Specifically, we explore how activity-based funding reflects and operationalizes ingrained assumptions about what is valuable and/or worthwhile within the organizational ecology of the hospital. Drawing on interviews with 36 executives from several hospital clinical care settings across two Australian states, we illuminate the ways the activity-based funding paradigm works against efforts to combat AMR. Concerningly, we further observe how activity-based funding models can inadvertently position rising rates of resistance as a benefit-at least in the short term-as the new and intensified interventions required to address resistant infections require more "activity" and thus deliver higher reimbursement at the level of annualized budgets. In failing to recognize the (social and economic) value of reduced activity, activity-based funding risks contributing to AMR, rather than working to resolve it.

Antibiotic prescription, dispensing and use in humans and livestock in East Africa: does morality have a role to play?

BACKGROUND

Antimicrobial resistance (AMR) is a global threat to human and livestock health. Although AMR is driven by use of antimicrobials, it is often attributed to "misuse" and "overuse", particularly for antibiotics. To curb resistance, there has been a global call to embrace new forms of moral personhood that practice "proper" use, including prescription, dispensing and consumption of antimicrobials, especially antibiotics. This paper seeks to reflect on complex questions about how morality has become embedded /embodied in the AMR discourse as presented in the data collected on antimicrobial prescription, dispensing and use in human and livestock health in Tanzania, primarily focusing on antibiotics.

METHODS

This reflection is anchored on Jarrett Zigon's morality framework that is comprised of three dimensions of discourse; the institutional, public, and embodied dispositions. The data we use within this framework are derived from a qualitative study targeting human and animal health care service providers and community members in northern Tanzania. Data were collected through 28 in-depth interviews and ten focus group discussions and analysed through content analysis after translation and transcription. In addition, a review of the Tanzania's National Action Plans on antimicrobial resistance was conducted.

RESULTS

Application of the framework demonstrates points of convergence and divergence in the institutional morality discourse articulated by the Tanzania National Action Plans, the public discourse and the embodied dispositions/ lived experiences of human and animal health care service providers and community members. We demonstrate that AMR is not just associated with "inappropriate" behaviour on the part of drug prescribers, dispensers, and users but also with shortcomings in health systems and service delivery.

CONCLUSION

Antibiotic dispensing and use practices that may be associated with the development of AMR should not be viewed in isolation from the broader health context within which they occur.

A Review on cLF36, a Novel Recombinant Antimicrobial Peptide-Derived Camel Lactoferrin

Lactoferrin is an antimicrobial peptide (AMP) playing a pivotal role in numerous biological processes. The primary antimicrobial efficacy of lactoferrin is associated with its N-terminal end, which contains various peptides, such as lactoferricin and lactoferrampin. In this context, our research team has developed a refined chimeric 42-mer peptide known as cLF36 over the past few years. This peptide encompasses the complete amino acid sequence of camel lactoferrampin and partial amino acid sequence of lactoferricin. The peptide's activity against human, avian, and plant bacterial pathogens has been assessed using different biological platforms, including prokaryotic (P170 and pET) and eukaryotic (HEK293) expression systems. The peptide positively influenced the growth performance and intestinal morphology of chickens challenged with pathogen bacteria. Computational methods and in vitro studies showed the peptide's antiviral effects against hepatitis C virus, influenza virus, and rotavirus. The chimeric peptide exhibited higher activity against certain tumor cell lines compared to normal cells, which may be attributed to the peptide's interaction with negatively charged glycosaminoglycans on the surface of tumor cells. Importantly, this peptide exhibited no toxicity against host cells and demonstrated remarkable thermal and protease stability in serum. In conclusion, while our investigations suggest that the chimeric peptide, cLF36, may offer potential as a candidate or complementary option to some available antibiotics, antiviral agents, and chemical pesticides, significant uncertainties remain regarding its cost-effectiveness, as well as its pharmacodynamic and pharmacokinetic characteristics, which require further elucidation.

Distributive justice and value trade-offs in antibiotic use in aged care settings

Residential aged care facilities (RACF) are sites of high antibiotic use in Australia. Misuse of antimicrobial drugs in RACF contributes to antimicrobial resistance (AMR) burdens that accrue to individuals and the wider public, now and in the future. Antimicrobial stewardship (AMS) practices in RACF, e.g. requiring conformation of infection, are designed to minimise inappropriate use of antibiotics. We conducted dialogue groups with 46 participants with a parent receiving aged care to better understand families' perspectives on antibiotics and care in RACF. Participants grappled with value trade offs in thinking about their own parents' care, juggling imagined population and future harms with known short term comfort of individuals and prioritising the latter. Distributive justice in AMR relies on collective moral responsibility and action for the benefit of future generations and unknown others. In RACF, AMS requires value trade-offs and compromise on antimicrobial use in an environment that is heavily reliant on antimicrobial drugs to perform caring functions. In the context of aged care, AMS is a technical solution to a deeply relational and socio-structural problem and there is a risk that carers (workers, families) are morally burdened by system failures that are not addressed in AMS solutions.

Extensively and multidrug-resistant bacterial strains: case studies of antibiotics resistance

The development of antibiotic resistance compromises the effectiveness of our most effective defenses against bacterial infections, presenting a threat to global health. To date, a large number of research articles exist in the literature describing the case reports associated with extensively drug-resistant (XDR) and multidrug-resistant (MDR) bacterial strains. However, these findings are scattered, making it time-consuming for researchers to locate promising results and there remains a need for a comparative study to compile these case reports from various geographical regions including the Kingdom of Saudi Arabia. Additionally, no study has yet been published that compares the genetic variations and case reports of MDR and XDR strains identified from Saudi Arabia, the Middle East, Central Europe, and Asian countries. This study attempts to provide a comparative analysis of several MDR and XDR case reports from Saudi Arabia alongside other countries. Furthermore, the purpose of this work is to demonstrate the genetic variations in the genes underlying the resistance mechanisms seen in MDR and XDR bacterial strains that have been reported in Saudi Arabia and other countries. To cover the gap, this comprehensive review explores the complex trends in antibiotic resistance and the growing risk posed by superbugs. We provide context on the concerning spread of drug-resistant bacteria by analyzing the fundamental mechanisms of antibiotic resistance and looking into individual case reports. In this article, we compiled various cases and stories associated with XDR and MDR strains from Saudi Arabia and various other countries including China, Egypt, India, Poland, Pakistan, and Taiwan. This review will serve as basis for highlighting the growing threat of MDR, XDR bacterial strains in Saudi Arabia, and poses the urgent need for national action plans, stewardship programs, preventive measures, and novel antibiotics research in the Kingdom.

Shifting targets: typhoid's transformation from an environmental to a vaccine-preventable disease, 1940-2019

160 years after the discovery of its waterborne transmission and 120 years after the development of the first-generation of vaccines, typhoid fever remains a major health threat globally. In this Historical Review, we use WHO's Institutional Repository for Information Sharing to examine changes in typhoid control policy from January, 1940, to December, 2019. We used a mixed-methods approach in the analysis of infection control priorities, combining semi-inductive thematic coding with historical analysis to show major thematic shifts in typhoid control policy, away from water, sanitation, and hygiene (WASH)-based control towards vaccine-based interventions concurrent with declining attention to the disease. Documentary analysis shows that, although international planners never officially disavowed WASH and low-income countries persistently lobbied for WASH, vaccines emerged as a permanent stopgap while meaningful support of sustained WASH strengthening lost momentum-with serious, long-term ramifications for typhoid control.

Participatory identification of the causes of antimicrobial use and how they may vary according to differences in sector structure: The case of the Flemish pork and veal sectors

The increasing threat of antimicrobial resistance (AMR) to human health has prompted many countries to adopt national action plans to reduce antimicrobial use (AMU) in farm animals. To achieve this goal, it is necessary to gain a deeper understanding of the factors driving AMU in farm animals. While previous research has focused on gaining a better understanding of AMU from the perspective of farmers and veterinarians, less emphasis has been placed on examining the systemic and contextual factors that influence AMU from multiple viewpoints within the food supply chain. To this end, this paper describes a participatory approach involving multiple stakeholders from two distinct livestock sectors to identify the underlying drivers of AMU and explore their case-specificity. For each sector, we identified causes of AMU during four online focus groups, by co-creating a "problem tree", which resulted in the identification of over 50 technical, economic, regulatory, and sociocultural causes per sector and exploration of causal links. Following this, we analysed the focus group discussion through a content analysis and clustered causes of AMU that were related into 17 categories (i.e. main drivers of AMU), that we then classified as drivers of AMU at sector level or drivers of AMU at farm level. Finally, we compared the two sectors by assessing whether the generated categories (i.e. main drivers for AMU) had been discussed for both sectors and, if so, whether they involved the same causes and had the same implications. Through our analysis, we gained a better understanding of several main drivers of AMU at sector level, that result from systemic and/or contextual causes. As these cannot always be addressed by farmers and/or their veterinarian, we suggest that interventions should also target other actors related to these causes or consider them to help implement certain strategies. Furthermore, based on the results of our comparative analysis, we suggest that systemic structural differences, such as size and level of supply chain integration/fragmentation, may lead to differences in how animal health management is approached. This in turn may influence AMU's decision-making and the effectiveness of interventions, if they are generic and not tailored to the specificities of the sector.

