Setting the standard: multidisciplinary hallmarks for structural, equitable and tracked antibiotic policy

Pharmacovigilance Strategies to Address Resistance to Antibiotics and Inappropriate Use-A Narrative Review

The spread of antimicrobial resistance (AMR) is a global challenge. Close and continuous surveillance for quick detection of AMR can be difficult, especially in remote places. This narrative review focuses on the contributions of pharmacovigilance (PV) as an auxiliary tool for identifying and monitoring the ineffectiveness, resistance, and inappropriate use of antibiotics (ABs). The terms "drug ineffective", "therapeutic failure", "drug resistance", "pathogen resistance", and "multidrug resistance" were found in PV databases and dictionaries, denoting ineffectiveness. These terms cover a range of problems that should be better investigated because they are useful in warning about possible causes of AMR. "Medication errors", especially those related to dose and indication, and "Off-label use" are highlighted in the literature, suggesting inappropriate use of ABs. Hence, the included studies show that the terms of interest related to AMR and use are not only present but frequent in PV surveillance programs. This review illustrates the feasibility of using PV as a complementary tool for antimicrobial stewardship activities, especially in scenarios where other resources are scarce.

The urban political ecology of antimicrobial resistance: A critical lens on integrative governance

The objective of this paper is to integrate Urban Political Ecology (UPE) as a theory for identifying under-exposed urban dimensions of Antimicrobial Resistance (AMR). A UPE lens allows us to conceptualize urbanization as a ubiquitous socio-ecological process and an interpretive frame that could inform AMR governance strategies across related contexts by: a) situating AMR risks in relation to urbanization processes shaping social and political co-determinants of such systemic threats as climate change; b) aligning UPE scholarship with One Health (OH) approaches that address AMR to reveal the under-exposed link of AMR to environmental threats and broader structural dimensions that influence these threats; and c) identifying shared AMR and environmental governance pathways that inform the rationale for more equitable governance arrangements. We delineate a context in which the speed and scale of human activity in the larger context of urbanization, driven by global market integration strategies, impacts human-animal-environmental health threats such as AMR. We demonstrate how UPE scholarship can be leveraged to offer theoretical depth to approaches considering the interdependencies of AMR and climate change threats. We then propose a strategic approach focused on identifying shared governance pathways and intersectoral accountability frameworks to address upstream structural drivers of AM-Environmental threats. The co-benefits of a UPE-informed framework to human-animal-environmental health that leverages enabling policy environments to foster a more collaborative, equitable and sustainable approach to address systemic global health threats are clarified. Just as the concept of "health in all policies" emphasized taking health implications into account in all public policy development, the integration of UPE in AMR governance arrangements would emphasize the need to take other sectors into account through an intersectoral whole-of-government approach that fosters shared AMR - climate change governance pathways.

Antibiotics online: digital pharmacy marketplaces and pastiche medicine

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

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

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

Household antibiotic use in Malawi: A cross-sectional survey from urban and peri-urban Blantyre

Antimicrobial resistance (AMR) is a significant threat to public health. Use of antibiotics, particularly in contexts where weaker regulatory frameworks make informal access easier, has been identified as an important driver of AMR. However, knowledge is limited about the ways antibiotics are used in communities in Malawi and sub-Saharan Africa. Between April and July 2021, we undertook a cross-sectional survey of community antibiotic use practices in Blantyre, Malawi. We selected two densely-populated neighbourhoods (Chilomoni and Ndirande) and one peri-urban neighbourhood (Chileka) and undertook detailed interviews to assess current and recent antibiotic use, supported by the innovative "drug bag" methodology. Regression modelling investigated associations with patterns of antibiotic recognition. We interviewed 217 households with a total of 1051 household members. The number of antibiotics recognised was significantly lower among people with poorer formal health care access (people with unknown HIV status vs. HIV-negative, adjusted odds ratio [aOR]: 0.76, 95% CI: 0.77-.099) and amongst men (aOR: 0.83, 95% CI: 0.69-0.99), who are less likely to support healthcare-seeking for family members. Reported antibiotic use was mostly limited to a small number of antibiotics (amoxicillin, erythromycin and cotrimoxazole), with current antibiotic use reported by 67/1051 (6.4%) and recent use (last 6 months) by 440/1051 (41.9%). Our findings support the need for improved access to quality healthcare in urban and peri-urban African settings to promote appropriate antibiotic use and limit the development and spread of AMR.

