Effectiveness of interventions to improve the public's antimicrobial resistance awareness and behaviours associated with prudent use of antimicrobials: a systematic review

"Arming half-baked people with weapons!" Information enclaving among professionals and the need for a care-centred model for antibiotic use information in Uganda, Tanzania and Malawi

BACKGROUND

The overuse of antimicrobial medicines is a global health concern, including as a major driver of antimicrobial resistance. In many low- and middle-income countries, a substantial proportion of antibiotics are purchased over-the-counter without a prescription. But while antibiotics are widely available, information on when and how to use them is not.

OBJECTIVE

We aimed to understand the acceptability among experts and professionals of sharing information on antibiotic use with end users - patients, carers and farmers - in Uganda, Tanzania and Malawi.

METHODS

Building on extended periods of fieldwork amongst end-users and antibiotic providers in the three countries, we conducted two workshops in each, with a total of 44 medical and veterinary professionals, policy makers and drug regulators, in December 2021. We carried out extensive documentary and literature reviews to characterise antibiotic information systems in each setting.

RESULTS

Participants reported that the general public had been provided information on medicine use in all three countries by national drug authorities, health care providers and in package inserts. Participants expressed concern over the danger of sharing detailed information on antibiotic use, particularly that end-users are not equipped to determine appropriate use of medicines. Sharing of general instructions to encourage professionally-prescribed practices was preferred.

CONCLUSIONS

Without good access to prescribers, the tension between enclaving and sharing of knowledge presents an equity issue. Transitioning to a client care-centred model that begins with the needs of the patient, carer or farmer will require sharing unbiased antibiotic information at the point of care.

Drug Inspector as an antibiotic Steward: challenges and recommendations to implement national action plan of Pakistan on antimicrobial resistance

BACKGROUND

Despite significant measures, low- and middle-income countries (LMICs), including Pakistan, struggle to curtail non-prescription antibiotic sales, enforce regulations, and implement National Action Plan (NAP) against antimicrobial resistance (AMR). NAP Pakistan entails drug inspectors (DIs) to ensure prescription-based sales of antibiotics. This study seeks to understand the perspective of DIs regarding antimicrobial sales without prescription, underlying factors, and policy implementation status.

METHODS

A qualitative study employing a semi-structured interview guide using in-depth interviews with purposively selected 17 DIs was conducted. Interviews were transcribed verbatim, and data were analyzed following a thematic analysis framework utilizing MAXQDA 2022 software.

RESULTS

Five main themes emerged after data analysis: (1) drug inspector - the regulator of the antimicrobial armamentarium, (2) the policy context, (3) awareness regarding AMR, (4) barriers to combatting AMR, and (5) the way forward: strategies and recommendations.

CONCLUSION

A weak regulatory framework, low level of awareness, quackery, vested interests, and socio-economic factors augment inappropriate antibiotic utilization. Opting for better policies and strengthening the DI fraternity as outlined in NAP Pakistan is recommended. Recognizing drug inspectors as effective surveilling units and mobilizing field force against irrational antibiotic utilization is the need of the hour and requires policy reformation.

High mortality associated with inappropriate initial antibiotic therapy in hematological malignancies with Klebsiella pneumoniae bloodstream infections

Bloodstream infections caused by multidrug-resistant organisms such as Klebsiella pneumoniae are a significant challenge in managing hematological malignancies. This study aims to characterize the epidemiology of Klebsiella pneumoniae bloodstream infections specifically in patients with hematological malignancies, delineate the patterns of initial antibiotic therapy, assess the prevalence of resistant strains, identify risk factors for these resistant strains, and evaluate factors influencing patient outcomes. A retrospective analysis was conducted at a single center from January 2017 to December 2020, focusing on 182 patients with hematological malignancies who developed Klebsiella pneumoniae bloodstream infections. We compared the 30-day mortality rates between patients receiving appropriate and inappropriate antibiotic treatments, including the effectiveness of both single-drug and combination therapies. Kaplan-Meier survival analysis and multivariate logistic and Cox regression were used to identify factors influencing mortality risk. The 30-day all-cause mortality rate was 30.2% for all patients. The 30-day all-cause mortality rates were 77.2% and 8.8% in patients who received inappropriate initial treatment and appropriate initial treatment (p < 0.001). Inappropriate initial treatment significantly influenced mortality and was a key predictor of 30-day mortality, along with septic shock and previous intensive care unit (ICU) stays. Patients with carbapenem-resistant Klebsiella pneumoniae (CRKP) bloodstream infections exhibited more severe clinical symptoms compared to the CSKP group. The study demonstrates a significant association between empirical carbapenem administration and the escalating prevalence of CRKP and multidrug-resistant K. pneumoniae (MDR-KP) infections. Furthermore, the study identified inappropriate initial antibiotic therapy, septic shock, and ICU admission as independent risk factors for 30-day mortality.

Influencing attitudes towards antimicrobial use and resistance in companion animals-the impact on pet owners of a short animation in a randomized controlled trial

Objectives

Antimicrobial resistance (AMR) is a vital One Health issue; the rational use of antimicrobials is essential to preserve their efficacy. Veterinarians cite pressure from pet owners as a contributor to antimicrobial prescription. Engaging pet owners in antimicrobial stewardship could reduce this pressure. A short educational animation could facilitate communication of this message. The impact of the animation on participant's opinions relating to antimicrobial prescribing and awareness of AMR was assessed via a randomized controlled trial.

Methods

A survey was created based on the health belief model. Owners attending six UK veterinary centres were randomized to the intervention or control group (ratio 1:1). All owners completed an agreement level survey of two questions followed by 18 statements scored using a Likert agreement scale. The control group responded without interruption, whereas the animation group was shown the animation after answering the first two questions and five statements.

Results

In total, 647 owners participated in the study; 350 complete responses were analysed. Responses to 10 of 13 statements asked after the animation were significantly different (all P < 0.050) between groups, whereas there was no significant difference between groups in response to any of the statements asked before the animation. The animation group were more likely to agree that lower antimicrobial use would help maintain future efficacy (P < 0.001) and that requesting antimicrobials from their vet could increase unnecessary use (P < 0.001). The animation group were more likely to disagree that they would expect antimicrobials if their pet had diarrhoea (P = 0.048).

Conclusions

Pet owners that watched a short AMR engagement animation displayed greater awareness of the impact of AMR and were more likely to support measures in line with antimicrobial stewardship. This behavioural-nudge resource could support owners towards contributing to a multi-faceted approach to AMR.

Analytic and heuristic process for prudent antimicrobial use in animals: What are triggers and how do they work?

The over and misuse of antimicrobials in animal agriculture causes a prevailing crisis for humans, animals, and the environment. From the One Health approach perspective, the formation process of adopting prudent antimicrobial use (AMU), once established, can be used to mitigate this crisis. The study aimed to determine the analytic-based and heuristic-based process that evoked prudent AMU among animal farmers by synthesis of stimulus-organism-response framework and dual-system theory and to explore gender differences on risk-benefit trade-offs. A structural equation model was employed to test the proposed hypotheses with field survey data from 1100 small-scale farmers. The results reveal that for the analytic-based process, social influence, antimicrobial-related threats, and self-efficacy are all salient stimuli having indirect effects on intention via the two organisms of perceived risks and perceived benefits. For heuristic-based process, farmers' altruistic value orientations are positively associated with intention. An interesting fact is that threat awareness has two opposite effects on intention, namely, the suppression effect and the enhancement effect. Moreover, the negative effect of perceived risks on intention is greater among female farmers, compared to male counterparts. These findings provide valuable insights for the forming of theory-based intervention strategies to perfect China's national action plan.

Impact of the ´Alforja Educativa' on Ecuadorian schoolchildren's knowledge of bacteria, antibiotics, and antibiotic resistance, a pretest-posttest study

BACKGROUND

Widespread use of antibiotics disrupts the balance in the microbial world and promotes development and spread of antibiotic resistant bacteria. Educational initiatives are important as part of strategies to mitigate antibiotic resistance. The Alforja Educativa is an innovative educational program developed in Ecuador with the aim to teach schoolchildren about antibiotic use and antibiotic resistance. The program places antibiotic resistance within a broader frame of health, well-being, and ecological awareness, highlighting the importance to maintain balance in the microbial world. The objective of this study was to evaluate the effect of the Alforja Educativa on knowledge about bacteria, antibiotics and antibiotic resistance amongst fifth and sixth grade Ecuadorian schoolchildren.

METHODS

This pretest-posttest intervention study was conducted between April and June 2017 and comprised fifth and sixth grade schoolchildren from 20 schools in Cuenca, Ecuador, recruited by purposeful sampling. The Alforja Educativa was implemented over twelve 80-minute sessions by trained university students. Schoolchildren's knowledge was assessed before and after participation in the educational program using a structured questionnaire. A mean total score, the proportion of correct responses for each individual knowledge-based question, as well as correct responses for each of the multiple-choice options of the knowledge-based questions were calculated for the pretest and posttest.

RESULTS

A total of 1,257 schoolchildren participated in the Alforja Educativa program, of which 980 (78%) completed both the pretest and posttest. Overall, the mean total knowledge score increased from pretest to posttest (2.58/7.00 vs. 3.85/7.00; CI = 0.5, p < 0.001). After participation in the program, the proportion of schoolchildren that correctly identified that bacteria can be both good and bad increased from 35.0 to 84.3%. In addition, scores increased for correctly identifying the meaning of antibiotic resistance (37.4-72.0%); how to prevent antibiotic resistance (63.2-74.6%); and for identifying the meaning of self-medication (46.3-54.3%).