Cycles of antibiotic use and emergent antimicrobial resistance in the South African tuberculosis programme (1950-2021): A scoping review and critical reflections on stewardship

The emergent threat of antimicrobial resistance (AMR) has resulted in debates around the use and preservation of effective antimicrobials. Concerns around AMR reflect a history of increasing dependence on antibiotics to address disease epidemics rooted in profound structural and systemic challenges. In the context of global health, this process, often referred to as pharmaceuticalisation, has commonly occurred within disease programmes, of which lessons are vital for adding nuance to conversations around antimicrobial stewardship. Tuberculosis (TB) is a notable example. A disease which accounts for one-third of AMR globally and remains the leading cause of death from a single infectious agent in many low - and middle-income countries, including South Africa. In this scoping review, we chart TB science in South Africa over 70 years of programming. We reviewed published manuscripts about the programme and critically reflected on the implications of our findings for stewardship. We identified cycles of programmatic responses to new drug availability and the emergence of drug resistance, which intersected with cycles of pharmaceuticalisation. These cycles reflect the political, economic, and social factors influencing programmatic decision-making. Our analysis offers a starting point for research exploring these cycles and drawing out implications for stewardship across the TB and AMR communities.

Antibiotics online: digital pharmacy marketplaces and pastiche medicine

The internet enables access to information and the purchasing of medical products of various quality and legality. Research and regulatory attention have focused on the trafficking of illicit substances, potential physical harms of pharmaceuticals, and possibilities like financial fraud. However, there is far less attention paid to antibiotics and other antimicrobials used to treat infections. With online pharmacies affording greater access, caution around antibiotic use is needed due to the increasing health risks of antimicrobial resistance (AMR). The COVID-19 pandemic has helped to normalise digital healthcare and contactless prescribing, amplifying the need for caution. Little is known of how antibiotics are consumed via digital pharmacy and implications for AMR prevention. To expand insight for AMR prevention policy in Australia and internationally, we use digital ethnographic methods to explore how digital pharmacies function in the context of health advice and policy related to AMR, commonly described as antimicrobial stewardship. We find that digital pharmacy marketplaces constitute 'pastiche medicine'. They curate access to pharmaceutical and information products that emulate biomedical authority combined with emphasis on the 'self-assembly' of healthcare. Pastiche medicine empowers the consumer but borrows biomedical expertise about antibiotics, untethering these goods from critical medicine information, and from AMR prevention strategies. We reflect on the implications of pastiche medicine for AMR policy, what the antibiotics case contributes to wider critical scholarship on digital pharmacy, and how medical humanities research might consider researching online consumption in future.

Microbial Fuel Cells as Effective Tools for Energy Recovery and Antibiotic Detection in Water and Food

This work demonstrates that microbial fuel cells (MFCs), optimized for energy recovery, can be used as an effective tool to detect antibiotics in water-based environments. In MFCs, electroactive biofilms function as biocatalysts by converting the chemical energy of organic matter, which serves as the fuel, into electrical energy. The efficiency of the conversion process can be significantly affected by the presence of contaminants that act as toxicants to the biofilm. The present work demonstrates that MFCs can successfully detect antibiotic residues in water and water-based electrolytes containing complex carbon sources that may be associated with the food industry. Specifically, honey was selected as a model fuel to test the effectiveness of MFCs in detecting antibiotic contamination, and tetracycline was used as a reference antibiotic within this study. The results show that MFCs not only efficiently detect the presence of tetracycline in both acetate and honey-based electrolytes but also recover the same performance after each exposure cycle, proving to be a very robust and reliable technology for both biosensing and energy recovery.

Pharmaceuticalised livelihoods: antibiotics and the rise of 'Quick Farming' in peri-urban Uganda

The 'livestock revolution' has seen the lives and livelihoods of peri-urban peoples increasingly intertwine with pigs and poultry across Africa in response to a rising demand for meat protein. This 'revolution' heralds the potential to address both poverty and nutritional needs. However, the intensification of farming has sparked concern, including for antibiotic misuse and its consequences for antimicrobial resistance (AMR). These changes reflect a micro-biopolitical conundrum where the agendas of microbes, farmers, publics, authorities and transnational agencies are in tension. To understand this requires close attention to the practices, principles and potentials held between these actors. Ethnographic research took place in a peri-urban district, Wakiso, in Uganda between May 2018 and March 2021. This included a medicine survey at 115 small- and medium-scale pig and poultry farms, 18 weeks of participant observation at six farms, 34 in-depth interviews with farmers and others in the local livestock sector, four group discussions with 38 farmers and 7 veterinary officers, and analysis of archival, media and policy documents. Wide-scale adoption of quick farming was found, an entrepreneurial phenomenon that sees Ugandans raising 'exotic' livestock with imported methods and measures for production, including antibiotics for immediate therapy, prevention of infections and to promote production and protection of livelihoods. This assemblage - a promissory assemblage of the peri-urban - reinforced precarity against which antibiotics formed a potential layer of protection. The paper argues that to address antibiotic use as a driver of AMR is to address precarity as a driver of antibiotic use. Reduced reliance on antibiotics required a level of biosecurity and economies of scale in purchasing insurance that appeared affordable only by larger-scale commercial producers. This study illustrates the risks - to finances, development and health - of expanding an entrepreneurial model of protein production in populations vulnerable to climate, infection and market dynamics.

Economic evaluation of antimicrobial resistance in curable sexually transmitted infections; a systematic review and a case study

OBJECTIVE

To provide a summary of the economic and methodological evidence on capturing antimicrobial resistance (AMR) associated costs for curable sexually transmitted infections (STIs). To explore approaches for incorporating the cost of AMR within an economic model evaluating different treatment strategies for gonorrhoea, as a case study.

METHODS

A systematic review protocol was registered on PROSPERO (CRD42022298232). MEDLINE, EMBASE, CINAHL, Cochrane Library, International Health Technology Assessment Database, National Health Service Economic Evaluation Database, and EconLit databases were searched up to August 2022. Included studies were analysed, quality assessed and findings synthesised narratively. Additionally, an economic evaluation which incorporated AMR was undertaken using a decision tree model and primary data from a randomised clinical trial comparing gentamicin therapy with standard treatment (ceftriaxone). AMR was incorporated into the evaluation using three approaches-integrating the additional costs of treating resistant infections, conducting a threshold analysis, and accounting for the societal cost of resistance for the antibiotic consumed.

RESULTS

Twelve studies were included in the systematic review with the majority focussed on AMR in gonorrhoea. The cost of ceftriaxone resistant gonorrhoea and the cost of ceftriaxone sparing strategies were significant and related to the direct medical costs from persistent gonorrhoea infections, sequelae of untreated infections, gonorrhoea attributable-HIV transmission and AMR testing. However, AMR definition, the collection and incorporation of AMR associated costs, and the perspectives adopted were inconsistent or limited. Using the review findings, different approaches were explored for incorporating AMR into an economic evaluation comparing gentamicin to ceftriaxone for gonorrhoea treatment. Although the initial analysis showed that ceftriaxone was the cheaper treatment, gentamicin became cost-neutral if the clinical efficacy of ceftriaxone reduced from 98% to 92%. By incorporating societal costs of antibiotic use, gentamicin became cost-neutral if the cost of ceftriaxone treatment increased from £4.60 to £8.44 per patient.

CONCLUSIONS

Inclusion of AMR into economic evaluations may substantially influence estimates of cost-effectiveness and affect subsequent treatment recommendations for gonorrhoea and other STIs. However, robust data on the cost of AMR and a standardised approach for conducting economic evaluations for STI treatment which incorporate AMR are lacking, and requires further developmental research.