Cultures of antibiotic prescribing in medical intensive care

Antimicrobial resistance (AMR) continues to present a challenge to international healthcare systems and structures of public health. The focus on optimizing antibiotic prescribing in human populations has challenged healthcare systems charged with making responsible their physician-prescribers. In the United States, physicians in almost every specialty and role use antibiotics as part of their therapeutic armamentariums. In United States hospitals, most patients are administered antibiotics during their stay. Therefore, antibiotic prescribing and utilization is a commonly accepted part of medical practice. In this paper, we utilize social science work on antibiotic prescribing to examine a critical space of care in United States hospital settings. From March to August 2018, we used ethnographic methods to study hospital-based medical intensive care unit physicians at the offices and hospital floors they frequent in two urban United States teaching hospitals. We focused on eliciting the interactions and discussions surrounding antibiotic decision-making that are uniquely influenced by the context of medical intensive care units. We argue that antibiotic use in the medical intensive care units under study was shaped by urgency, hierarchy, and uncertainty representative of the medical intensive care unit's role within the larger hospital system. We conclude that by studying the culture of antibiotic prescribing in medical intensive care units, we can see more clearly both the vulnerability of the looming antimicrobial resistance crisis and by contrast the perceived insignificance of stewarding antibiotic use when considered alongside the fragility of life amidst acute medical concerns regularly experienced in the unit.

Establishing an Antimicrobial Stewardship Program in Sierra Leone: A Report of the Experience of a Low-Income Country in West Africa

Antimicrobial Resistance (AMR) is a growing global health challenge that threatens to undo gains in human and animal health. Prevention and control of AMR requires functional antimicrobial stewardship (AMS) program, which is complex and often difficult to implement in low- and middle-income countries. We aimed to describe the processes of establishing and implementing an AMS program at Connaught Hospital in Sierra Leone. The project involved the setting up of an AMS program, capacity building and performing a global point prevalence survey (GPPS) at Sierra Leone’s national referral hospital. Connaught Hospital established a multidisciplinary AMS subcommittee in 2021 to provide AMS services such as awareness campaigns, education and training and review of guidelines. We performed a GPPS on 175 patients, of whom more than half (98, 56.0%) were prescribed an antibiotic: 63 (69.2%) in the surgical wards and 53 (51.2%) in the medical wards. Ceftriaxone (60, 34.3%) and metronidazole (53, 30.3%) were the most common antibiotics prescribed to patients. In conclusion, it is feasible to establish and implement an AMS program in low-income countries, where most hospitalized patients were prescribed an antibiotic.

How Antimicrobial Resistance Is Linked to Climate Change: An Overview of Two Intertwined Global Challenges

Globally, antimicrobial resistance (AMR) and climate change (CC) are two of the top health emergencies, and can be considered as two interlinked public health priorities. The complex commonalities between AMR and CC should be deeply investigated in a One Health perspective. Here, we provided an overview of the current knowledge about the relationship between AMR and CC. Overall, the studies included pointed out the need for applying a systemic approach to planetary health. Firstly, CC increasingly brings humans and animals into contact, leading to outbreaks of zoonotic and vector-borne diseases with pandemic potential. Although it is well-established that antimicrobial use in human, animal and environmental sectors is one of the main drivers of AMR, the COVID-19 pandemic is exacerbating the current scenario, by influencing the use of antibiotics, personal protective equipment, and biocides. This also results in higher concentrations of contaminants (e.g., microplastics) in natural water bodies, which cannot be completely removed from wastewater treatment plants, and which could sustain the AMR spread. Our overview underlined the lack of studies on the direct relationship between AMR and CC, and encouraged further research to investigate the multiple aspects involved, and its effect on human health.