CONCLUSION

The Alforja Educativa was effective in improving the knowledge of participating schoolchildren about concepts related to bacteria, antibiotics and antibiotic resistance. The holistic perspective taken to explain the complex relationship between humans and bacteria, as well as the effect of antibiotics on the microbial world, may help provide a foundation for more sustainable antibiotic use.

Evaluating population-level interventions to reduce inappropriate antibiotic use in healthcare and community settings: A systematic review protocol

BACKGROUND

Inappropriate antibiotic use contributes significantly to the global challenge of antimicrobial resistance. While government-initiated population-level interventions are fundamental in addressing this issue, their full potential remains to be explored. This systematic review aims to assess the effectiveness of such interventions in reducing inappropriate antibiotic use among antibiotic providers and users in healthcare and community settings.

METHODS

We will conduct a systematic literature search across multiple databases and grey literature sources. We will include studies which evaluate the effectiveness of population-level interventions to reduce inappropriate antibiotic use in healthcare and community settings in both high-income and low- and middle-income countries. This includes government-initiated measures targeting antibiotic use through education, restriction, incentivization, coercion, training, persuasion, context modification, behavior modeling, or barrier reduction. Two reviewers will independently perform screening to select eligible studies, followed by data extraction. The outcomes of interest are various measures of antibiotic prescription and consumption, such as Defined Daily Dose (DDD) or number of prescriptions per year. We anticipate including a broad range of study designs and outcome measures. Therefore, we will narratively synthesize results using the categories of the population-level policy interventions of the Behavior Change Wheel Framework. We will organize outcome data by economic contexts, target populations, and implementation settings.

DISCUSSION

This review will strengthen the evidence base for the use of population-level interventions to address inappropriate antibiotic use. Drawing lessons from global experiences, the findings will provide valuable guidance to health policymakers, public health authorities, and researchers on tailoring interventions to specific economic contexts, populations, and settings, thereby enhancing their capacity to drive substantial improvement in appropriate antibiotic use.

Early-career general practitioners' antibiotic prescribing for acute infections: a systematic review

BACKGROUND

Antimicrobial resistance is a worldwide threat, exacerbated by inappropriate prescribing. Most antibiotic prescribing occurs in primary care. Early-career GPs are important for the future of antibiotic prescribing and curbing antimicrobial resistance.

OBJECTIVES

To determine antibiotic prescribing patterns by early-career GPs for common acute infections.

METHODS

A systematic literature search was conducted using PubMed, Embase and Scopus. Two authors independently screened abstracts and full texts for inclusion. Primary outcomes were antibiotic prescribing rates for common acute infections by GPs with experience of 10 years or less. Secondary outcomes were any associations between working experience and antibiotic prescribing.

RESULTS

Of 1483 records retrieved, we identified 41 relevant studies. Early-career GPs were less likely to prescribe antibiotics compared with their more experienced colleagues (OR range 0.23-0.67). Their antibiotic prescribing rates for 'any respiratory condition' ranged from 14.6% to 52%, and for upper respiratory tract infections from 13.5% to 33%. Prescribing for acute bronchitis varied by country, from 15.9% in Sweden to 26% in the USA and 63%-73% in Australia. Condition-specific data for all other included acute infections, such as sinusitis and acute otitis media, were limited to the Australian context.

CONCLUSIONS

Early-career GPs prescribe fewer antibiotics than later-career GPs. However, there are still significant improvements to be made for common acute conditions, as their prescribing is higher than recommended benchmarks. Addressing antimicrobial resistance requires an ongoing worldwide effort and early-career GPs should be the target for long-term change.

Improving Antimicrobial Resistance Awareness Among Medical Students in India: The Sensitization of Medical Students on Antimicrobial Resistance (SOS-AMR) Study

OBJECTIVES

To evaluate the impact of an online educational intervention on improving knowledge of antimicrobial resistance (AMR) and stewardship among final-year medical students in Chennai, India.

METHODS

This was a prospective 'before-after' study conducted across 5 medical colleges in Chennai, India. Participants who were final-year (fourth year) undergraduate medical students were administered a pretest to evaluate baseline knowledge. Students were then provided access to online educational material comprising 20 short lectures. Lectures were delivered by content experts and covered a range of topics which included basics of microbiology, fundamental concepts in AMR and stewardship, diagnosis and management of common infections, basics of antimicrobial pharmacokinetics and pharmacodynamics, and vaccination. Students were required to take a posttest at the end of these modules. Primary outcome was improvement in test scores from pretest baseline which was analyzed using a t test. A 30% improvement in the mean scores from baseline was predefined as a measure of success.

RESULTS

A total of 599 students participated from 5 medical colleges among whom 339 (56.6%) were female participants; 542 (90.4%) students completed the posttest. Mean pretest score was 11.6 (maximum possible score of 25) (SD: 4.3) and the mean posttest score was 14.0 (SD: 4.6). Comparing pre and posttest scores, there was an improvement of 2.4 marks (20%) from the baseline (95% confidence interval: 1.9, 2.9) (P < .001). Improvement in scores was similar for male and female participants.

CONCLUSIONS

In this before-after study evaluating the impact of an educational intervention on AMR among final-year medical students, there was an improvement in knowledge; however, the extent of improvement did not meet the predefined metric of success.

The public's antibiotic use behavioural patterns and their determinants for upper respiratory tract infections: a latent class analysis based on consumer behaviour model in China

Background

The irrational use of antibiotics among the public is a major contributor to antimicrobial resistance (AMR), which is a serious global threat. Prior studies have demonstrated that there are different behavioural patterns regarding antibiotic use among the public, and targeted interventions for subgroups with different behavioural patterns may be more effective. Thus, this study aimed to identify the public's behavioural patterns of antibiotic use for upper respiratory tract infections (URTIs) and their influencing factors.

Methods

A cross-sectional survey was conducted among the general population in Chongqing, China. Consumer decision-making (Consumer Behaviour Model, CBM) was used to assess the public's behaviours regarding antibiotic use, including need recognition, information searching, alternative evaluation, obtaining antibiotics, antibiotic consumption, and postuse evaluation. Furthermore, a latent class analysis was used to identify the underlying behavioural patterns among the public. The identified behavioural patterns of antibiotic use were further linked with individuals' capacity, opportunity, and motivation factors of antibiotic use based on a multinominal logistic regression to explore possible determinants.

Results

A total of 815 respondents were enrolled in the study. The public's irrational use of antibiotics was prevalent, including antibiotic self-medication (39.63%), nonprescription antibiotic purchasing (59.02%), and early stopping of antibiotic prescriptions (76.56%). Participants had inadequate knowledge of antibiotics (Mean = 2.33, SD = 1.71), reported high availability to antibiotics (Mean = 7.13, SD = 2.41), held strong belief in antibiotic effectiveness (Mean = 10.29, SD = 2.71), and demonstrated a high perceived threat of AMR (Mean = 12.30, SD = 3.20). Four behavioural patterns regarding antibiotic use for URTIs were identified, namely, "antibiotic self-medicators" (n = 165, 20.25%), "formal health care seekers" (n = 216, 26.50%), "various treatment users" (n = 198, 24.20%), and "self-medication without antibiotics" (n = 236, 28.96%). Individuals' self-efficacy of antibiotic use, belief in antibiotic effectiveness, awareness of antibiotic side effects, perceived antibiotic availability, social influence, and demographics (age, education, medical insurance, and having a medical background) were significantly associated with the public's different behavioural patterns of antibiotic use for URTIs.

Conclusion

This study calls for collaborative efforts among the public, physicians, policy makers, and the implementation of precise and multifaceted interventions to effectively reduce irrational use of antibiotics in the public. Such interventions include identifying subgroups within the public to provide more targeted education about antibiotics and the management of URTIs, reinforcing the regulation of antibiotic dispensing, and improving physicians' rational antibiotic prescriptions.

Addressing antimicrobial resistance through community engagement: a framework for developing contextually relevant and impactful behaviour change interventions

Background

Community engagement (CE) interventions often explore and promote behaviour change around a specific challenge. Suggestions for behaviour change should be co-produced in partnership with the community. To facilitate this, it is essential that the intervention includes key content that unpacks the challenge of interest via multiple sources of knowledge. However, where community lived experience and academic evidence appear misaligned, tensions can appear within the co-production dynamic of CE. This is specifically so within the context of antimicrobial resistance (AMR) where ideal behaviours are often superseded by what is practical or possible in a particular community context.

Methods

Here we describe a framework for the equitable development of contextually appropriate, clearly evidenced behavioural objectives for CE interventions. This framework explores different sources of knowledge on AMR, including the potentially competing views of different stakeholders.

Findings

The framework allows key content on AMR to be selected based upon academic evidence, contextual appropriateness and fit to the chosen CE approach. A case study of the framework in action exemplifies how the framework is applicable to a range of contexts, CE approaches and One Health topics beyond just AMR.

Conclusions

Within CE interventions, academic evidence is crucial to develop well-informed key content. However, this formative work should also involve community members, ensuring that their contextual knowledge is valued. The type of CE approach also needs careful consideration because methodological constraints may limit the breadth and depth of information that can be delivered within an intervention, and thus the scope of key content.