How to approach a study in ethnopharmacology? Providing an example of the different research stages for newcomers to the field today

Ethnopharmacology seeks to investigate humankind's use of natural materials, such as plants, fungi, microorganisms, animals, and minerals, for medicinal purposes. In this highly interdisciplinary field, which can be described as a bridge between the natural/medical and socio-cultural sciences, pharmacological, anthropological, and socio-cultural research methods are often applied, along with methods from other branches of science. When entering the field of ethnopharmacology as a newcomer, student, or early career researcher today, the tremendous amount of scientific publications, and even classical books from this field and related scientific disciplines, can be overwhelming. Ethnopharmacology has evolved over the past decades, and new key topics, such as the decolonization of the field, issues on intellectual property and benefit-sharing, species conservation, the preservation of traditional knowledge, the protection of indigenous communities, science outreach, and climate change, have become important and urgent aspects of the field that must not be disregarded by today's ethnopharmacologists. One of the questions of newcomers will be, "Where to begin?" This review article offers a brief (and certainly not comprehensive) introduction to the science of ethnopharmacology, highlighting some of its past most notable achievements and future prospects. In addition, this article provides an example for newcomers to the field of how to address different stages that may be involved in conducting ethnopharmacological field and lab studies, including early-stage drug discovery and community work. The example presented summarizes a series of studies conducted in the remote Greater Mpigi region of Uganda, located in East Africa. Stages of ethnopharmacological research described include ethnobotanical surveying and fieldwork, the pharmacological assessment of activity with diverse targets in the laboratory, and the transfer of results back to indigenous communities, that is, non-financial benefit sharing as a potential best practice example. As a result of this research example, a total of six original research articles have been published on the medicinal application and ethnopharmacology of 16 plant species from the Ugandan study site, offering a large quantity of results. These six publications reflect the multifaceted nature of the interdisciplinary science of ethnopharmacology, which may serve as a reference point and inspiration for newcomers to design and conduct their own independent ethnopharmacological research endeavors at other study sites. Major bottlenecks and solutions are provided, and the current social media channels with educational ethnopharmacological content are briefly introduced.

Assessment of anticancer, antimicrobial, antidiabetic, anti-obesity and antioxidant activity of Ocimum Basilicum seeds essential oil from Palestine

BACKGROUND

Many modern pharmaceutical researchers continue to focus on the discovery and evaluation of natural compounds for possible therapies for obesity, diabetes, infections, cancer, and oxidative stress. Extraction of Ocimum basilicum seed essential oil and evaluation of its antioxidant, anti-obesity, antidiabetic, antibacterial, and cytotoxic activities were the goals of the current study.

METHOD

O. basilicum seed essential oil was extracted and evaluated for its anticancer, antimicrobial, antioxidant, anti-obesity, and anti-diabetic properties utilizing standard biomedical assays.

RESULTS

O. basilicum seed essential oil showed good anticancer activity against Hep3B (IC₅₀ 56.23 ± 1.32 µg/ml) and MCF-7 (80.35 ± 1.17 µg/ml) when compared with the positive control, Doxorubicin. In addition, the essential oil showed potent antibacterial (against Klebsiella pneumoniae, Escherichia coli, Staphylococcus aureus, Proteus mirabilis, and Pseudomonas aeruginosa) and antifungal (against Candida albicans) activities. Moreover, as for the anti-amylase test, IC₅₀ was 74.13 ± 1.1 µg/ml, a potent effect compared with the IC₅₀ of acarbose, which was 28.10 ± 0.7 µg/ml. On the other hand, for the anti-lipase test, the IC₅₀ was 112.20 ± 0.7 µg/ml a moderate effect compared with the IC₅₀ of orlistat, which was 12.30 ± 0.8 µg/ml. Finally, the oil had a potent antioxidant effect with an IC₅₀ of 23.44 ± 0.9 µg/ml compared with trolox (IC₅₀ was 2.7 ± 0.5 µg/ml).

CONCLUSION

This study has provided initial data that supports the importance of O. basilcum essential oil in traditional medicine. The extracted oil not only exhibited significant anticancer, antimicrobial, and antioxidant properties but also antidiabetic and anti-obesity effects, which provided a foundation for future research.

Knowledge, Attitude and Practice Regarding Antibacterial and Their Resistance in Medellín-Colombia: A Cross-Sectional Study

OBJECTIVE

To describe the knowledge, attitudes, and practices (KAPs) profile on bacterial resistance and antibiotic in the general population of Medellín.

MATERIAL AND METHODS

A cross-sectional study was conducted from September to December 2022, with 902 participants selected through stratified sampling with proportional allocation of different sectors of the city. The KAP scale was developed through a literature review, elimination of duplicate items, validity assessment, and reliability evaluation using Cronbach's alpha. Each item was presented with absolute and relative frequencies on a Likert scale, with a total score ranging from 0 to 100, where a higher score indicates better knowledge, attitudes, and practices. Comparisons were made using Mann-Whitney U, Kruskal-Wallis H, and linear regression.

RESULTS

The knowledge score median was 73.3 (IQR 63.3-93.3), with 36.9% reporting that antibiotics can be stopped once symptoms improve and 26.1% considering them as analgesics or antipyretics. The attitudes score was 83.3 (IQR 73.3-93.3), with 95.3% expressing concern about the impact on their health or that of their family and over 90% agreeing that more information is needed on antibiotic resistance. The practice score was the lowest at 63.9 (IQR 50-75), with 48% having been prescribed antibiotics at the pharmacy and 42.6% taking them to treat flu symptoms. Economic status (β 2.645), education in health-related areas (β 6.224), gender (β 2.892), and education level (β 3.257) determined knowledge. Knowledge (β 0.387), gender (β 2.807), and education level (β 0.686) influenced attitudes, but practices were only determined by Knowledge (β 0.084) attitudes (β 0.552) and age group (β 2.858).

CONCLUSIONS

Knowledge about antibiotics and bacterial resistance does not significantly influence the practices of the population. Therefore, interventions aimed at improving knowledge need to be reconsidered as they may not contribute to the appropriate use of antibiotics and prevention of resistance to these drugs.

Unravelling patient pathways in the context of antibacterial resistance in East Africa

BACKGROUND

A key factor driving the development and maintenance of antibacterial resistance (ABR) is individuals' use of antibiotics (ABs) to treat illness. To better understand motivations and context for antibiotic use we use the concept of a patient treatment-seeking pathway: a treatment journey encompassing where patients go when they are unwell, what motivates their choices, and how they obtain antibiotics. This paper investigates patterns and determinants of patient treatment-seeking pathways, and how they intersect with AB use in East Africa, a region where ABR-attributable deaths are exceptionally high.

METHODS

The Holistic Approach to Unravelling Antibacterial Resistance (HATUA) Consortium collected quantitative data from 6,827 adult outpatients presenting with urinary tract infection (UTI) symptoms in Kenya, Tanzania, and Uganda between February 2019- September 2020, and conducted qualitative in-depth patient interviews with a subset (n = 116). We described patterns of treatment-seeking visually using Sankey plots and explored explanations and motivations using mixed-methods. Using Bayesian hierarchical regression modelling, we investigated the associations between socio-demographic, economic, healthcare, and attitudinal factors and three factors related to ABR: self-treatment as a first step, having a multi-step treatment pathway, and consuming ABs.

RESULTS

Although most patients (86%) sought help from medical facilities in the first instance, many (56%) described multi-step, repetitive treatment-seeking pathways, which further increased the likelihood of consuming ABs. Higher socio-economic status patients were more likely to consume ABs and have multi-step pathways. Reasons for choosing providers (e.g., cost, location, time) were conditioned by wider structural factors such as hybrid healthcare systems and AB availability.

CONCLUSION

There is likely to be a reinforcing cycle between complex, repetitive treatment pathways, AB consumption and ABR. A focus on individual antibiotic use as the key intervention point in this cycle ignores the contextual challenges patients face when treatment seeking, which include inadequate access to diagnostics, perceived inefficient public healthcare and ease of purchasing antibiotics without prescription. Pluralistic healthcare landscapes may promote more complex treatment seeking and therefore inappropriate AB use. We recommend further attention to healthcare system factors, focussing on medical facilities (e.g., accessible diagnostics, patient-doctor interactions, information flows), and community AB access points (e.g., drug sellers).

Do you see the problem? Visualising a generalised 'complex local system' of antibiotic prescribing across the United Kingdom using qualitative interview data

Antimicrobial resistance (AMR) is often referred to as a complex problem embedded in a complex system. Despite this insight, interventions in AMR, and in particular in antibiotic prescribing, tend to be narrowly focused on the behaviour of individual prescribers using the tools of performance monitoring and management rather than attempting to bring about more systemic change. In this paper, we aim to elucidate the nature of the local antibiotic prescribing 'system' based on 71 semi-structured interviews undertaken in six local areas across the United Kingdom (UK). We applied complex systems theory and systems mapping methods to our qualitative data to deepen our understanding of the interactions among antibiotic prescribing interventions and the wider health system. We found that a complex and interacting set of proximal and distal factors can have unpredictable effects in different local systems in the UK. Ultimately, enacting performance management-based interventions in the absence of in-depth contextual understandings about other pressures prescribers face is a recipe for temporary solutions, waning intervention effectiveness, and unintended consequences. We hope our insights will enable policy makers and academics to devise and evaluate interventions in future in a manner that better reflects and responds to the dynamics of complex local prescribing systems.