A review of new emerging livestock-associated methicillin-resistant Staphylococcus aureus from pig farms

Methicillin-resistant Staphylococcus aureus (MRSA) is a S. aureus strain resistant to β-lactam antibiotics and is often associated with livestock, known as livestock-associated (LA)-MRSA. Using molecular typing with multi-locus sequence typing, MRSA clones have been classified in pigs, including clonal complex 398. Livestock-associated-methicillin-resistant S. aureus was first discovered in pigs in the Netherlands in 2005. Since then, it has been widely detected in pigs in other countries. Livestock-associated-methicillin-resistant S. aureus can be transmitted from pigs to pigs, pigs to humans (zoonosis), and humans to humans. This transmission is enabled by several risk factors involved in the pig trade, including the use of antibiotics and zinc, the size and type of the herd, and the pig pen management system. Although LA-MRSA has little impact on the pigs' health, it can be transmitted from pig to pig or from pig to human. This is a serious concern as people in direct contact with pigs are highly predisposed to acquiring LA-MRSA infection. The measures to control LA-MRSA spread in pig farms include conducting periodic LA-MRSA screening tests on pigs and avoiding certain antibiotics in pigs. This study aimed to review the emerging LA-MRSA strains in pig farms.

Contextualized understandings of dairy farmers' perspectives on antimicrobial use and regulation in Alberta, Canada

Antimicrobial resistance (AMR) has been largely attributed to antimicrobial use (AMU). To achieve judicious AMU, much research and many policies focus on knowledge translation and behavioral change mechanisms. To address knowledge gaps in contextual drivers of decisions made by dairy farmers concerning AMU, we conducted ethnographic fieldwork to investigate one community's understanding of AMU, AMR, and associated regulations in the dairy industry in Alberta, Canada. This included participation in on-farm activities and observations of relevant interactions on dairy farms in central Alberta for 4 mo. Interviews were conducted with 25 dairy farmers. The interviews were analyzed using thematic analysis and yielded several key findings. Many dairy farmers in this sample: (1) value their autonomy and hope to maintain agency regarding AMU; (2) have shared cultural and immigrant identities which may inform their perspectives of future AMU regulation as it relates to their farming autonomy; (3) feel that certain AMU policies implemented in other contexts would be impractical in Alberta and would constrain their freedom to make what they perceive to be the best animal welfare decisions; (4) believe that their knowledge and experience are undervalued by consumers and policy makers; (5) are concerned that the public does not have a complex understanding of dairy farming and, consequently, worry that AMU policy will be based on misguided consumer concerns; and (6) are variably skeptical of a link between AMU in dairy cattle and AMR in humans due to their strict adherence to milk safety protocols that is driven by their genuine care for the integrity of the product. A better understanding of the sociocultural and political-economic infrastructure that supports such perceptions is warranted and should inform efforts to improve AMU stewardship and future policies regarding AMU.

Challenges and shortcomings of antibacterial discovery projects

OBJECTIVES

Antibacterial drug discovery activities are essential for filling clinical pipelines with promising clinical candidates. Little information is available about the challenges and shortcomings of small companies and academic institutions in performing these important discovery tasks.

METHODS

We performed a content analysis of 463 reviewer comments on 91 funding applications of antibacterial drug discovery projects submitted to two major global funders between 2016 and 2020 that had not proceeded further in the selection process. This quality assessment was complemented with the inputs (via e-mail) from a panel involving six antibiotic research and development (R&D) experts with long-standing expertise and experience in antibiotic drug discovery.

RESULTS

Common critical comments of reviewers are grouped into three main categories: scientific and technical shortcomings, unclear potential societal impact, and insufficient capability and expertise of the project team regarding the R&D process. Insufficient characterization of in vitro activity and/or testing of the hits/leads and insufficient antibacterial activity were the most common critical comments. Other areas of concern were insufficient or lack of differentiation from available drugs or projects with a long R&D history, and the research team's insufficient knowledge of a structured streamlined R&D process as reflected in severe gaps in the expertise of the R&D team. Little appreciation for the problem of the emergence of target-based resistance, especially in single-target approaches, and little awareness of toxicological issues, including approaches with historical liabilities were also commonly mentioned. The shortcomings identified through the analysis of funding applications are echoed by the results of the expert panel.

DISCUSSION

Our analysis identified an urgent need of strengthening the support for antibacterial drug discovery teams to help more projects reach such a quality to be eligible for global funders and private investors.