Assessing the impact of a national social marketing campaign for antimicrobial resistance on public awareness, attitudes, and behaviour, and as a supportive tool for healthcare professionals, England, 2017 to 2019

BackgroundPrevious United Kingdom campaigns targeting antimicrobial resistance (AMR) recommended running multimedia campaigns over an increased timeframe. The 3-year-long Keep Antibiotics Working (KAW) campaign was a mass media campaign in England targeting the public and general practitioners (GPs).MethodsEvery year, pre- and post-campaign questionnaire data were collected from the public, whereas post-campaign interview data were obtained from GPs. Data were weighted to allow pre- and post-campaign comparisons between independent samples. Significant changes in nominal and ordinal data were determined using Pearson's chi-squared (X2) and Mann-Whitney U tests, respectively.ResultsPrompted campaign recognition was high, increasing by 6% from 2018 to 2019 (2017: data unavailable; 2018: 68% (680/1,000); 2019: 74% (740/1,000); X2 = 8.742, p = 0.003). Knowledge regarding declining antibiotic effectiveness when taken inappropriately improved following the campaign (net true: pre-2017 = 69.1% (691/1,000); post-2019 = 77.6%; (776/1,000); X2 = 5.753, p = 0.016). The proportion of individuals reporting concern for themselves or for children (≤ 16 years) about AMR increased by 11.2% (Z = -5.091, p < 0.001) and 6.0% (Z = -3.616, p < 0.001) respectively, pre- to post-campaign. Finally, in 2017, reported confidence to say no to patients requesting antibiotics differed significantly between GPs who were and were not aware of the campaign (net agree: 98.9% (182/184) vs 92.4% (97/105) respectively; X2 = 4.000, p = 0.045).ConclusionA high level of prompted campaign recognition was achieved. The KAW campaign improved aspects of AMR knowledge and certain attitudes towards appropriate antimicrobial use. It increased awareness of and concern about AMR, supporting GP confidence to appropriately prescribe antibiotics. Future determination of measurable behaviour changes resulting from AMR campaigns is important.

Joining Forces against Antibiotic Resistance: The One Health Solution

Antibiotic resistance is a significant global health concern that affects both human and animal populations. The One Health approach acknowledges the interconnectedness of human health, animal health, and the environment. It emphasizes the importance of collaboration and coordination across these sectors to tackle complex health challenges such as antibiotic resistance. In the context of One Health, antibiotic resistance refers to the ability of bacteria to withstand the efficacy of antibiotics, rendering them less effective or completely ineffective in treating infections. The emergence and spread of antibiotic-resistant bacteria pose a threat to human and animal health, as well as to the effectiveness of medical treatments and veterinary interventions. In particular, One Health recognizes that antibiotic use in human medicine, animal agriculture, and the environment are interconnected factors contributing to the development and spread of antibiotic resistance. For example, the misuse and overuse of antibiotics in human healthcare, including inappropriate prescribing and patient non-compliance, can contribute to the selection and spread of resistant bacteria. Similarly, the use of antibiotics in livestock production for growth promotion and disease prevention can contribute to the development of antibiotic resistance in animals and subsequent transmission to humans through the food chain. Addressing antibiotic resistance requires a collaborative One Health approach that involves multiple participants, including healthcare professionals, veterinarians, researchers, and policymakers.

Exploring the potential for children to act on antimicrobial resistance in Nepal: Valuable insights from secondary analysis of qualitative data

This study explores the perceived roles of children in antimicrobial resistance (AMR) in two sites across Nepal. AMR is a global challenge and underpinned by many complex behavioural drivers including how antimicrobial medicines are sourced and used. Because of this social dynamic, several research groups are using community engagement (CE) approaches to understand AMR at community level. However, most data negate the importance of children in behaviours linked to, and potentially driving AMR. In this study, authors apply secondary analysis methods to 10 transcripts representing the views of 23 adults engaged in an AMR-focused film-making project. By focusing on participants' reference to children, we reveal that antimicrobial usage and adherence to health providers' messages can be influenced by the age of the patient. Secondly that children are involved in some of the behaviours which are known to drive antimicrobial resistance such as purchasing over-the-counter antibiotic drugs. Finally, community members discuss that, with careful creation of resources, AMR could be meaningfully presented in educational settings with a view to children acting as agents of change around AMR-driving behaviours. Findings suggest that age-inclusive community engagement projects could be effective in tackling AMR at community level in Nepal and other low resource settings.

Prevalence and Predictors of Using Antibiotics without a Prescription in a Pediatric Population in the United States

Non-prescription antibiotic use (using antibiotics without clinical guidance) increases the risk of the development of antibiotic resistance, adverse drug reactions, and other potential patient harm. Few studies have explored non-prescription use in children in the U.S. From January 2021 to April 2022, a diverse sample of caregivers of children under 18 years were surveyed in English and Spanish at two safety net clinics in Texas. We assessed the prevalence of antibiotic use in children in the previous 12 months, storage of antimicrobials, and intended use of non-prescription antibiotics (professed intention for future non-prescription antibiotic use). We also measured sociodemographic factors, types of antibiotics used, and symptoms that trigger non-prescription use. The response rate was 82%, and 17% were surveyed in Spanish. Of 322 participants surveyed, three Spanish-speaking caregivers reported giving non-prescription antibiotics to their child in the previous 12 months. Approximately 21% (n = 69) reported storing antimicrobials at home, specifically amoxicillin (n = 52), clindamycin (n = 10), cephalexin (n = 5), penicillin (n = 3), and trimethoprim/sulfamethoxazole (n = 3). Nearly 15% (n = 46) reported intention to give non-prescription antibiotics to their children. Younger caregiver age was associated with storage and intended use of non-prescription antibiotics. Our findings will guide the development of an educational intervention to decrease non-prescription antibiotic use.

Does antibiotic awareness campaigns exposure decrease intention to demand antibiotic treatment? Testing a structural model among parents in Western Australia

Antimicrobial resistance (AMR) is one of the key public health concerns the world is facing today. The effect of antibiotic awareness campaigns (AACs) on consumer behaviour has been documented in the literature with mixed results. Understanding the mechanism for how AACs affect target populations is vital in designing effective and tailored campaigns. Using structural equation modelling our study examined the relationships among people's exposure to antibiotic awareness campaigns, knowledge of AMR prevention, AMR risk perception, and intention to seek antibiotic treatment. This study also tested the moderating effect of anxiety and societal responsibility on preventing AMR, and on their intention to demand antibiotic treatment mediated by knowledge of AMR prevention and risk-perception. Primary data was generated using an online survey of 250 Western Australian parents. We tested our hypotheses using reliability and validity tests and structural equation modelling. Our results show that exposure to AACs alone may not be enough to change parental intention to demand antibiotic prescription for their children. Parental risk perception of AMR and parental anxiety affect intention to demand antibiotics, and the view that AMR is a social responsibility has a moderating effect on intention to demand antibiotics. These factors could be considered and combine messaging strategies in designing future antibiotic awareness campaigns.

Systematic review of surveillance systems for AMR in Africa

AIMS

Surveillance is a useful tool for tracking antimicrobial resistance (AMR) trends, patterns, therapeutic and policy interventions. Proper correlation of surveillance data gives meaningful insight into the underlying epidemiology and facilitates development of rational interventions. This comprehensive review aims to identify, classify and assess gaps in Global Antimicrobial Resistance and Use Surveillance System (GLASS) reporting and national action plan (NAP) implementation in Africa.

METHODS

Articles published in English were searched across five electronic databases (PubMed, Scopus, Embase, AJOL and Cochrane) and grey literature. Articles were screened against inclusion/exclusion criteria and data from eligible studies were retrieved and analysed. This systematic review was registered in the International Prospective Register of Systematic Reviews (PROSPERO) on 31 July 2020 under protocol CRD42020192165.

RESULTS

Of the 4304 records found, only 32 met the initial inclusion criteria (4 peer reviews and 28 were grey literature). From these records, 41 surveillance systems were identified (30 national and 11 transnational). After final review of reported outcomes, only 23 national surveillance systems met the inclusion criteria. Indicators recorded from these systems shows lack of external quality assessment (EQA) in some systems and limited reporting of parameters such as infection origin, patient population and pathogen types.

CONCLUSIONS

The outcome of the review shows that although AMR surveillance has been implemented in 23 out of the 47 countries in the region, a number of limitations exist in the surveillance methods and reporting protocols that can impair the usefulness, validity and trustworthiness of data generated from these surveillance systems.

The impact of antimicrobial resistance awareness interventions involving schoolchildren, development of an animation and parents engagements: a pilot study

Background

Antimicrobial resistance (AMR) is a global health challenge, particularly in low- and middle-income countries where antibiotics are widely available to consumers, leading to their misuse. However, AMR educational interventions for engaging parents of schoolchildren are mainly lacking in Sub-Saharan Africa. This study aimed to assess the potential of AMR animation and schoolchildren in influencing parents’ AMR knowledge, attitudes, and beliefs.

Methods

Parents of schoolchildren aged 11–15 years in Tema, a city in Ghana, watched and discussed an AMR animation designed with ideas from the schoolchildren’s top stories and picture drawings. The children from two schools were first engaged with AMR lessons, with one school using storytelling, the other school using picture drawing, and none serving as a control. The children were then asked to discuss the lessons with their parents. Baseline surveys of parents of randomly selected children were conducted to assess AMR knowledge, attitudes and beliefs before engaging the students and parents, and immediately after the parents participated in viewing and discussing the animation. McNemar and t-tests were used to assess changes in AMR knowledge, attitudes and beliefs.

Results

Parents who participated in the animation event, and whose schoolchildren were in the storytelling intervention school had significantly improved knowledge regarding the statement “Antibiotics will cure any infection” (p = 0.021, χ2 = 0.711; 88% vs 50%) between baseline and endline. However, these parents also had statistically significant decreased scores regarding the statement “Antibiotics do not kill our good bacteria” (p = 0.021, χ2 = 1.042; 71.4% vs 40%) between baseline and endline. There was no significant effect on any statement among parents whose children were in the picture drawing school. However, t-test results combining the statements as composite scores showed statistically significant difference in only the attitude construct among parents whose children participated in storytelling intervention (p = 0.043) or picture drawing intervention (p = 0.019). There were no statistically significant changes in knowledge and beliefs constructs.