Harnessing the probiotic properties and immunomodulatory effects of fermented food-derived Limosilactobacillus fermentum strains: implications for environmental enteropathy

Introduction

Environmental enteropathy (EE), a chronic small intestine disease characterized by gut inflammation, is widely prevalent in low-income countries and is hypothesized to be caused by continuous exposure to fecal contamination. Targeted nutritional interventions using potential probiotic strains from fermented foods can be an effective strategy to inhibit enteric pathogens and prevent chronic gut inflammation.

Methods

We isolated potential strains from fermented rice water and lemon pickle and investigated their cell surface properties, antagonistic properties, adhesion to HT-29 cells, and inhibition of pathogen adherence to HT-29 cells. Bacteriocin-like inhibitory substances (BLIS) were purified, and in vivo, survival studies in Caenorhabditis elegans infected with Salmonella enterica MW116733 were performed. We further checked the expression pattern of pro and anti-inflammatory cytokines (IL-6, IL8, and IL-10) in HT-29 cells supplemented with strains.

Results

The strains isolated from rice water (RS) and lemon pickle (T1) were identified as Limosilactobacillus fermentum MN410703 and MN410702, respectively. Strains showed probiotic properties like tolerance to low pH (pH 3.0), bile salts up to 0.5%, simulated gastric juice at low pH, and binding to extracellular matrix molecules. Auto-aggregation of T1 was in the range of 85% and significantly co-aggregated with Klebsiella pneumoniae, S. enterica, and Escherichia coli at 48, 79, and 65%, respectively. Both strains had a higher binding affinity to gelatin and heparin compared to Bacillus clausii. Susceptibility to most aminoglycoside, cephalosporin, and macrolide classes of antibiotics was also observed. RS showed BLIS activity against K. pneumoniae, S. aureus, and S. enterica at 60, 48, and 30%, respectively, and the protective effects of BLIS from RS in the C. elegans infection model demonstrated a 70% survival rate of the worms infected with S. enterica. RS and T1 demonstrated binding efficiency to HT-29 cell lines in the 38-46% range, and both strains inhibited the adhesion of E. coli MDR and S. enterica. Upregulation of IL-6 and IL-10 and the downregulation of IL-8 were observed when HT-29 cells were treated with RS, indicating the immunomodulatory effects of the strain.

Discussion

The potential strains identified could effectively inhibit enteric pathogens and prevent environmental enteropathy.

Antibiotic Use in Pregnancy: A Global Survey on Antibiotic Prescription Practices in Antenatal Care

Antibiotic prescription and use practices in the antenatal care setting varies across countries and populations and has the potential to significantly contribute to the global spread of antibiotic resistance. This study aims to explore how healthcare practitioners make decisions about antibiotic prescriptions for pregnant women and what factors play a role in this process. A cross-sectional exploratory survey consisting of 23 questions, including 4 free-text and 19 multiple-choice questions, was distributed online. Quantitative data were collected through multiple-choice questions and was used to identify the most common infections diagnosed and the type of antibiotics prescribed. Qualitative data were gathered through free-text answers to identify gaps, challenges, and suggestions, and the data were analyzed using thematic analysis. A total of 137 complete surveys mostly from gynecologists/obstetricians from 22 different countries were included in the analysis. Overall, national and international clinical guidelines and hospital guidelines/protocols were the most frequently used sources of information. This study highlights the crucial role of laboratory results and guidelines at different levels and emphasizes region-specific challenges and recommendations. These findings underscore the pressing need for tailored interventions to support antibiotic prescribers in their decision-making practice and to address emerging resistance.

The dilemmas of antimicrobial stewardship in aged care: The perspectives of the family members of older Australians

Antimicrobial resistance makes the misuse of antibiotics in residential aged care facilities (RACFs) a significant concern. Family members influence antibiotic prescribing for RACF residents, but there is limited understanding of the beliefs and knowledge that drive their involvement. Drawing on a fictional scenario, forty-six participants with a parent aged 75 or over took part in eight dialogue groups exploring family members' perspectives on antibiotic use and risks in older relatives. Main themes were identified using framework analysis. Participants supported judicious use of antibiotics in RACFs, but perceived vulnerabilities of older people, both structural and physiological prompt family pressure for antibiotics. Empirical antibiotic use became more acceptable when pathways to a prompt diagnosis are not apparent or confidence in RACF monitoring and care is lacking. The role of antibiotics in end-of-life decision-making was significantly under-recognised. Overall, elevation of discussion around antibiotics and end of life care are required.

Coping with the ESKAPE pathogens: Evolving strategies, challenges and future prospects

Globally, the ESKAPE pathogens (Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa, and Enterobacter species) are the major cause of nosocomial infections. These pathogens are multidrug resistant, and their negative impacts have brought serious health challenges and economic burden on many countries worldwide. Thus, this narrative review exploits different emerging alternative therapeutic strategies including combination antibiotics, antimicrobial peptides ((AMPs), bacteriophage and photodynamic therapies used in the treatment of the ESKAPE pathogens, their merits, limitations, and future prospects. Our findings indicate that ESKAPE pathogens exhibit resistance to drug using different mechanisms including drug inactivation by irreversible enzyme cleavage, drug-binding site alteration, diminution in permeability of drug or drug efflux increment to reduce accumulation of drug as well as biofilms production. However, the scientific community has shown significant interest in using these novel strategies with numerous benefits although they have some limitations including but not limited to instability and toxicity of the therapeutic agents, or the host developing immune response against the therapeutic agents. Thus, comprehension of resistance mechanisms of these pathogens is necessary to further develop or modify these approaches in order to overcome these health challenges including the barriers of bacterial resistance.

"If You Do Not Take the Medicine and Complete the Dose…It Could Cause You More Trouble": Bringing Awareness, Local Knowledge and Experience into Antimicrobial Stewardship in Tanzania

Antimicrobial resistance (AMR) is a global health issue disproportionately affecting low- and middle-income countries. In Tanzania, multi-drug-resistant bacteria (MDR) are highly prevalent in clinical and community settings, inhibiting effective treatment and recovery from infection. The burden of AMR can be alleviated if antimicrobial stewardship (AMS) programs are coordinated and incorporate local knowledge and systemic factors. AMS includes the education of health providers to optimise antimicrobial use to improve patient outcomes while minimising AMR risks. For programmes to succeed, it is essential to understand not just the awareness of and receptiveness to AMR education, but also the opportunities and challenges facing health professionals. We conducted in-depth interviews (n = 44) with animal and human health providers in rural northern Tanzania in order to understand their experiences around AMR. In doing so, we aimed to assess the contextual factors surrounding their practices that might enable or impede the translation of knowledge into action. Specifically, we explored their motivations, training, understanding of infections and AMR, and constraints in daily practice. While providers were motivated in supporting their communities, clear issues emerged regarding training and understanding of AMR. Community health workers and retail drug dispensers exhibited the most variation in training. Inconsistencies in understandings of AMR and its drivers were apparent. Providers cited the actions of patients and other providers as contributing to AMR, perpetuating narratives of blame. Challenges related to AMR included infrastructural constraints, such as a lack of diagnostic testing. While health and AMR-specific training would be beneficial to address awareness, equally important, if not more critical, is tackling the challenges providers face in turning knowledge into action.

Coping with in-locus factors and systemic contradictions affecting antibiotic prescription and dispensing practices in primary care-A qualitative One Health study in Brazil

Antimicrobial resistance (AMR) is an increasing threat to global health. The risks and sanitary consequences of AMR are disproportionately experienced by those living in Low- and Middle-Income Countries (LMICs). While addressing antibiotic use has largely been documented in hospital settings, the understanding of social drivers affecting antibiotic prescribing and dispensing practices in the context of human and animal health in primary care (PC) in LMICs remains extremely limited. We seek to explore how in-locus and multi-level social factors influence antibiotic prescriptions and dispensing practices in the context of human and animal health in primary care in Brazil. This is a baseline qualitative One Health study; semi-structured interviews and field observations were undertaken in primary care sites located in a socioeconomically vulnerable area in the city of São Paulo, the most populated city of Brazil. Twenty-five human and animal healthcare professionals (HP) were purposely sampled. Interview data were subject to thematic analysis. Three overlapping social drivers were identified across HPs' discourses: individual and behavioral challenges; relational and contextual factors influencing the overprescription of antibiotics (AB); and structural barriers and systemic contradictions in the health system. As a result of the interaction between multilevel in-locus and structural and contextual factors, HPs experience contextual and territorial challenges that directly influence their risk perception, diagnosis, use of laboratorial and image exams, time and decision to undergo treatment, choice of AB and strategies in coping with AB prescriptions. Additionally, in-locus factors influencing antibiotic prescriptions and dispensing practices are intertwined with individual accounts of risk management, systemic contradictions and ambivalences in the national health system. Our findings suggest interventions tackling AB use and AMR in Brazil should consider the social context, the complex health system structure and current integrated programs and services in PC.