The New Precision Stewards?

The precision health era is likely to reduce and respond to antimicrobial resistance (AMR). Our stewardship and precision efforts share terminology, seeking to deliver the “right drug, at the right dose, at the right time.” Already, rapid diagnostic testing, phylogenetic surveillance, and real-time outbreak response provide just a few examples of molecular advances we dub “precision stewardship.” However, the AMR causal factors range from the molecular to that of global health policy. Mirroring the cross-sectoral nature of AMR science, the research addressing the ethical, legal and social implications (ELSI) of AMR ranges across academic scholarship. As the rise of AMR is accompanied by an escalating sense of its moral and social significance, what is needed is a parallel field of study. In this paper, we offer a gap analysis of this terrain, or an agenda for “the ELSI of precision stewardship.” In the first section, we discuss the accomplishments of a multi-decade U.S. national investment in ELSI research attending to the advances in human genetics. In the next section, we provide an overview of distinct ELSI topics pertinent to AMR. The distinctiveness of an ELSI agenda for precision stewardship suggests new opportunities for collaboration to build the stewardship teams of the future.

Closing the GAP in Antimicrobial Resistance Policy in Benin and Burkina Faso

Antimicrobial resistance (AMR) is a global concern that is geographically unevenly distributed, with low- and middle-income countries and African countries suffering in particular. The World Health Organization (WHO) Global Action Plan (GAP) for antimicrobial resistance identified five key objectives that aim to ensure the continued treatment and prevention of infectious diseases with the use of antibiotics. Countries signatory to the WHO GAP are expected to develop their own national action plans (NAPs) based on the global model. How low-income countries are able to achieve the GAP objectives is not well understood. This paper analyzes the progress of two West African countries in achieving the GAP targets, Benin and Burkina Faso, countries among the lowest bracket in the World Development Index. We present qualitative data from interviews and focus group discussions with local policy-makers, nurses, doctors, animal breeders, veterinarians, and laboratory researchers, supported by participant observations and surveys within rural communities. The analysis is organized according to the five WHO GAP objectives to show the countries’ challenges in fulfilling them. The analysis shows that there are shortcomings in all of the WHO GAP areas in the two countries, making it a compounded and multifactorial problem—a stacking of lacks. In such contexts, calibrating a society toward AMR resilience/prevention requires overall development and attention to interdependencies. Active local research and policy communities with international, sustained financial support are essential for achieving the targets.

IMPORTANCE The burden of antimicrobial resistance (AMR) is unequally distributed across the globe. Low-income countries face a more severe AMR situation and have fewer means to solve the problem. This paper brings out the voices of local experts, policy-makers, and members of the community in Benin and Burkina Faso across human health, animal health, and food production sectors, where the majority of antibiotic use is concentrated. We describe the difficulties that they face in implementing global action plans, targets set by the World Health Organization, for securing antibiotics and preventing the spread of antimicrobial resistance. This paper argues that the various deficits in implementation are stacked, multisectoral, and compounded. We highlight the role of active local scientists and policy-maker networks in setting priorities to address the AMR problem; however, their activities need technical and financial support from international partners.

Hardwiring antimicrobial resistance mitigation into global policy

In the wake of COVID-19, antimicrobial resistance (AMR) has become termed the ‘silent pandemic’, with a growing number of editorials warning that international momentum for AMR mitigation is being lost amidst the global turmoil of COVID-19, economic crises and the climate emergency. Yet, is it sufficient to now simply turn the volume of the pre-existing AMR policy discourse back up? Although existing AMR initiatives have previously achieved high levels of international attention, their impact remains limited. We believe it is time to critically reflect on the achievements of the past 7 years and adapt our AMR policies based on the substantial literature and evidence base that exists on the socioecological drivers of AMR. We argue that developing a more sustainable and impactful response requires a shift away from framing AMR as a unique threat in competition with other global challenges. Instead, we need to move towards an approach that emphasizes AMR as inherently interlinked and consciously hardwires upstream interventions into broader global developmental agendas.