Conclusions

This study shows that interventions involving schoolchildren with parents engagements and AMR animation could influence parents’ AMR attitudes. The intervention could also positively or negatively impact parents’ AMR knowledge. Modifications of the interventions may be needed for tackling AMR.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13756-022-01062-6.

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.

A qualitative investigation of perceptions towards antibiotics by members of the public after choosing to pledge as an Antibiotic Guardian

INTRODUCTION

Antimicrobial resistance is one of the biggest threats facing global humanity. In 2014, Public Health England (now the UK Health Security Agency) launched the Antibiotic Guardian (AG) campaign as a national health promotion initiative to increase public and health professionals' commitment to reducing the threat of antibiotic resistance (ABR). The aim of this research study was to gain a snapshot of public AG attitudes towards antibiotic use, the AG campaign and illness postpledge.

METHODOLOGY

This research used an exploratory study design using thematic and framework analysis of semistructured, in-depth interviews. A purposive convenience sampling strategy was used to recruit 10 participants; adults in the general population who had registered with and chosen an AG pledge via the AG online platform during November 2020 were eligible for inclusion. Interviews were conducted via Zoom.

RESULTS

Six main themes were identified: campaign awareness, motivators to pledge (uncertainty about the future of ABR, personal gratification, personal responsibility, moral obligation and COVID-19), perceptions of personal responsibility (and patient perspectives of moral obligation in clinicians), the impact of the campaign and campaign promotion. Pledging appeared to solidify existing perceptions AGs held. Behavioural motivations for responsible antibiotic behaviours stemmed from perceptions of personal responsibility, moral obligation and concerns about ABR. AGs attributed responsibility to variable patterns in overprescribing. Perceptions towards COVID-19, coinciding with the previously established study period, appeared mixed. AGs were keen to promote responsible perceptions in relation to antibiotics, resistance and the AG campaign. However, poor social acceptability of ABR concern was raised as a barrier to campaign promotion.

DISCUSSION

The AGs' longstanding commitment to antimicrobial resistance demonstrates the importance of a pre-existing interest in the public's self-reported judicious behaviours and decision to pledge to an ABR-focused campaign. Presenting the local and global threat to human mortality and morbidity in a more relatable format in public messaging should be considered in future strategies promoting ABR awareness and shifts in public perceptions. More frequent messaging to existing AGs is further recommended to propagate positive behaviour change among a wider audience.

PATIENT OR PUBLIC CONTRIBUTION

This study was based on interviews with adult members of the public who had pledged to be AGs via the website www.AntibioticGuardian.com. Interviews were based on the public's perceptions of the AG campaign, antibiotic use and ABR.

"Antibiotics are for everyone, our past and our future generations, right? If antibiotics are dead, we will be in big trouble": Building on community values for public engagement on appropriate use of antibiotics in Singapore

Introduction

Shared decision-making (SDM) and trust building through continuity of care are known to play a pivotal role in improving appropriate antibiotic prescribing and use.

Problem

However, less is known about how to effectively leverage these factors when present-or overcome them when not-to address community needs and improve patient liaison.

Methods

We addressed this question using a convergent parallel mixed-methods design. Focus group discussions (N = 13; August 2018-September 2020), were analyzed alongside a nationally-representative cross-sectional survey (N = 2004; November 2020-January 2021), in Singapore. Descriptive quantitative analyses and multivariable logistic regression were undertaken to examine antibiotic knowledge and factors associated with preference for SDM. Qualitative applied thematic analysis was integrated with these data to further explain the findings.

Findings

Poor knowledge and misbeliefs on appropriate antibiotic use and antimicrobial resistance (AMR) were identified. For example, only 9% of the surveyed population understood that AMR occurs when the bacteria, not the human body, become resistant to antibiotics. Qualitative data corroborated the survey findings and suggested a shared value was placed on public education to avoid the fallout from resistant bacterial strains on current and future generations. This study also identified the opportunity to harness community trust in primary care doctors, who were described as highly valued educators for antibiotic use and AMR. Those who had trust in doctors were 75% more likely to prefer SDM (aOR 1.75, 95% CI 1.10-2.77, P = 0.017), especially adults aged ≥50 years who were receiving continued care with a regular doctor (aOR 1.83, 95% CI 1.18-2.86, P = 0.007). Continuity of care was observed to value-add SDM by building trusting relationships, though it was often absent in younger populations.

Conclusion

This study highlights the long-term value-add of building on cultural capital pertaining to appropriate antibiotic use and AMR, by leveraging on the role of trust in doctors, desire for SDM and anchoring these in continuity of care when possible.

Recommendations

Using focused messaging and exploring alternative channels of communications such as annual check-ins or tele-consultations with a regular doctor, and emphasizing continuity of care across all age groups would help bridge the identified gaps.

The effectiveness of hand hygiene interventions for preventing community transmission or acquisition of novel coronavirus or influenza infections: a systematic review

BACKGROUND

Novel coronaviruses and influenza can cause infection, epidemics, and pandemics. Improving hand hygiene (HH) of the general public is recommended for preventing these infections. This systematic review examined the effectiveness of HH interventions for preventing transmission or acquisition of such infections in the community.

METHODS

PubMed, MEDLINE, CINAHL and Web of Science databases were searched (January 2002-February 2022) for empirical studies related to HH in the general public and to the acquisition or transmission of novel coronavirus infections or influenza. Studies on healthcare staff, and with outcomes of compliance or absenteeism were excluded. Study selection, data extraction and quality assessment, using the Cochrane Effective Practice and Organization of Care risk of bias criteria or Joanna Briggs Institute Critical Appraisal checklists, were conducted by one reviewer, and double-checked by another. For intervention studies, effect estimates were calculated while the remaining studies were synthesised narratively. The protocol was pre-registered (PROSPERO 2020: CRD42020196525).

RESULTS

Twenty-two studies were included. Six were intervention studies evaluating the effectiveness of HH education and provision of products, or hand washing against influenza. Only two school-based interventions showed a significant protective effect (OR: 0.64; 95% CI 0.51, 0.80 and OR: 0.40; 95% CI 0.22, 0.71), with risk of bias being high (n = 1) and unclear (n = 1). Of the 16 non-intervention studies, 13 reported the protective effect of HH against influenza, SARS or COVID-19 (P < 0.05), but risk of bias was high (n = 7), unclear (n = 5) or low (n = 1). However, evidence in relation to when, and how frequently HH should be performed was inconsistent.

CONCLUSIONS

To our knowledge, this is the first systematic review of effectiveness of HH for prevention of community transmission or acquisition of respiratory viruses that have caused epidemics or pandemics, including SARS-CoV-1, SARS-CoV-2 and influenza viruses. The evidence supporting the protective effect of HH was heterogeneous and limited by methodological quality; thus, insufficient to recommend changes to current HH guidelines. Future work is required to identify in what circumstances, how frequently and what product should be used when performing HH in the community and to develop effective interventions for promoting these specific behaviours in communities during epidemics.

Knowledge, Social Influences, Perceived Risks and Benefits, and Cultural Values Explain the Public's Decisions Related to Prudent Antibiotic Use

People should use antibiotics (AB) prudently to mitigate antibiotic resistance (ABR). Previous studies-and, subsequently, interventions-on ABR have focused mainly on improving public awareness and knowledge. We investigated a comprehensive theory-based explanatory model to understand the public's decision making regarding prudent AB use, based on, among others, the theory of planned behavior. In a cross-sectional online survey, the psychological determinants of people's decisions about prudent AB use were examined in a sample of 1,228 Swiss adults. The questionnaire assessed respondents' demand for AB, willingness to adopt measures that prevent the need for AB, perceived risks of ABR, perceived benefits of AB, attitudes and social influences regarding AB, knowledge of AB and ABR, and cultural values. Mokken scale analysis revealed three types of knowledge: knowledge of the functioning of AB, of ABR, and of preventive measures. Structural equation modeling indicated that respondents' demand for AB was mostly predicted by social influences, perceived benefits of AB, and knowledge of AB functioning. Willingness to prevent AB use was mainly related to conservative values, perceived risks of ABR, negative attitudes toward AB, and knowledge of preventive measures. Our study suggests that the provision of information about AB and preventive measures is a first step toward changing people's decisions related to prudent AB use. Future interventions that additionally utilize cultural values to convey important messages and target additional factors, such as social influences, the risks of ABR, and the benefits of cautious AB use, can be more successful in promoting prudent AB use.

Health Information Orientation Profiles and Their Association with Knowledge of Antibiotic Use in a Population with Good Internet Access: A Cross-Sectional Study

Background: Poor knowledge of antibiotic use drives poor antibiotic practices, but little is known about the influence of health information orientation (HIO) on knowledge of antibiotic use in the general public. Methods: We conducted a nationally-representative population-wide cross-sectional study (November 2020−January 2021), on a proportionately stratified random sample of 2004 Singapore residents aged ≥21 years. Multivariable logistic regression analysis was performed to assess the association between HIO and knowledge of antibiotic use. Results: Forty percent of respondents had low-levels of HIO (LL-HIO); they tended to be younger, not currently married, and did not have family/friends working in the healthcare sector. Respondents with LL-HIO (aOR 1.82, 95% CI 1.32−2.51, p < 0.001) were 82% more likely to have poor knowledge of antibiotic use. In particular, older adults aged ≥50 years with LL-HIO (aOR 1.81, 95% CI [1.32−2.51], p < 0.001) were much more likely to have poor knowledge than their HL-HIO counterparts. They were also less likely to use the Internet to seek health information and had poor eHealth efficacy. Conclusion: LL-HIO is independently associated with poor knowledge of antibiotic use. Educational strategies on antibiotic use should disseminate a consistent message through both online and offline platforms, involving traditional and non-traditional healthcare and non-healthcare influencers.