The emerging significance of nanomedicine-based approaches to fighting COVID-19 variants of concern: A perspective on the nanotechnology’s role in COVID-19 diagnosis and treatment

COVID-19, one of the worst-hit pandemics, has quickly spread like fire across nations with very high mortality rates. Researchers all around the globe are making consistent efforts to address the main challenges faced due to COVID-19 infection including prompt diagnosis and therapeutics to reduce mortality. Conventional medical technology does not effectively contain the havoc caused by deadly COVID-19. This signals a crucial mandate for innovative and novel interventions in diagnostics and therapeutics to combat this ongoing pandemic and counter its successor or disease if it were ever to arise. The expeditious solutions can spring from promising areas such as nanomedicine and nanotechnology. Nanomedicine is a dominant tool that has a huge potential to alleviate the disease burden by providing nanoparticle-based vaccines and carriers. Nanotechnology encompasses multidisciplinary aspects including artificial intelligence, chemistry, biology, material science, physical science, and medicine. Nanoparticles offer many advantages compared to larger particles, including better magnetic properties and a multiplied surface-to-volume ratio. Given this, the present review focuses on promising nanomedicine-based solutions to combat COVID-19 and their utility to control a broad range of pathogens and viruses, along with understanding their role in the therapy, diagnosis, and prevention of COVID-19. Various studies, reports, and recent research and development from the nanotechnology perspective are discussed in this article.

Making morbidity multiple: History, legacies, and possibilities for global health

Multimorbidity has been framed as a pressing global health challenge that exposes the limits of systems organised around single diseases. This article seeks to expand and strengthen current thinking around multimorbidity by analysing its construction within the field of global health. We suggest that the significance of multimorbidity lies not only in challenging divisions between disease categories but also in what it reveals about the culture and history of transnational biomedicine. Drawing on social research from sub-Saharan Africa to ground our arguments, we begin by describing the historical processes through which morbidity was made divisible in biomedicine and how the single disease became integral not only to disease control but to the extension of biopolitical power. Multimorbidity, we observe, is hoped to challenge single disease approaches but is assembled from the same problematic, historically-loaded categories that it exposes as breaking down. Next, we highlight the consequences of such classificatory legacies in everyday lives and suggest why frameworks and interventions to integrate care have tended to have limited traction in practice. Finally, we argue that efforts to align priorities and disciplines around a standardised biomedical definition of multimorbidity risks retracing the same steps. We call for transdisciplinary work across the field of global health around a more holistic, reflexive understanding of multimorbidity that foregrounds the culture and history of translocated biomedicine, the intractability of single disease thinking, and its often-adverse consequences in local worlds. We outline key domains within the architecture of global health where transformation is needed, including care delivery, medical training, the organisation of knowledge and expertise, global governance, and financing.

The governance of antimicrobial resistance in Brazil: Challenges for developing and implementing a one health agenda

This article explores stakeholders' perceptions of the challenges for developing a One Health agenda to tackle antimicrobial resistance (AMR) in Brazil, including the development and implementation of the Brazilian National Action Plan (BR-NAP). The data originate from 27 interviews conducted with human, environmental, and animal health stakeholders, including academics, managers, and policymakers involved in developing the BR-NAP. Through thematic analysis, we identified three interconnected themes: governance, the health system, and technical and scientific challenges. The findings draw particular attention to failures in the agenda-setting process, revealed by interviewees strongly emphasising that AMR is not considered a policy priority in Brazil. The lack of political will and awareness of the clinical, social, and economic impacts of AMR are considered the main impediments to the agenda's progress. The joint work across disciplines and ministries must be reinforced through policymaker engagement and better environmental sector integration. The agenda must include sustainable governance structures less affected by political winds. Policies should be designed jointly with state and local governments to create strategies to engage communities and improve their translation into effective implementation.

The role of multidimensional poverty in antibiotic misuse: a mixed-methods study of self-medication and non-adherence in Kenya, Tanzania, and Uganda

BACKGROUND

Poverty is a proposed driver of antimicrobial resistance, influencing inappropriate antibiotic use in low-income and middle-income countries (LMICs). However, at subnational levels, studies investigating multidimensional poverty and antibiotic misuse are sparse, and the results are inconsistent. We aimed to investigate the relationship between multidimensional poverty and antibiotic use in patient populations in Kenya, Tanzania, and Uganda.

METHODS

In this mixed-methods study, the Holistic Approach to Unravelling Antimicrobial Resistance (HATUA) Consortium collected data from 6827 outpatients (aged 18 years and older, or aged 14-18 years and pregnant) with urinary tract infection (UTI) symptoms in health-care facilities in Kenya, Tanzania, and Uganda. We used Bayesian hierarchical modelling to investigate the association between multidimensional poverty and self-reported antibiotic self-medication and non-adherence (ie, skipping a dose and not completing the course). We analysed linked qualitative in-depth patient interviews and unlinked focus-group discussions with community members.

FINDINGS

Between Feb 10, 2019, and Sept 10, 2020, we collected data on 6827 outpatients, of whom 6345 patients had complete data; most individuals were female (5034 [79·2%]), younger than 35 years (3840 [60·5%]), worked in informal employment (2621 [41·3%]), and had primary-level education (2488 [39·2%]). Antibiotic misuse was more common among those least deprived, and lowest among those living in severe multidimensional poverty. Regardless of poverty status, difficulties in affording health care, and more familiarity with antibiotics, were related to more antibiotic misuse. Qualitative data from linked qualitative in-depth patient interviews (n=82) and unlinked focus-group discussions with community members (n=44 groups) suggested that self-medication and treatment non-adherence were driven by perceived inconvenience of the health-care system, financial barriers, and ease of unregulated antibiotic access.

INTERPRETATION

We should not assume that higher deprivation drives antibiotic misuse. Structural barriers such as inefficiencies in public health care, combined with time and financial constraints, fuel alternative antibiotic access points and treatment non-adherence across all levels of deprivation. In designing interventions to reduce antibiotic misuse and address antimicrobial resistance, greater attention is required to these structural barriers that discourage optimal antibiotic use at all levels of the socioeconomic hierarchy in LMICs.

FUNDING

UK National Institute for Health Research, UK Medical Research Council, and the Department of Health and Social Care.

Trust, agreements, and occasional breakdowns: Veterinarians' perspectives on farmer-veterinarian relationships and use of antimicrobials for Swedish dairy cattle

Studies have shown that farmer-veterinarian relationships influence antimicrobial use (AMU) in livestock, though how they do so is unclear. On the one hand, research shows that well-established veterinarian-farmer relationships are positive for implementation of antibiotic stewardship and restrictive AMU. On the other hand, studies also show that farmer demands can increase antimicrobial prescribing and that prescribing antimicrobials can strengthen the veterinarian's relationship with farmer clients. In the present study, we focus on veterinarians' perspectives on the relationships between dairy cattle farmers and veterinarians in Sweden and explore what characterizes these relationships when restrictive AMU is described as unproblematic and when AMU becomes a matter of tension or conflict. The study draws on semistructured interviews with 21 veterinarians working with livestock in Sweden. Interviews were analyzed thematically. The study shows that from the perspectives of veterinarians, well-established veterinarian-farmer relationships generally facilitate restrictive AMU in 3 slightly different but related ways: (1) they create trust in the veterinarian and their prescribing decisions; (2) they create shared understanding concerning when antimicrobials are needed and not needed; and (3) they facilitate constructive discussions between veterinarians and farmers on AMU. To make the farmer feel listened to and to come to an agreement on AMU was described as central for the veterinarians. However, the veterinarians described agreements on restrictive AMU as sometimes requiring strategic work, such as discussions to motivate the farmer and leave the door open for antimicrobials later if needed. Such work takes time and energy and is easier within well-established relationships according to the veterinarians. We also identified examples where veterinarians explained that they occasionally make compromises with farmers concerning antimicrobials-compromises that, according to the veterinarians, facilitate the relationship with the farmer, which in turn facilities restrictive AMU in the longer term. The examples in our interviews where antimicrobials became a matter of tension and even conflict between veterinarians and farmers could, with a few exceptions, be traced to absence of well-established relationships. However, some veterinarians also described AMU as a matter of tension within well-established relationships, especially with older farmers who do not trust new treatment strategies. We also found a small number of examples where disagreements on antimicrobials made a relationship with specific farmers impossible. Thus, even though the interviewed veterinarians generally meant that their restrictive antimicrobial prescribing did not threaten the relationship with the farmer, our study also, to some extent, confirms research showing that restrictive AMU can harm the relationship with some clients who simply choose another, less restrictive, veterinarian. In summary, our study supports that decisions on AMU cannot be reduced to the individual prescriber's behavior, nor to a strict medical judgment. Antimicrobial use for dairy cattle needs to be understood as taking form in relationships in which both veterinarians and farmers are active parts.