Understanding antimicrobial use in subsistence farmers in Chikwawa District Malawi, implications for public awareness campaigns

Drug resistant infections are increasing across the world and urgent action is required to preserve current classes of antibiotics. Antibiotic use practices in low-and-middle-income countries have gained international attention, especially as antibiotics are often accessed beyond the formal health system. Public awareness campaigns have gained popularity, often conceptualising antimicrobial resistance (AMR) as a problem of excess, precipitated by irrational behaviour. Insufficient attention has been paid to people's lived experiences of accessing medicines in low-income contexts. In Chikwawa District, Malawi, a place of extreme scarcity, our study aimed to understand the care and medicine use practices of households dependent on subsistence farming. Adopting an anthropological approach, we undertook medicine interviews (100), ethnographic fieldwork (six-month period) and key informant interviews (33) with a range of participants in two villages in rural Chikwawa. The most frequently used drugs were cotrimoxazole and amoxicillin, not considered to be of critical importance to human health. Participants recognised that keeping, sharing, and buying medicines informally was not the "right thing." However, they described using antibiotics and other medicines in these ways due to conditions of extreme precarity, the costs and limitations of seeking formal care in the public sector, and the inevitability of future illness. Our findings emphasise the need in contexts of extreme scarcity to equip policy actors with interventions to address AMR through strengthening health systems, rather than public awareness campaigns that foreground overuse and the dangers of using antibiotics beyond the formal sector.

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

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

Studying Factors Affecting Success of Antimicrobial Resistance Interventions through the Lens of Experience: A Thematic Analysis

Antimicrobial resistance (AMR) affects the environment, and animal and human health. Institutions worldwide have applied various measures, some of which have reduced antimicrobial use and AMR. However, little is known about factors influencing the success of AMR interventions. To address this gap, we engaged health professionals, designers, and implementers of AMR interventions in an exploratory study to learn about their experience and factors that challenged or facilitated interventions and the context in which interventions were implemented. Based on participant input, our thematic analysis identified behaviour; institutional governance and management; and sharing and enhancing information as key factors influencing success. Important sub-themes included: correct behaviour reinforcement, financial resources, training, assessment, and awareness of AMR. Overall, interventions were located in high-income countries, the human sector, and were publicly funded and implemented. In these contexts, behaviour patterns strongly influenced success, yet are often underrated or overlooked when designing AMR interventions. Improving our understanding of what contributes to successful interventions would allow for better designs of policies that are tailored to specific contexts. Exploratory approaches can provide encouraging results in complex challenges, as made evident in our study. Remaining challenges include more engagement in this type of study by professionals and characterisation of themes that influence intervention outcomes by context.

A 'whole of United Nations approach' to tackle antimicrobial resistance? A mapping of the mandate and activities of international organisations

The 2015 World Health Organization Global Action Plan and other international policy documents have stressed the need for a 'whole of United Nations approach' in addressing antimicrobial resistance (AMR). As several years have passed, the goal of this paper is to take stock of the current role, mandate, and activities of international organisations and other global stakeholders on AMR. Relevant information is identified through a web-based search and a review of policy documents from international organisations. Based on the assessment of 78 organisations, 21 have AMR-specific activities in the broader sense, although for many of these organisations, their involvement is limited in scope, and 36 have AMR-sensitive activities reflecting the wide scope of AMR. An interdisciplinary framework based on six relevant challenges of global collective actions regarding AMR as well as the main functions of international organisations in global governance is used to organise the findings into several ‘clusters’. AMR is not a priority for many international organisations, but some of them can leverage current efforts to tackle AMR while contributing to their core agenda. Overall, a ‘whole of UN approach’ to AMR within the framework of Sustainable Development Goals is critical to move the global governance of AMR forward.