Public Health Interventions to Improve Antimicrobial Resistance Awareness and Behavioural Change Associated with Antimicrobial Use: A Systematic Review Exploring the Use of Social Media

Introduction: Over the years there have been several interventions targeted at the public to increase their knowledge and awareness about Antimicrobial Resistance (AMR). In this work, we updated a previously published review by Price et al. (2018), on effectiveness of interventions to improve the public’s antimicrobial resistance awareness and behaviours associated with prudent use of antimicrobials to identify which interventions work best in influencing public behaviour. Methods: Five databases—Medline (OVID), CINAHL (EBSCO), Embase, PsycINFO, and Cochrane Central Register of Controlled Trials (CENTRAL-OVID)—were searched for AMR interventions between 2017 and 2021 targeting the public. All studies which had a before and after assessment of the intervention were considered for inclusion. Results: In total, 17 studies were found to be eligible for inclusion in the review. Since there was a variety in the study interventions and in particular outcomes, a narrative synthesis approach was adopted for analysis. Whereas each study showed some impact on awareness and knowledge, none measured long-term impact on behaviours towards antibiotic use, awareness, or knowledge. Engagement was higher in interventions which included interactive elements such as games or videos. Social media was not used for recruitment of participants or as a mode of communication in any AMR interventions included in this review.

Impact of antimicrobial stewardship programs on antibiotic consumption and antimicrobial resistance in four Colombian healthcare institutions

BACKGROUND

Antimicrobial stewardship programs (ASPs) have become a fundamental pillar in optimizing antimicrobial usage, improving patient care, and reducing antimicrobial resistance (AMR). Herein we evaluated the impact of an ASP on antimicrobial consumption and AMR in Colombia.

METHODS

We designed a retrospective observational study and measured trends in antibiotic consumption and AMR before and after the implementation of an ASP using interrupted time series analysis over a 4-year period (24 months before and 24 months after ASP implementation).

RESULTS

ASPs were implemented according to the available resources in each of the institutions. Before ASP implementation, there was a trend toward an increase in the antibiotic consumption of all measured antimicrobials selected. Afterward, an overall decrease in antibiotic consumption was observed. The use of ertapenem and meropenem decreased in hospital wards, while a decrease in the use of ceftriaxone, cefepime, piperacillin/tazobactam, meropenem, and vancomycin was observed in intensive care units. After ASP implementation, the trend toward an increase of oxacillin-resistant Staphylococcus aureus, ceftriaxone-resistant Escherichia coli, and meropenem-resistant Pseudomonas aeruginosa was reversed.

CONCLUSIONS

In our study, we showed that ASPs are a key strategy in tackling the emerging threat of AMR and have a positive impact on antibiotic consumption and resistance.

In-Hospital Macro-, Meso-, and Micro-Drivers and Interventions for Antibiotic Use and Resistance: A Rapid Evidence Synthesis of Data from Canada and Other OECD Countries

Hospitals continue to face challenges in reducing incorrect antibiotic use due to social and cultural factors at the level of the health system, the care facility, the provider, and the patient. The objective of this paper is to highlight the social and cultural drivers of antimicrobial use and resistance and targeted interventions for secondary and tertiary care settings in Canada and other OECD countries. This paper is an extension of the synthesis conducted for the Public Health Agency of Canada's 2019 Spotlight Report: Preserving Antibiotics Now and Into the Future. We conducted a systematic review with a few modifications to meet rapid timelines. We conducted a search in Ovid MEDLINE and McMaster University's evidence databases for systematic reviews and then for individual Canadian studies. To cast a wider net, we searched OECD organization websites and screened reference lists from systematic reviews. We synthesized the evidence narratively and categorized the evidence into macro-, meso-, and microlevel. A total of 70 studies were (a) from OCED countries and summarized evidence of potential sociocultural antimicrobial resistance and use barriers or facilitators and/or interventions addressing these challenges; (b) systematic reviews with 50% of included studies that are situated in secondary and tertiary settings; and (c) published in Canada's two official languages, English and French. We found that hospital structures and policies may influence antibiotic utilization and variations in antimicrobial management. Microlevel factors may sway inappropriate prescribing among clinicians. The amount and type of antibiotics used may affect resistance rates. Interventions were mainly comprised of antibiotic stewardship and training that modify clinician behavior and that educate patients and carers. This evidence synthesis illustrates the various drivers of, and interventions for, antimicrobial use and resistance at the macro-, meso-, and microlevel in secondary and tertiary settings. We demonstrate that upstream drivers may lead to downstream events that influence antimicrobial resistance.

Associations between socio-spatially different urban areas and knowledge, attitudes, practices and antibiotic use: A cross-sectional study in the Ruhr Metropolis, Germany

Inappropriate and excessive antibiotic use fuels the development of antibiotic resistance. Determinants of antibiotic use, including knowledge and attitudes, are manifold and vary on different spatial scales. The objective of this study was to examine the associations between socio-spatially diverse urban areas and knowledge, attitudes, practices and antibiotic use within a metropolitan city. A cross-sectional survey was conducted in the general population in socio-spatially different areas in Dortmund, Germany, in February and March 2020. Three urban areas were chosen to represent diverse socio-spatial contexts (socio-spatially disadvantaged: A, intermediate: B, socio-spatially disadvantaged: C). Participants were selected via simple random sampling. The questionnaire comprised knowledge and attitude statements and questions around antibiotic use and handling practices. Differences between the areas were examined by estimating odds ratios (OR) and corresponding 95% confidence intervals by multiple logistic regression. Overall, 158 participants were included. Participants of Area C showed the lowest proportions of correct knowledge statements, indicated more often attitudes contrary to common recommendations, lower risk awareness and reported more often antibiotic use (C: 40.8%; A: 32.7%; B: 26.5%) and potential mishandling practices (C: 30.4%; A: 9.6%; B: 17.3%). The multiple logistic regression confirmed these differences. Around 42.3% (C), 33.3% (A) and 20.0% (B) of the diseases mentioned for which an antibiotic was used are mainly caused by viral pathogens. A common misconception across all areas was the perception of antibiotic resistance as an individual rather than a universal issue. This study reveals distinct differences between socio-spatially diverse urban areas within a metropolitan city, regarding knowledge, attitudes and practices around antibiotics and ABR. Our findings confirm that enhanced efforts are required to better inform the population about the adequate use and handling of antibiotics. This study emphasizes the need for future interventions to be tailored to the specific local socio-economic context.

Omani senior secondary school students’ knowledge of and attitudes to antibiotic resistance

Antibiotic resistance is a worldwide problem that is increasing largely due to the misuse of antibiotics in human health and agriculture. This situation is further exacerbated by a dearth of new antibiotic development, the focus of pharmaceutical companies having shifted to more lucrative treatments for chronic conditions such as elevated blood pressure. To conserve the efficacy of the current crop of antibiotics, it is vital that they are used appropriately by individuals. Effective education may be a means to achieve such appropriate use. This paper reports on a large-scale, mixed methods study, which employed a survey and oral questionnaires, undertaken with senior secondary Omani students. The study explored students’ understanding of antibiotic resistance as well as their attitudes to the issue of antibiotic resistance. The study findings indicated that, although some students had a reasonably clear understanding of antibiotic resistance, many had serious misconceptions that could result in misuse of antibiotics. The article concludes with suggestions for amending secondary school pedagogy in Oman to address the misconceptions.

Comparing public attitudes, knowledge, beliefs and behaviours towards antibiotics and antimicrobial resistance in Australia, United Kingdom, and Sweden (2010-2021): A systematic review, meta-analysis, and comparative policy analysis

BACKGROUND

Social and behavioural drivers of inappropriate antibiotic use contribute to antimicrobial resistance (AMR). Recent reports indicate the Australian community consumes more than twice the defined daily doses (DDD) of antibiotics per 1000 population than in Sweden, and about 20% more than in the United Kingdom (UK). We compare measures of public knowledge, attitudes and practices (KAP) surrounding AMR in Australia, the UK and Sweden against the policy approaches taken in these settings to address inappropriate antibiotic use.

METHODS

National antimicrobial stewardship policies in Australia, Sweden, and the UK were reviewed, supplemented by empirical studies of their effectiveness. We searched PubMed, EMBASE, PsycINFO, Web of Science and CINAHL databases for primary studies of the general public's KAP around antibiotic use and AMR in each setting (January 1 2011 until July 30 2021). Where feasible, we meta-analysed data on the proportion of participants agreeing with identical or very similar survey questions, using a random effects model.

RESULTS

Policies in Sweden enact tighter control of community antibiotic use; reducing antibiotic use through public awareness raising is not a priority. Policies in the UK and Australia are more reliant on practitioner and public education to encourage appropriate antibiotic use. 26 KAP were included in the review and 16 were meta-analysable. KAP respondents in Australia and the UK are consistently more likely to report beliefs and behaviours that are not aligned with appropriate antibiotic use, compared to participants in similar studies conducted in Sweden.