Carbon-based glyco-nanoplatforms: towards the next generation of glycan-based multivalent probes

Cell surface carbohydrates mediate a wide range of carbohydrate-protein interactions key to healthy and disease mechanisms. Many of such interactions are multivalent in nature and in order to study these processes at a molecular level, many glycan-presenting platforms have been developed over the years. Among those, carbon nanoforms such as graphene and their derivatives, carbon nanotubes, carbon dots and fullerenes, have become very attractive as biocompatible platforms that can mimic the multivalent presentation of biologically relevant glycosides. The most recent examples of carbon-based nanoplatforms and their applications developed over the last few years to study carbohydrate-mediate interactions in the context of cancer, bacterial and viral infections, among others, are highlighted in this review.

In critique of anthropocentrism: a more-than-human ethical framework for antimicrobial resistance

Antimicrobial resistance (AMR) is often framed as a One Health issue, premised on the interdependence between human, animal and environmental health. Despite this framing, the focus across policymaking, implementation and the ethics of AMR remains anthropocentric in practice, with human health taking priority over the health of non-human animals and the environment, both of which mostly appear as secondary elements to be adjusted to minimise impact on human populations. This perpetuates cross-sectoral asymmetries whereby human health institutions have access to bigger budgets and technical support, limiting the ability of agricultural, animal health or environmental institutions to effectively implement policy initiatives. In this article, we review these asymmetries from an ethical perspective. Through a review and analysis of contemporary literature on the ethics of AMR, we demonstrate how the ethical challenges and tensions raised still emerge from an anthropocentric framing, and argue that such literature fails to address the problematic health hierarchies that underlie policies and ethics of AMR. As a consequence, they fail to provide the necessary tools to ethically evaluate the more-than-human challenges that the long list of actors involved in managing AMR face in their everyday practices. In response to such shortcomings, and to make sense of these challenges and tensions, this article develops an ethical framework based on relationality, care ethics and ambivalence that attends to the more-than-human character of AMR. We formulate this approach without overlooking everyday challenges of implementation by putting the framework in conversation with concrete situations from precarious settings in West Africa. This article concludes by arguing that a useful AMR ethics framework needs to consider and take seriously non-human others as an integral part of both health and disease in any given ecology.

Antibiotic assemblages and their implications for the prevention of antimicrobial resistance

Individual antibiotic use for common infections is a focus for public health efforts seeking to prevent antimicrobial resistance (AMR). These approaches employ a binary opposition of responsible and irresponsible antibiotic use with a focus on the knowledge, behaviours and intentions of the individual. To overcome these unhelpful tendencies and reveal new entry points for AMR prevention, we adopted assemblage theory to analyse personal experience narratives on individual antibiotic use in community settings. Antibiotic use was irregular, situationally diverse and shaped by factors not always under personal control. Individuals were focussed on preventing, moderating and treating infections that threatened their health. Our analysis shows that antibiotic assemblages are both cause and effect of individual efforts to manage infections. We suggest that AMR prevention needs to look beyond the antibiotic as object and the (ir)responsible use binary to engage with the antibiotic effects individuals seek in order to manage infectious diseases. This antibiotic assemblage orientation is likely to be more meaningful for individuals seeking out methods for promoting their health in the face of common infections.

Mystifying medicines and maximising profit: Antibiotic distribution in community pharmacies in Thailand

Thailand's antimicrobial stewardship strategy has focussed on promoting 'rational drug use' in the public sector, to reduce the threat of drug resistance and control healthcare expenditure. The strategy's next ambition is to attend to the private sector, where antibiotics are widely available over the counter without prescription. Using ethnographic and survey data, this paper follows antibiotics through community pharmacies, to explore drug distribution and access, and identify potential challenges for stewardship. We extend the analytical frame beyond 'irrational' dispenser-customer transactions, to explore the logics of practice of a multiplicity of actors in the context of a highly competitive pharmaceutical market. Highlighting the role of the pharmaceutical industry in mystifying medicines, we show how antibiotics are collapsed into a category of 'strong medicines' and requested by customers using 'prescriptions by proxy'. We further examine how Thailand's drug regulation and classificatory systems, historically orientated around access to medicines, enable the proliferation of antibiotics in the context of contemporary efforts to control distribution. Recognising the negotiations involved in dispensing antibiotics in a pluralistic health system, we attempt to reconfigure allocations of responsibility, advocating for stewardship approaches that take into account local ecologies of care, as well as implications for access, equity, and accountability.

Antibiotic use in children under 5 years of age in Northern Tanzania: a qualitative study exploring the experiences of the caring mothers

Background

Antimicrobial resistance is a serious threat to the global achievements in child health thus far. Previous studies have found high use of antibiotics in children in Northern Tanzania, but the experiences of the primary care-givers, who play a key role in accessing and administering antibiotics for the sick child, have remained largely unknown. Therefore, the aim of this study was to understand mothers’ conceptions of antibiotic use in their children, which is of importance when forming strategies to improve antibiotic use in the community.

Method

A qualitative study including eight focus group discussions with mothers of under-five children in Moshi urban and rural districts, Northern Tanzania, was performed during 2019. The discussions were recorded, transcribed verbatim, translated into English and analysed according to the phenomenographic approach.

Findings

Three conceptual themes emerged during analysis; (1) conceptions of disease and antibiotics, (2) accessing treatment and (3) administering antibiotics. Antibiotics were often perceived as a universal treatment for common symptoms or diseases in children with few side-effects. Although mothers preferred to attend a healthcare facility, unforeseen costs, long waits and lack of financial support from their husbands, posed barriers for healthcare seeking. However, pharmacies were perceived as a cheap and convenient option to access previously used or prescribed antibiotics. Some mothers sought advice from a trusted neighbour regarding when to seek healthcare, thus resembling the function of the community health worker.

Conclusions

To improve antibiotic use in children under 5 years of age in Northern Tanzania, the precarious situation that women often find themselves in as they access treatment for their sick children needs to be taken into consideration. It is necessary to improve structures, including the healthcare system, socioeconomic inequalities and promoting gender equality both in the household and in the public arena to reduce misuse of antibiotics. Meanwhile, equipping community health workers to support Tanzanian women in appropriate healthcare seeking for their children, may be a feasible target for intervention.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13756-022-01169-w.

Understanding antimicrobial resistance through the lens of antibiotic vulnerabilities in primary health care in rural Malawi

The diminishing effectiveness of antimicrobials raises serious concerns for human health. While policy makers grapple to reduce the overuse of antimicrobial medicines to stem the rise of antimicrobial resistance, insufficient attention has been paid to how this applies to low-resource contexts. We provide an in-depth portrayal of antimicrobial prescribing at primary health care level in rural Chikwawa District, Malawi. Ethnographic fieldwork took place over 18 months (2018-2020). We surveyed 22 health facilities in the district, observed 1348 health worker-patient consultations, and carried out 49 in-depth interviews with staff and patients. Care was centred around provision of an antimicrobial. Amid chronic lack of essential medicines and other resources, clinic interactions were tightly scripted, providing patients little time to question or negotiate their treatment. We develop the concept of 'antibiotic vulnerabilities' to reveal multiple ways in which provision of antimicrobials in rural Malawi impacts care in conditions of extreme scarcity. Antibiotics are central and essential to primary care. As targets for optimal antimicrobial prescribing take a more central role in global policy, close attention is required of the ramifications for the delivery of care to ensure that efforts to stem resistance do not undermine the goal of improved health for all.