The UK Antimicrobial Resistance Strategy 2013–18: A Qualitative Study of International and Domestic Policy and Action Related to Livestock and the Food Chain

Antimicrobial resistance (AMR) is an increasingly important challenge within global health, and growing action is being taken by countries across the world. The UK Government established a national AMR Strategy in 2013, encompassing human and animal health. An evaluation of the implementation of the Strategy was commissioned, to feed into a refresh of the Strategy in 2018. This article addresses the implementation of the parts of the Strategy related to food sourced from animals. It is based on 15 semi-structured interviews with policy officials and professionals from UK and international agencies. Four themes comprise the findings from thematic analysis. (1) The UK's advocacy and leadership at the global level to encourage international action, which was praised. However, the UK's actions were limited in permeating complex international food supply chains. (2) Integrating a One Health approach, adopted in the Strategy, which had successfully facilitated bringing together human and animal health sectors, but still lacked input from environmental agencies and integration of the role of environmental factors in understanding and tackling AMR. (3) Changes in antimicrobial use and attempts to reduce AMR brought about by the Strategy, including the disparity in variations of actions and progress between livestock sectors, the pros and cons of antimicrobial usage reduction targets—felt to be best when adapted for each livestock species sector, the preference for voluntary sector-led approaches to reduction in antimicrobial use, and the need for changes in production systems and animal husbandry. (4) The challenges relating to costs, drivers and incentives identified to reduce antimicrobial use, and how research, data and surveillance systems support continued action. In particular, the need for adequate investment and financial incentives to enable changes in production and husbandry to take a more preventative approach, the importance of working with different actors throughout the food chain in each livestock sector, and the need for adequate and consistent surveillance data to measure antimicrobial use and continued research to understand AMR. The findings have implications for how to implement further changes at both farm and policy level, how to implement harmonized surveillance whilst maintaining sectoral autonomy, the need for a whole food chain approach, and greater integration of research, actions and actors working on environmental factors of AMR.

Antimicrobial Resistance and the Evolution of International Health Politics (1945-2022)

Despite being acknowledged as a major global health challenge, growing levels of antimicrobial resistance (AMR) in pathogenic and commensal organisms have proven an awkward fit for international health frameworks. This article surveys the history of attempts to coordinate international responses to AMR alongside the origins and evolution of the current international health regulations (IHR). It argues that AMR, which encompasses a vast range of microbial properties and ecological reservoirs, is an awkward fit for the 'organismal' philosophies that centre on the rapid control of individual pathogens that have characterised international policy-making since the 19th century.

Compliance of imipenem and meropenem administration with the national antimicrobial stewardship program in a referral teaching hospital in Iran

INTRODUCTION

Considering the great significance of antimicrobial resistance, implementation of antimicrobial stewardship programs (ASPs) in healthcare facilities is of particular importance. This study aimed to evaluate the compliance of imipenem and meropenem administration with the ASP guidelines in a referral teaching hospital in Iran.

METHODS

In this retrospective cross-sectional study, the medical records of patients, who received either imipenem or meropenem at xx Hospital in Semnan, Iran, from March 21, 2017 until March 20, 2019, were reviewed using the developed ASP, according to the instructions issued by the Ministry of Health of Iran. The obtained findings were recorded in a checklist consisted of six items. If the action taken for the patient complied with the item requirement specified in the ASP, it would receive a score of one; otherwise, a score of zero. The sum of scores (range: 0-6) was reported and analyzed. Data were analyzed in SPSS version 23, using Chi-square, ANOVA, and independent t-test, and P <0.05 was considered as significant.

RESULTS

The mean duration of imipenem/meropenem administration was 9.2±8.0 days. A total of 6,032 imipenem/meropenem vials (1 g/vial) were prescribed during the study (meropenem for 210 patients and imipenem for 87 patients). In 64.2% of the patients, there was no indication, and the mean score of the subjects was 1.55±1.2. The obtained score was three in 53 (17.8%) records and four in 18 (6.1%) records. The mean score of ASP in the intensive care units was higher, while it was lower in the surgical ward as compared to the other wards (P=0.002).

DISCUSSION

Antibiotic prescription was inappropriate in our center, and compliance with the ASP guidelines was very low, especially in the surgical wards. It seems necessary to take effective steps for planning continuing education programs on rational antibiotic prescription and supervision of prescription patterns.