CONCLUSIONS

Interactions between public knowledge, attitudes and their impacts on behaviours surrounding community use of antibiotics are complex and contingent. Despite a greater focus on raising public awareness in Australia and the UK, neither antibiotic consumption nor community knowledge and attitudes are changing significantly. Clearly public education campaigns can contribute to mitigating AMR. However, the relative success of policy approaches taken in Sweden suggests that practice level interventions may also be required to activate prescribers and the communities they serve to make substantive reductions in inappropriate antibiotic use.

The Associations between Poor Antibiotic and Antimicrobial Resistance Knowledge and Inappropriate Antibiotic Use in the General Population Are Modified by Age

OBJECTIVES

Understanding factors influencing inappropriate antibiotic use can guide the design of interventions to improve antibiotic practices and reduce antimicrobial resistance (AMR).

METHODS

A nationally representative cross-sectional survey (N = 2004) was conducted between November 2020 and January 2021. Knowledge of antibiotic use and AMR using the World Health Organization's Multi-Country AMR Survey questionnaire, and antibiotic practices were examined. Multivariable logistic regression was performed to identify factors associated with inappropriate antibiotic use and examine effect measure modifications.

RESULTS

After adjusting for potential confounding, poor knowledge of antibiotic use was associated with a 3x increased odds of inappropriate antibiotic use in adults aged ≥50 years (aOR 3.11, 95% CI [2.24-4.32]), 5× increased odds in those aged 35-49 years (aOR 4.88, 95% CI [3.32-7.16]), and 7× increased odds in those aged 21-34 years (aOR 6.58, 95% CI [4.19-10.33]). While there was no statistically significant association in adults aged ≥50 years, poor knowledge of AMR increased the odds of inappropriate antibiotic use by 4 times in adults aged 35-49 years (aOR 3.73, 95% CI [1.53-9.11]) and 5 times in those aged 21-34 years (aOR 4.90, 95% CI [1.84-13.02]).

CONCLUSIONS

Targeted educational interventions for specific age groups are needed in conjunction with empowering the public with knowledge of antibiotic use and AMR.

Children against antibiotics misuse and antimicrobial resistance: assessing effectiveness of storytelling and picture drawing as public engagement approaches

Background: Interventions delivered in schools have been found to be effective in improving knowledge of antibiotics and antimicrobial resistance (AMR) among school-aged children, particularly those in high-income countries, but the evidence is largely lacking in low- and middle-income countries. This study aimed to design, implement and assess storytelling in one school and picture drawing in another school as engagement approaches for improving knowledge, attitudes and beliefs about antibiotics and AMR among schoolchildren in Ghana.  Methods: Two schools with a total population of 375 schoolchildren ages 11-15 years in Tema, a city in Ghana, participated in public engagement interventions involving storytelling in one school and picture drawing in another school. The interventions included eight weeks of engagement led by science teachers and a competition held in each school. For quantitative outcome-based evaluation, schoolchildren were randomly sampled in each school (31 in the storytelling school and 32 in the picture-drawing school). Purposive sampling was also used to select 20 schoolchildren in each school for qualitative outcome-based evaluation. Respondents completed identical knowledge, attitudes and beliefs questionnaires and were interviewed at two time points (before and at most a week) after key interventions to assess changes in antibiotics and AMR knowledge, attitudes and beliefs. McNemar test was conducted to assess statistical significance between baseline and endline scores. Framework analysis was used for analysing the qualitative data. Results: Picture drawing had more significant effects (both positive and negative) on schoolchildren's AMR knowledge, attitudes and beliefs, whereas storytelling had a negative effect on children's AMR knowledge and no significant impact on beliefs and attitudes.  Conclusions: Our project's findings suggest that public engagement interventions that use picture drawing and storytelling may influence the knowledge, attitudes and beliefs of schoolchildren regarding antibiotic misuse and AMR. However, modifications are required to make them much more effective.

Factors influencing inappropriate use of antibiotics: Findings from a nationwide survey of the general public in Malaysia

Antibiotic resistance is one of the biggest threats to global public health. Misuse of antibiotics has never been investigated on a nationwide scale among the general public in Malaysia. This study aimed to identify sociodemographic and knowledge factors associated with inappropriate use of antibiotics in the Malaysian context to inform the development of interventions to mitigate inappropriate antibiotic use. We conducted computer-assisted telephone interviews (CATI) between June 2019 and December 2019. The telephone numbers were randomly generated from the electronic residential telephone directory of all 13 states and 3 Federal Territories in Malaysia. The survey consisted of questions on demographics, knowledge about antibiotics and antibiotic resistance (53 items), and practices of antibiotic use (16 questions). A total of 864 complete responses were received. Pronounced erroneous beliefs that antibiotics are effective against infections caused by viruses and that antibiotics can speed up recovery from coughs and colds were evident. The proportions that were aware of the terms ‘drug resistance’, ‘antimicrobial resistance’, and ‘superbugs’ were low. The mean and standard deviation (SD) for the antibiotic knowledge score was 23.7 (SD ±9.25; range 0 to 50) out of a possible score of 52. Regarding antibiotic practices, a considerable proportion reported non-adherence to recommended doses. The mean and SD for the antibiotic practices score was 37.9 (SD ± 6.5; range 17 to 47) out of a possible score of 48. Participants who earned an average monthly household income of MYR1001-3000 (OR 1.61, 95% CI 1.04–2.50) were more likely to report higher antibiotic practice scores than those with <MYR1000. Participants with tertiary education attainment reported higher antibiotic practice scores (OR 1.99; 95%CI 1.02–3.91) than those with primary school and below. High antibiotic knowledge scores (OR 3.94; 95% CI 2.71–5.73) were associated with higher antibiotic practice scores. Inappropriate antibiotic use is influenced by demographics and antibiotic knowledge. This study calls for education interventions focused on the lower socio-economic status population to increase awareness and to promote appropriate antibiotic use.

Impact of interprofessional service-learning on the effectiveness of knowledge transfer of antimicrobial resistance to Hong Kong elders: a quasi-experiment

Background

Community perception on antimicrobials plays a role in driving the development of antimicrobial resistance (AMR). The aim of the study was to evaluate the impact of interprofessional service-learning on the effectiveness of AMR knowledge transfer in Hong Kong elders aged 65 or above and students from university and secondary schools.

Methods

A quasi-experimental pretest–posttest controlled study was carried out from July 2018 to March 2019 for elderly subjects and a pre- and post-test were conducted in students from May to August 2018. Elderly subjects were recruited from the university-based community outreach program. The community outreach team consisted of both university and secondary school students. Students were provided with training of geriatric care and AMR before they reached out to the community. The one-to-one intervention with the aid of video and verbal explanation to educate the elderly about the definition, causes, and consequences of AMR, and preventive measures against AMR was provided. Questionnaires on knowledge of antibiotics and AMR were used as tools to reflect on the effectiveness for both students and elderly subjects. The questionnaire was completed twice, before and 1 week after the intervention. Chi-square test, t tests and regression analysis were used to analyze the data.

Results

A total of 93 Chinese elders, 61 of them in the intervention group and 32 in the control group participated in the study. The score obtained by the intervention group increased from 40.1 to 83.3% (p < 0.001) following intervention, while that of control group increased from 33.0 to 44.0% (p < 0.001). The increase attained in the intervention group was significantly greater than that of the control group (p < 0.001). A total of 95 secondary students and 88 university students have completed the pre-post questionnaires with 42.21% and 13% increment in AMR knowledge after the training (p < 0.001).

Conclusion

The significant change in knowledge level showed effective AMR knowledge transfer to both elders and students. The study could be used as a reference when allocating resources to implement effective interprofessional service-learning for better community health education in elderly populations.

Trial registration: This study was approved by the Chinese University of Hong Kong Survey and Behavioural Research Ethics Committee in December 2018 (Ref no. SBRE-18-214).

The immune self, hygiene and performative virtue in general public narratives on antibiotics and antimicrobial resistance

This paper employs an assemblage lens to generate analyses of general public narratives on antimicrobial resistance (AMR). Global efforts to reduce AMR include communications aiming to promote general public awareness, provide knowledge, encourage careful antibiotics use, and discourage demands for them. These efforts are somewhat compromised by the assumptions they make of individual lack of knowledge and motivation and the manner in which the AMR problem is framed in isolation from the biological, social and economic structures that produce it. Conceptualising AMR as an effect of antimicrobial assemblages of which publics are but one part, we analysed interviews with the general public on the lived experience of infections, antibiotic treatments and AMR. Far from science and policy discourse on AMR, these narratives showed antibiotics to be partly solutions to the social and biomedical challenges of infection, framed by self-defensive immunity and hygiene, the affective benefits of 'immune boosting', and the imperative to sustain the moral standing of the healthy citizen. Failing public awareness and action on AMR can be attributed to public health messages that overlook the social, affective and moral dimensions of infection care and separate AMR from its socio-economic drivers.

Characterizing social-ecological context and success factors of antimicrobial resistance interventions across the One Health spectrum: analysis of 42 interventions targeting E. coli

Background

Antimicrobial resistance (AMR) is among the most pressing One Health issues. While interventions and policies with various targets and goals have been implemented, evidence about factors underpinning success and failure of interventions in different sectors is lacking. The objective of this study is to identify characteristics of AMR interventions that increase their capacity to impact AMR. This study focuses on AMR interventions targeting E. coli.

Methods

We used the AMR-Intervene framework to extract descriptions of the social and ecological systems of interventions to determine factors contributing to their success.