Waiting for markets to change me—High-stakeholders' views of antibiotic use and antibiotic resistance in pig production in Brazil

Overuse of veterinary antibiotics is a risk factor for antimicrobial resistance (AMR), which is a global public health emergency. More than 70% of the antibiotics consumed worldwide are used in farm animals, mainly in poultry and pig herds. Brazil is the fourth largest pork producer globally and the second-largest user of antibiotics in animals. Qualitative research can help understand the complexities around antibiotic use (AMU) in Brazilian pig herds and identify stakeholders' attitudes concerning the rational AMU and AMR in the production chain. This study aimed to explore the knowledge and attitudes of high-level professionals in the animal production chain about AMU and AMR in pig farming, the relationship with pig welfare and AMU in Brazil. We conducted 32 in-depth interviews with individuals active in the pig industry. The majority of the participants considered AMU excessive and inappropriate in pig farms in Brazil. However, attitudes toward a restrictive AMU scenario in Brazilian pig farms were predominantly negative, justified by economic, sanitary and social barriers. These included unsatisfactory management and biosecurity conditions in pig farms that, in their opinion, justify AMU to prevent diseases; issues surrounding prescription and acquisition of veterinary drugs; and employment and income relationships arising from the sale of antibiotics. The views of high-level professionals in the Brazilian livestock chain reveal antibiotics as a structural element that enables pig production. Antibiotics were viewed as essential resources for producing cheap food. Foreign markets were considered the most relevant driver of change in AMU practices rather than pressure from Brazilian consumers. A common belief expressed was that AMR is more associated with the inappropriate AMU in human medicine than in the livestock sector. Resistance to change in these stakeholders may hinder the implementation of future public policies to restrict the use of antibiotics in Brazil. Our findings suggest that successful measures to deal with the AMU/AMR challenges in the pig chain shall not be rooted in personal behavior change. Instead, honest interdisciplinary dialogues and structural changes are needed to define common grounds and a way forward to break the cycle perpetuating antibiotics as structural commodities.

Antibacterial Activities of Monsonia Angustifolia and Momordica Balsamina Linn Extracts against Carbapenem-Resistant Acinetobacter Baumannii

Carbapenemase-producing Acinetobacter baumannii (A. baumannii) is resistant to most of the available antibiotics and poses serious therapeutic challenges. The study investigated Monsonia angustifolia (M. angustifolia) and Momordica balsamina Linn (M. balsamina Linn) extracts for antibacterial activity against a clinical isolate of carbapenemase-producing A. baumannii using the Kirby Bauer disc diffusion and TLC coupled with bioautography. MIC determination experiments were conducted on a molecularly characterized A. baumannii isolate identified using VITEK2. Positive PCR detection of bla_OXA-51 and bla_OXA-23 confirmed isolate identity and the presence of a carbapenemase-encoding gene. Antibacterial activity was observed with the methanolic extract of M. balsamina Linn with a MIC of 0.5 mg/mL. Compounds with Rf values of 0.05; 0.17; 0.39 obtained from M. angustifolia hexane extract; compounds with Rf values of 0.58; 0.78; 0.36; 0.48; 0.5; 0.56; 0.67; 0.9 obtained from M. angustifolia dichloromethane extract; compounds with Rf values of 0.11; 0.56; 0.24; 0.37 obtained from M. angustifolia acetone extract and compounds with Rf values of 0.11; 0.27 obtained from M. angustifolia methanol extract demonstrated a level of antibacterial activity. M. angustifolia and M. balsamina Linn plant extracts have a clinically significant antibacterial activity against a carbapenemase-producing A. baumannii strain.

Imagining the postantibiotic future: the visual culture of a global health threat

This article is concerned with the visual culture of global health data using antimicrobial resistance (AMR) as an example. I explore how public health data and knowledge are repackaged into visualisations and presented in four contemporary genres: the animation, the TED Talk, the documentary and the satire programme. I focus on how different actors describe a world in which there are no or few antibiotics that are effective against bacterial infections. I examine the form, content and style of the visual cultural of AMR, examining how these genres tell a story of impending apocalypse while also trying to advert it. This is a form of story-telling based around the if/then structure: we are told that if we do not take certain actions today, then we will face a postantibiotic future with certain, often catastrophic, consequences. Within this if/then structure, there are various aims and objectives: the goal may be preventing further spread of AMR, building awareness or pushing for certain policy or funding decisions. These stories also serve to place or deflect blame, on animals, occupations, patients, industries and others and to highlight risks and consequences. These examples share similarities in the forms of story-telling and narrative, and in the use of specific data sources and other images. By using several Swedish examples, I demonstrate how global data are reinterpreted for a national audience. Overall, I argue that while the convergence of a dominant narrative indicates scientific consensus, this consensus also stifles our collective imagination in finding new solutions to the problem. Finally, I also use the example of AMR to discuss the need for a broader social science and humanities engagement with the visual culture of global health data.

Wars and sweets: microbes, medicines and other moderns in and beyond the(ir) antibiotic era

Once upon a time, many of us moderns dreamt that our future was bright, squeaky clean, germ-free. Now, we increasingly fear that bacterial resistance movements and hordes of viruses are cancelling our medicated performances, and threatening life as many of us have come to know it. In order for our modern antibiotic theatre of war to go on, we pray for salvation through our intensive surveillance of microbes, crusades for more rational antibiotic wars, increased recruitment of resistance fighters and development of antibiotic armaments through greater investment in our medical-industrial-war complex. But not all of us are in favour of the promise of perpetual antimicrobial wars, no matter how careful or rational their proponents aspire to be. An increasing vocal and diverse opposition has amassed in academic journals, newspapers and other fields of practice denouncing medicalisation and pharamceuticalisation of our daily lives, as well as our modern medicine as overly militaristic. In this paper, rather than simply rehearsing many of these well-made and meaning debates to convert you to yet another cause, I enrol them in redescriptions of our modern medical performances in the hope of awakening you from your aseptic dream. What follows is my invitation for you to re-enact our mythic antibiotic era in all its martial g(l)ory. I promise that it will bring you no physically harm, yet I can't promise it will leave your beliefs unscathed, as you follow its playful redescription of how our objective scientific descriptions, clinical prescriptions, economic strategies, political mandates and military orders, not to mention our warspeak, have always been deeply entangled with triumphs and devastations of The(ir) Great anti-Microbial Wars (aka our antibiotic era).

Vulnerability and One Health assessment approaches for infectious threats from a social science perspective: a systematic scoping review

Vulnerability assessments identify vulnerable groups and can promote effective community engagement in responding to and mitigating destabilising events. This scoping review maps assessments for local-level vulnerabilities in the context of infectious threats. We searched various databases for articles written between 1978 and 2019. Eligible documents assessed local-level vulnerability, focusing on infectious threats and antimicrobial resistance. Since few studies provided this dual focus, we included tools from climate change and disaster risk reduction literature that engaged the community in the assessment. We considered studies using a One Health approach as essential for identifying vulnerability risk factors for zoonotic disease affecting humans. Of the 5390 records, we selected 36 articles for review. This scoping review fills a gap regarding vulnerability assessments by combining insights from various approaches: local-level understandings of vulnerability involving community perspectives; studies of social and ecological factors relevant to exposure; and integrated quantitative and qualitative methods that make generalisations based on direct observation. The findings inform the development of new tools to identify vulnerabilities and their relation to social and natural environments.

A comprehensive review on genomics, systems biology and structural biology approaches for combating antimicrobial resistance in ESKAPE pathogens: computational tools and recent advancements

In recent decades, antimicrobial resistance has been augmented as a global concern to public health owing to the global spread of multidrug-resistant strains from different ESKAPE pathogens. This alarming trend and the lack of new antibiotics with novel modes of action in the pipeline necessitate the development of non-antibiotic ways to treat illnesses caused by these isolates. In molecular biology, computational approaches have become crucial tools, particularly in one of the most challenging areas of multidrug resistance. The rapid advancements in bioinformatics have led to a plethora of computational approaches involving genomics, systems biology, and structural biology currently gaining momentum among molecular biologists since they can be useful and provide valuable information on the complex mechanisms of AMR research in ESKAPE pathogens. These computational approaches would be helpful in elucidating the AMR mechanisms, identifying important hub genes/proteins, and their promising targets together with their interactions with important drug targets, which is a crucial step in drug discovery. Therefore, the present review aims to provide holistic information on currently employed bioinformatic tools and their application in the discovery of multifunctional novel therapeutic drugs to combat the current problem of AMR in ESKAPE pathogens. The review also summarizes the recent advancement in the AMR research in ESKAPE pathogens utilizing the in silico approaches.