Understanding antibiotic use: practices, structures and networks

In this article, we consider how social sciences can help us to understand the rising use of antibiotics globally. Drawing on ethnography as a way to research how we are in the world, we explore scholarship that situates antibiotic use in relation to interactions of pathogens, humans, animals and the environment in the context of globalization, changes in agriculture and urbanization. We group this research into three areas: practices, structures and networks. Much of the public health and related social research concerning antimicrobial resistance has focused on antibiotic use as a practice, with research characterizing how antibiotics are used by patients, farmers, fishermen, drug sellers, clinicians and others. Researchers have also positioned antibiotic use as emergent of political-economic structures, shedding light on how working and living conditions, quality of care, hygiene and sanitation foster reliance on antibiotics. A growing body of research sees antibiotics as embedded in networks that, in addition to social and institutional networks, comprise physical, technical and historical connections such as guidelines, supply chains and reporting systems. Taken together, this research emphasizes the multiple ways that antibiotics have become built into daily life. Wider issues, which may be invisible without explication through ethnographic approaches, need to be considered when addressing antibiotic use. Adopting the complementary vantage points of practices, networks and structures can support the diversification of our responses to AMR.

Changes in the Framing of Antimicrobial Resistance in Print Media in Australia and the United Kingdom (2011-2020): A Comparative Qualitative Content and Trends Analysis

Educating the public about antimicrobial resistance (AMR) is considered a key part of an optimal public health response. In both media depictions and policy discourses around health risks, how a problem is framed underpins public awareness and understanding, while also guiding opinions on what actions can and should be taken. Using a mixed methods approach we analyse newspaper content in Australia and the United Kingdom (UK) from 2011 to 2020 to track how causes, consequences and solutions to AMR are represented in countries with different policy approaches. Analyses demonstrate greater variability in the frames used in UK newspapers reflecting large hospital and community outbreaks and a sustained period of policy reform mid-decade. Newspapers in Australia focus more on AMR causes and consequences, highlighting the importance of scientific discovery, whereas UK coverage has greater discussion of the social and economic drivers of AMR and their associated solutions. Variations in the trends of different frames around AMR in UK newspapers indicate greater levels of public deliberation and debate around immediate and actionable solutions; whereas AMR has not had the same health and political impacts in Australia resulting in a media framing that potentially encourages greater public complacency about the issue.

Waves of attention: patterns and themes of international antimicrobial resistance reports, 1945-2020

This article uses quantitative and qualitative approaches to review 75 years of international policy reports on antimicrobial resistance (AMR). Our review of 248 policy reports and expert consultation revealed waves of political attention and repeated reframings of AMR as a policy object. AMR emerged as an object of international policy-making during the 1990s. Until then, AMR was primarily defined as a challenge of human and agricultural domains within the Global North that could be overcome via 'rational' drug use and selective restrictions. While a growing number of reports jointly addressed human and agricultural AMR selection, international organisations (IOs) initially focused on whistleblowing and reviewing data. Since 2000, there has been a marked shift in the ecological and geographic focus of AMR risk scenarios. The Global South and One Health (OH) emerged as foci of AMR reports. Using the deterritorialised language of OH to frame AMR as a Southern risk made global stewardship meaningful to donors and legitimised pressure on low-income and middle-income countries to adopt Northern stewardship and surveillance frameworks. It also enabled IOs to move from whistleblowing to managing governance frameworks for antibiotic stewardship. Although the environmental OH domain remains neglected, realisation of the complexity of necessary interventions has increased the range of topics targeted by international action plans. Investment nonetheless continues to focus on biomedical innovation and tends to leave aside broader socioeconomic issues. Better knowledge of how AMR framings have evolved is key to broadening participation in international stewardship going forward.

Antibiotic stories: a mixed-methods, multi-country analysis of household antibiotic use in Malawi, Uganda and Zimbabwe

BACKGROUND

As concerns about the prevalence of infections that are resistant to available antibiotics increase, attention has turned toward the use of these medicines both within and outside of formal healthcare settings. Much of what is known about use beyond formal settings is informed by survey-based research. Few studies to date have used comparative, mixed-methods approaches to render visible patterns of use within and between settings as well as wider points of context shaping these patterns.

DESIGN

This article analyses findings from mixed-methods anthropological studies of antibiotic use in a range of rural and urban settings in Zimbabwe, Malawi and Uganda between 2018 and 2020. All used a 'drug bag' survey tool to capture the frequency and types of antibiotics used among 1811 households. We then undertook observations and interviews in residential settings, with health providers and key stakeholders to better understand the stories behind the most-used antibiotics.