Results

We identified 52 scientific publications referring to 42 unique E. coli AMR interventions. We mainly identified interventions implemented in high-income countries (36/42), at the national level (16/42), targeting primarily one sector of society (37/42) that was mainly the human sector (25/42). Interventions were primarily funded by governments (38/42). Most intervention targeted a low leverage point in the AMR system, (36/42), and aimed to change the epidemiology of AMR (14/42). Among all included publications, 55% (29/52) described at least one success factor or obstacle (29/52) and 19% (10/52) identified at least one success factor and one obstacle. Most reported success factors related to communication between the actors and stakeholders and the role of media, and stressed the importance of collaboration between disciplines and external partners. Described obstacles covered data quality, access to data and statistical analyses, and the validity of the results.

Conclusions

Overall, we identified a lack of diversity regarding interventions. In addition, most published E. coli interventions were poorly described with limited evidence of the factors that contributed to the intervention success or failure. Design and reporting guidelines would help to improve reporting quality and provide a valuable tool for improving the science of AMR interventions.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-021-06483-z.

Children against antibiotics misuse and antimicrobial resistance: assessing effectiveness of storytelling and picture drawing as public engagement approaches

Background: Interventions delivered in schools have been found to be effective in improving knowledge of antibiotics and antimicrobial resistance (AMR) among school-aged children, particularly those in high-income countries, but the evidence is largely lacking in low- and middle-income countries. This study aimed to design, implement and assess storytelling and picture drawing as engagement approaches for improving knowledge, attitudes and beliefs about antibiotics and AMR among schoolchildren in Ghana. Methods: Two schools with a total population of 375 schoolchildren ages 11-15 years in Tema, a city in Ghana, participated in public engagement interventions involving storytelling in one school and picture drawing in another school. The interventions included eight weeks of engagement led by science teachers and a competition held in each school. For quantitative outcome-based evaluation, some schoolchildren were randomly sampled in each school. Purposive sampling was also used to select some schoolchildren in each school for qualitative outcome-based evaluation. Respondents completed identical knowledge, attitudes and beliefs questionnaires and were interviewed at two time points (before and at most a week) after key interventions to assess changes in antibiotics and AMR knowledge, attitudes and beliefs. Results: Picture drawing had more significant effects (both positive and negative) on schoolchildren's AMR knowledge, attitudes and beliefs, whereas storytelling had a negative effect on children's AMR knowledge and no significant impact on beliefs and attitudes. Conclusions: Our project's findings suggest that public engagement interventions that use picture drawing and storytelling may influence the knowledge, attitudes and beliefs of schoolchildren regarding antibiotic misuse and AMR. However, modifications are required to make them more effective. These include making the storytelling effective by turning it into drama or plays.

Ten Years of Inaction on Antimicrobial Resistance: An Environmental Scan of Policies in Canada from 2008 to 2018

We surveyed Canadian healthcare experts to identify policies to address antimicrobial resistance (AMR) in Canada between 2008 and 2018. Respondents identified AMR policy interventions implemented in Canada during the previous 10 years. Additional policies were identified through systematic searches of seven electronic databases and a review of government documents. Fifty-two unique policies were identified, with at least one policy in most provinces and territories. This environmental scan suggests that Canadian AMR efforts are disjointed and inadequate, given the urgency of this public health threat. Governments have mostly refrained from using more powerful policy tools, including regulation, legislation and fiscal measures.

What are the most effective community-based antimicrobial stewardship interventions in low- and middle-income countries? A narrative review

Antimicrobial resistance (AMR) is a major global issue and antimicrobial stewardship is central to tackling its emergence. The burden of AMR disproportionately impacts low- and middle-income countries (LMICs), where capacity for surveillance and management of resistant pathogens is least developed. Poorly regulated antibiotic consumption in the community is a major driver of AMR, especially in LMICs, yet community-based interventions are neglected in stewardship research, which is often undertaken in high-income settings and/or in hospitals. We reviewed the evidence available to researchers and policymakers testing or implementing community-based antimicrobial stewardship strategies in LMICs. We critically appraise that evidence, deliver recommendations and identify outstanding areas of research need. We find that multifaceted, education-focused interventions are likely most effective in our setting. We also confirm that the quality and quantity of community-based stewardship intervention research is limited, with research on microbiological, clinical and economic sustainability most urgently needed.

Drivers of antibiotic use in Vietnam: implications for designing community interventions

INTRODUCTION

Antimicrobial resistance is a global challenge that threatens our ability to prevent and treat common infectious diseases. Vietnam is affected by high rates of antimicrobial resistant infections, driven by the overuse of antibiotics and the Vietnamese government has recognised antimicrobial resistance as a health security priority. This study aimed to understand how people in Vietnam use antibiotics in community settings, and the factors that impact their practices and decision-making regarding antibiotics.

METHODS

We conducted 43 qualitative in-depth interviews with 50 community members in two urban and two rural sites in Vietnam. We conducted iterative, inductive thematic analysis alongside data collection through a process of systematic debriefings based on detailed interview summaries. Through this process, we developed a coding framework that was then applied to transcribed interview data.

RESULTS

Frequent and indiscriminate use of antibiotics was driven by the powerful appeal that antibiotics held for many Vietnamese consumers. Consumers were discerning in making decisions in their purchase and use of antibiotics. Consumers' decisions were affected by perceptions of what constitutes high-quality medicine (effective, strong, accessible and affordable); privileging symptom control over diagnosis; social constructions of antibiotics as a trusted remedy with embodied evidence of prior efficacy, which is reinforced by advice from trusted sources in their community; and varied, generally incomplete, understanding of the concept of antibiotic resistance and its implications for individuals and for public health.

CONCLUSION

Antibiotic use at the community and primary care level in Vietnam is driven by community members' social and economic response to what constitutes effective healthcare, rather than biomedical logic. Community-based interventions to reduce unnecessary antibiotic use need to engage with the entangled socio-structural factors that 'resist' current public health efforts to ration antibiotic use, alongside biomedical drivers. This study has informed the design of a community-based trial to reduce unnecessary antibiotic use.

Analysing incompliant attitudes towards antibiotic prescription completion in the UK

Objectives

To analyse demographic, social and geographic predictors of incompliant attitudes towards prescription completion in the UK.

Methods

Two waves of the Eurobarometer survey (85.1 and 90.1) were analysed, with a final sample size of 2016. Using logistic regression, the best-fitting combination of a set of identified variables was specified. The regression output and the model-averaged importance of each variable were analysed.

Results

Compared with a median prevalence region, respondents in the Nomenclature of Territorial Units for Statistics (NUTS) 1 London (OR = 2.358, 95% CI = 1.100–5.398) and Scotland (OR = 2.418, 95% CI = 1.083–5.693) regions were most likely to report an incompliant attitude. Respondents who correctly answered questions about whether unnecessary use of antibiotics could make them ineffective in future (OR = 0.353, 95% CI = 0.230–0.544), whether antibiotics kill viruses (OR = 0.644, 95% CI = 0.450–0.919) and whether antibiotics treat colds (OR = 0.412, 95% CI = 0.287–0.591) were less likely to report incompliant attitudes. Conversely, respondents who correctly responded that antibiotics can cause side effects (OR = 1.419, 95% CI = 1.014–1.999) were more likely to report incompliant attitudes. There was some evidence of associations between political orientation and level of compliance. Uncooperative survey respondents (OR = 2.001, 95% CI = 1.108–3.526) were more likely to report incompliant attitudes.

Conclusions

Incompliant attitudes towards antibiotic prescription compliance in the UK are associated with a variety of factors, including regional geographic variation in attitudes. Knowledge about antibiotics can relate to good stewardship attitudes, but concerns over side effects are associated with poor attitudes. Further research should examine the underlying attitudes and beliefs that political orientation may be a marker for in the context of antibiotic stewardship. Survey samples reliant on self-selection are likely to be biased towards good stewardship.

Identifying global research gaps to mitigate antimicrobial resistance: A scoping review

OBJECTIVE

Identify research gaps relevant to the global effort to combat antimicrobial resistance.

METHODS

Web of Science, PubMed, Scopus, and Ovid MEDLINE were searched for reviews on antimicrobial resistance published between January 1, 2015 and December 31, 2019. Recommendations for future research were identified.

FINDINGS

Seventy-four reviews met inclusion criteria; 300 research gaps and recommendations were identified. The largest number were from the human health sector (105; 35%) followed by environmental health (72; 23%), animal health (66; 22%), food and feed (14; 5%), and plants and crops (8; 3%); 35 (12%) involved more than one sector. The largest number of gaps concerned surveillance of resistance (68; 23%), followed by study design or methodology (52; 17%), interventions (41; 14%), risk assessment and modeling (35; 12%), ecological (26; 9%) and biochemical (28; 9%) aspects of resistance, interface between reservoirs of resistant pathogens (24; 8%), and economic (15; 5%) and awareness- and behavior-related (11; 4%) aspects of antimicrobial resistance.

CONCLUSIONS

Important research gaps remain in our complete understanding of antimicrobial resistance, and more research is needed about its development, transmission, and impact across the interface of human, animal, and environmental reservoirs.

Development and randomized controlled trial of an animated film aimed at reducing behaviours for acquiring antibiotics

BACKGROUND

Antimicrobial resistance (AMR) is a global health crisis but reducing antibiotic use can help. Some antibiotic use is driven by patient demand.

OBJECTIVES

To develop an intervention to discourage antibiotic-seeking behaviour in adults.

METHODS

Literature reviewed to identify behaviours for acquiring antibiotics among adults in the community. Behaviour change wheel approach was used to select the target behaviour and behaviour change techniques. An intervention in the form of a short animated film was developed and its potential impact evaluated in a randomized, controlled, online questionnaire study.