A Qualitative Study of Antibiotic Use Practices in Intensive Small-Scale Farming in Urban and Peri-Urban Blantyre, Malawi: Implications for Antimicrobial Resistance

The routine use of antimicrobials in meat production has been identified as a driver of antimicrobial resistance (AMR) in both animals and humans. Significant knowledge gaps exist on antibiotic use practices in farming, particularly in sub-Saharan Africa. This paper sought to generate in-depth understanding of household antibiotic use practices in food animals in urban- and peri-urban Blantyre. We used a qualitative research methodology focusing on households that kept scavenging animals and those engaged in small-scale intensive farming of food animals. Methods used were: medicine-use surveys with 130 conducted with a range of households; in-depth interviews (32) with a range of participants including farmers, community based veterinary health workers and veterinary shop workers; and stakeholder interviews (17) with policy makers, regulators, and academics. Six months of ethnographic fieldwork was also undertaken, with households engaged in farming, veterinary officers and veterinary stores. Our findings suggest antibiotic use in animals was more common in households that used small-scale intensive farming techniques, but rare in households that did not. For farmers engaged in small-scale intensive farming, antibiotics were often considered vital to remain solvent in a precarious economic and social environment, with limited access to veterinary services. A complex regulatory framework governed the import, prescription, and administration of antibiotics. Veterinary stores provided easy access to antibiotics, including colistin, an antibiotic on the WHO's critically important antibiotics for human health. Our work suggests that the high dependence on antibiotics for small-scale intensive farming may contribute to the growth of drug resistant infections in Malawi. The socio-economic drivers of antibiotic use mean that interventions need to take a holistic approach to address the high dependence on antibiotics. Key interventions could include improving farmers' access to affordable veterinary services, providing information about appropriate antibiotic use including withdrawal periods and feed supplementation, as well as improvements in regulation (nationally and internationally) and enforcement of current regulations. Taken together these approaches could lead to antibiotic use being optimised in feed animals.

Perceptions, views and practices regarding antibiotic prescribing and stewardship among hospital physicians in Jakarta, Indonesia: a questionnaire-based survey

OBJECTIVES

Antibiotic overuse is one of the main drivers of antimicrobial resistance (AMR), especially in low-income and middle-income countries. This study aimed to understand the perceptions and views towards AMR, antibiotic prescribing practice and antimicrobial stewardship (AMS) among hospital physicians in Jakarta, Indonesia.

DESIGN

Cross-sectional, self-administered questionnaire-based survey, with descriptive statistics, exploratory factor analysis (EFA) to identify distinct underlying constructs in the dataset, and multivariable linear regression of factor scores to analyse physician subgroups.

SETTING

Six public and private acute-care hospitals in Jakarta in 2019.

PARTICIPANTS

1007 of 1896 (53.1% response rate) antibiotic prescribing physicians.

RESULTS

Physicians acknowledged the significance of AMR and contributing factors, rational antibiotic prescribing, and purpose and usefulness of AMS. However, this conflicted with reported suboptimal local hospital practices, such as room cleaning, hand hygiene and staff education, and views regarding antibiotic decision making. These included insufficiently applying AMS principles and utilising microbiology, lack of confidence in prescribing decisions and defensive prescribing due to pervasive diagnostic uncertainty, fear of patient deterioration or because patients insisted. EFA identified six latent factors (overall Crohnbach's α=0.85): awareness of AMS activities; awareness of AMS purpose; views regarding rational antibiotic prescribing; confidence in antibiotic prescribing decisions; perception of AMR as a significant problem; and immediate actions to contain AMR. Factor scores differed across hospitals, departments, work experience and medical hierarchy.

CONCLUSIONS

AMS implementation in Indonesian hospitals is challenged by institutional, contextual and diagnostic vulnerabilities, resulting in externalising AMR instead of recognising it as a local problem. Appropriate recognition of the contextual determinants of antibiotic prescribing decision making will be critical to change physicians' attitudes and develop context-specific AMS interventions.

Antimicrobial resistance in Antarctica: is it still a pristine environment?

Although the rapid spread of antimicrobial resistance (AMR), particularly in relation to clinical settings, is causing concern in many regions of the globe, remote, extreme environments, such as Antarctica, are thought to be relatively free from the negative impact of human activities. In fact, Antarctica is often perceived as the last pristine continent on Earth. Such remote regions, which are assumed to have very low levels of AMR due to limited human activity, represent potential model environments to understand the mechanisms and interactions underpinning the early stages of evolution, de novo development, acquisition and transmission of AMR. Antarctica, with its defined zones of human colonisation (centred around scientific research stations) and large populations of migratory birds and animals, also has great potential with regard to mapping and understanding the spread of early-stage zoonotic interactions. However, to date, studies of AMR in Antarctica are limited. Here, we survey the current literature focussing on the following: i) Dissection of human-introduced AMR versus naturally occurring AMR, based on the premise that multiple drug resistance and resistance to synthetic antibiotics not yet found in nature are the results of human contamination ii) The potential role of endemic wildlife in AMR spread There is clear evidence for greater concentrations of AMR around research stations, and although data show reverse zoonosis of the characteristic human gut bacteria to endemic wildlife, AMR within birds and seals appears to be very low, albeit on limited samplings. Furthermore, areas where there is little, to no, human activity still appear to be free from anthropogenically introduced AMR. However, a comprehensive assessment of AMR levels in Antarctica is virtually impossible on current data due to the wide variation in reporting standards and methodologies used and poor geographical coverage. Thus, future studies should engage directly with policymakers to promote the implementation of continent-wide AMR reporting standards. The development of such standards alongside a centralised reporting system would provide baseline data to feedback directly into wastewater treatment policies for the Antarctic Treaty Area to help preserve this relatively pristine environment. Video Abstract.

Taking stock of global commitments on antimicrobial resistance

Over the last six years, antimicrobial resistance (AMR) has generated an unprecedented amount of global attention. This global attention has coincided with an increase in discussion around AMR at various multilateral organisations and international fora. This study catalogues and analyses AMR-related commitments made by the global community following the implementation of the AMR Tripartite's Global Action Plan (GAP) in 2015. In examining these commitments, we elucidated emergent themes and gaps in AMR discourse through a qualitative content analysis of global political resolutions, declarations and statements made by members of the United Nations, the World Health Assembly, Food and Agriculture Organization Conferences, World Organisation for Animal Health General Sessions, and the G7 and G20 summits and ministerial meetings between the years 2015 and 2021. Emergent themes included AMR research, surveillance and stewardship. Across sectors, fewer commitments were made for specific action on AMR in the environment. The themes and types of commitments were found to be consistent across time and fora but did not evolve into more concrete or nuanced pledges to action between 2015 and 2021. GAP objectives relating to infection prevention and efforts to address the root drivers of AMR appeared the least frequently in our analysis, indicating a lack of global commitment to take a proactive prevention-focused approach to AMR.

Attitudes towards vaccination and knowledge about antibiotics: Analysis of Wellcome Monitor survey data

Vaccine hesitancy and antimicrobial resistance are biomedically connected public health challenges, but to date minimal research has examined social connections between the UK public's attitudes towards vaccination and attitudes towards antibiotic use. Understanding the extent to which these issues are attitudinally parallel would be valuable for implementing and evaluating public health interventions. Using data from the Wellcome Trust Monitor Wave 4 this study examined social associations between these two areas. An ordinal logistic regression model predicting knowledge level about antibiotics was fitted using 2,654 observations, controlling for known outcome covariates, with perceptions of the risk of side-effects from vaccination and of the efficacy of vaccination as a preventative intervention as independent variables. Compared to the modal response category of 'Fairly low', respondents who rated the risk of serious side-effects from vaccination as 'Very high' (OR = 2.87, 95% CI = 1.71-4.89) or 'Fairly high' (OR = 1.51, 95% CI = 1.21-1.88) were more likely to have provided incorrect responses to questions about the utility of antibiotics for treating different types of infection. Conversely, respondents who felt there was 'No risk at all' (OR = 0.69, 95% CI = 0.50-0.95) were less likely to have provided incorrect responses about the utility of antibiotics. Compared to the modal category of 'Almost always effective', only respondents who felt that vaccines were 'Sometimes effective' (OR = 1.26, 95% CI = 1.05-1.51) or 'Almost never or never effective' (OR = 2.32, CI = 1.32-4.19) were more likely provide incorrect responses regarding antibiotics' utility. Negative perceptions of vaccination and misperceptions about the role of antibiotics for treating infections are associated with one other within the general UK public. Qualitative research is needed to understand the nature of this association and identify areas of public understanding that are not exclusive to specific health interventions but that may be targeted to improve responsiveness to vaccine- and antibiotic-related public health interventions.