RESULTS

Asking a general medical/dental practitioner for antibiotics was identified as the target behaviour. A short stop-motion animated film was chosen to deliver several behaviour-change techniques. Education and persuasion were delivered around information about the normal microbial flora, its importance for health, the negative effect of antibiotics, and about AMR. 417 UK-based individuals completed the questionnaire; median age 34.5 years, 71% female, 91% white ethnicity. 3.8% of participants viewing the test film intended to ask for antibiotics compared with 7.9% viewing the control film. Test film viewers had significantly higher knowledge scores. At 6 week follow up, knowledge scores remained significantly different, while most attitude and intention scores were not different.

CONCLUSIONS

Some patients continue to ask for antibiotics. The film increased knowledge and reduced intentions to ask for antibiotics. At 6 weeks, knowledge gains remained but intentions not to ask for antibiotics had waned. Evaluation in the clinical environment, probably at the point of care, is needed to see if antibiotic prescribing can be impacted.

Native and foreign healthcare workers' knowledge of appropriate use of antibiotics: a prospective pre-post study in Danish nursing homes

Aim:

The aim was to determine the association between healthcare workers’ (HCWs) country of birth and their knowledge of appropriate use of antibiotics, and whether the association changed after an educational intervention.

Background:

Older residents in nursing homes have been recognized to receive excessively antibiotic treatments. HCWs often represent an important link between the older resident and the general practitioner prescribing the antibiotics, thus their knowledge of appropriate use of antibiotics is important.

Methods:

This study was conducted as a prospective pre-post study. Totally, 312 HCWs from 7 nursing homes in Denmark were included. For statistical analyses, χ² test and a linear mixed regression model were applied.

Findings:

Native HCWs were more likely to have a higher percentage of correct responses to single statements related to knowledge of appropriate use of antibiotics. Native HCWs had a significantly higher knowledge-of-antibiotic score compared to foreign HCWs (−7.53, P < 0.01). This association remained significant after adjusting for relevant covariates (−5.64, P < 0.01). Native HCWs’ mean change in knowledge-of-antibiotic score after the intervention did not differ from the foreign HCWs’ mean change in knowledge-of-antibiotic score.

Conclusion:

Our findings indicate that HCWs born outside Denmark reveal a lower knowledge-of-antibiotic score than HCWs born in Denmark despite comparable educational backgrounds. All participants increased their knowledge from baseline to follow-up. Our findings also indicate that an educational seminar cannot equalize the difference in knowledge between native and foreign HCWs. Studies with larger sample size and a more detailed measurement of cultural identity should investigate this association further.

Self-Medication with Antibiotics for Protection against COVID-19: The Role of Psychological Distress, Knowledge of, and Experiences with Antibiotics

Self-medication with antibiotics is a major contributing factor to antimicrobial resistance. Prior research examining factors associated with antibiotic self-medication has focused on an individual’s knowledge about antibiotics, antibiotic usage practices, accessibility to antibiotic medication, and demographic characteristics. The role of psychological distress associated with perceived health risks in explaining antibiotic self-medication is less understood. This study was designed to address this knowledge gap in the context of the COVID-19 pandemic in Australia. An online survey of 2217 participants was conducted at the height of the initial outbreak and revealed that 19.5% of participants took antibiotics to protect themselves from COVID-19. Multivariate logistic analysis examined the predictors of taking antibiotics for protection against COVID-19. An integrative framework developed from the results illustrates potential pathways and facilitating factors that may contribute to prophylactic self-medication with antibiotics. Specifically, COVID-19 pandemic-induced psychological distress was significantly positively related to self-medication. Preventive use of antibiotics was also facilitated by a lack of understanding about antibiotics, inappropriate antibiotics usage practices, the nature of the patient-doctor relationship, and demographic characteristics. The findings highlight that to combat antimicrobial resistance due to self-medication, interventions need to focus on interrupting entrenched behavioural responses and addressing emotional responses to perceived health risks.

Antimicrobial resistance awareness and antibiotic prescribing behavior among healthcare workers in Nigeria: a national survey

BACKGROUND

Antimicrobial resistance (AMR) is a global problem compromising the effective treatment of infectious diseases. The World Health Organization (WHO) is encouraging and promoting awareness creation among health workers as one of its strategies to reduce the rate of emergence and transmission of AMR. Available data on the prescribing behavior of healthcare workers (HCWs) in Nigeria remains incomplete. This study was designed to provide an up-to-date estimate of the knowledge, attitude and antibiotic prescribing behavior of HCWs in Nigeria.

METHODS

This is a cross-sectional study. Self-administered questionnaires were distributed to healthcare workers selected from six states, one each from the 6 geopolitical zones in Nigeria. A multi-stage sampling technique was used to reflect the three tiers of healthcare: primary, secondary and tertiary levels. Quantitative data was summarized using descriptive statistics. All data analysis was done using the Statistical package for social sciences version 26.0.

RESULTS

Of the 420 questionnaires distributed, 358 (85.2%) responded. The mean year of practice of the respondents was 9.32 ± 7.8 years. About a half (50.3%) agreed that their prescribing behavior could promote antimicrobial resistance. 49.2% had a good knowledge of AMR and physicians had significantly better knowledge than other HCWs (X2 = 69.59, P < 0.001). Several participants prescribed antibiotics for common viral infections such as sore throats (75.7%), measles (37.7%), common cold and flu (21.2%). Over 60.3% admitted prescribing antibiotics just to be on the safe side. In general, 70.9% of the respondents frequently or moderately use practice guidelines while 25.7% often apply the delayed antibiotic prescription (DAP) strategy to reduce antimicrobial prescription.

CONCLUSION

This study reveals an overall moderate level of knowledge of AMR and attitude towards minimizing the emergence of antimicrobial resistance though this did not translate significantly to practice. Further efforts must be made in order to improve rational prescription of antimicrobials among HCWs in Nigeria.

Using evidence-based infographics to increase parents' understanding about antibiotic use and antibiotic resistance: a proof-of-concept study

Background

Communities need to see antibiotic stewardship campaigns as relevant to enhance understanding of antibiotic use and influence health-seeking behaviour. Yet, campaigns have often not sought input from the public in their development.

Objectives

To co-produce evidenced-based infographics (EBIs) about antibiotics for common childhood infections and to evaluate their effectiveness at increasing parents’ understanding of antibiotic use.

Methods

A mixed-methods study with three phases. Phase 1 identified and summarized evidence of antibiotic use for three childhood infections (sore throat, acute cough and otitis media). In phase 2, we co-designed a series of prototype EBIs with parents and a graphic design team (focus groups). Thematic analysis was used to analyse data. Phase 3 assessed the effect of EBIs on parents’ understanding of antibiotic use for the three infections using a national online survey in the UK.

Results

We iteratively co-produced 10 prototype EBIs. Parents found the evidence displayed in the EBIs novel and relevant to their families. Parents did not favour EBIs that were too medically focused. Parents preferred one health message per EBI. We included eight EBIs in a national survey of parents (n = 998). EBIs improved knowledge by more than a third across the board (34%, IQR 20%–46%, P < 0.001). Respondents confirmed that EBIs were novel and potentially useful, corroborating our focus groups findings.

Conclusions

Co-designed EBIs have the potential to succinctly change parents’ perceptions about antibiotics for acute respiratory tract infections in children. Further research should test EBIs in real-world settings to assess their reach as a potential public-facing intervention.

Evidence for action: a One Health learning platform on interventions to tackle antimicrobial resistance

Improving evidence for action is crucial to tackle antimicrobial resistance. The number of interventions for antimicrobial resistance is increasing but current research has major limitations in terms of efforts, methods, scope, quality, and reporting. Moving the agenda forwards requires an improved understanding of the diversity of interventions, their feasibility and cost-benefit, the implementation factors that shape and underpin their effectiveness, and the ways in which individual interventions might interact synergistically or antagonistically to influence actions against antimicrobial resistance in different contexts. Within the efforts to strengthen the global governance of antimicrobial resistance, we advocate for the creation of an international One Health platform for online learning. The platform will synthesise the evidence for actions on antimicrobial resistance into a fully accessible database; generate new scientific insights into the design, implementation, evaluation, and reporting of the broad range of interventions relevant to addressing antimicrobial resistance; and ultimately contribute to the goal of building societal resilience to this central challenge of the 21st century.

Antibiotic Use and Antibiotic Resistance: Public Awareness Survey in the Republic of Cyprus

We aimed to assess the knowledge and understanding of antibiotic use and resistance in the general population of Cyprus, in order to inform future antibiotic awareness campaigns with local evidence. Cross-sectional survey following the methodology of the “Antibiotic resistance: Multi-country public awareness survey” of the World Health Organization, during December 2019–January 2020. A total of 614 respondents participated: 64.3% were female and most were aged 35–44 years (33.2%) or 25–34 years (31.8%). One-third had used antibiotics >1 year ago and 91.6% reported receiving advice on appropriate use from a medical professional. Despite high awareness on correct use of antibiotics, lack of knowledge was noted for specific indications, where approximately one-third believed that viral infections respond to antibiotics and 70.7% lack understanding of how antibiotic resistance develops. Higher education graduates exhibited significantly higher knowledge rates. As high as 72.3% were informed about “antibiotic resistant bacteria” from healthcare professionals or social media. Most agreed on the usefulness of most suggested actions to address antibiotic resistance, with higher proportions acknowledging the role of prescribers. Up to 47% could not identify their role in decreasing antibiotic resistance. Our study provides local evidence to inform future efforts in a country characterized by high antibiotic consumption rates.