RESULTS

The most self-reported 'frequently used' antibiotics across settings were amoxicillin, cotrimoxazole and metronidazole. The stories behind their use varied between settings, reflecting differences in the configuration of health systems and antibiotic supplies. At the same time, these stories reveal cross-cutting features and omissions of contemporary global health programming that shape the contours of antibiotic (over)use at national and local levels.

CONCLUSIONS

Our findings challenge the predominant focus of stewardship frameworks on the practices of antibiotic end users. We suggest future interventions could consider systems-rather than individuals-as stewards of antibiotics, reducing the need to rely on these medicines to fix other issues of inequity, productivity and security.

Why do people purchase antibiotics over-the-counter? A qualitative study with patients, clinicians and dispensers in central, eastern and western Nepal

Introduction

Over-the-counter (OTC) use of antibiotics contributes to the burgeoning rise in antimicrobial resistance (AMR). Drawing on qualitative research methods, this article explores the characteristics of OTC sales of antibiotic in Nepal, its drivers and implications for policy.

Methods

Data were collected in and around three tertiary hospitals in eastern, western and central Nepal. Using pre-defined guides, a mix of semi-structured interviews and focus group discussions were conducted with dispensers at drug stores, patients attending a hospital and clinicians. Interviews were audio-recorded, translated and transcribed into English and coded using a combination of an inductive and deductive approach.

Results

Drug shops were the primary location where patients engaged with health services. Interactions were brief and transactional: symptoms were described or explicit requests for specific medicine made, and money was exchanged. There were economic incentives for clients and drug stores: patients were able to save money by bypassing the formal healthcare services. Clinicians described antibiotics as easily available OTC at drug shops. Dispensing included the empirical use of broad-spectrum antibiotics, often combining multiple antibiotics, without laboratory diagnostic and drug susceptibility testing. Inappropriately short regimens (2–3 days) were also offered without follow-up. Respondents viewed OTC antibiotic as a convenient alternative to formal healthcare, the access to which was influenced by distance, time and money. Respondents also described the complexities of navigating various departments in hospitals and little confidence in the quality of formal healthcare. Clinicians and a few dispensers expressed concerns about AMR and referred to evadable policies around antibiotics use and poor enforcement of regulation.

Conclusions

The findings point to the need for clear policy guidance and rigorous implementation of prescription-only antibiotics.

Towards Solving Health Inequities: A Method to Identify Ideological Operation in Global Health Programs

The function of ideology is to naturalize and maintain unequal relations of power. Making visible how ideology operates is necessary for solving health inequities grounded in inequities of resources and power. However, discerning ideology is difficult because it operates implicitly. It is not necessarily explicit in one’s stated aims or beliefs. Philosopher Slavoj Žižek conceptualizes ideology as a belief in overarching unity or harmony that obfuscates immanent tension within a system. Drawing from Žižek’s conceptualization of ideology, we identify what may be considered as ‘symptoms’ of ideological practice: (1) the recurrent nature of a problem, and (2) the implicit externalization of the cause. Our aim is to illustrate a method to identify ideological operation in health programs on the basis of its symptoms, using three case studies of persistent global health problems: inequitable access to vaccines, antimicrobial resistance, and health inequities across racialized communities. Our proposed approach for identifying ideology allows one to identify ideological practices that could not be identified by particular ideological contents. It also safeguards us from an illusory search for an emancipatory content. Critiquing ideology in general reveals possibilities that are otherwise kept invisible and unimaginable, and may help us solve recalcitrant problems such as health inequities.

Exploring Farmers' Reasons for Antibiotic Use and Misuse in Pig Farms in Brazil

Stressful management that makes farmed pigs susceptible to infections is associated with high antibiotic use (AMU) and resistance (AMR). Pig farmers are key stakeholders to support the international agenda pushing AMU restrictions. We interviewed 58 pig farmers on AMU/AMR, biosecurity, veterinary assistance, disease prevention and treatment, aiming to understand practices and attitudes towards the AMU/AMR problem. Farmers described a reliance on antibiotics to prevent and treat disease while neglecting biosecurity measures. We identified inappropriate AMU practices (high use of broad-spectrum antibiotics, incorrect dosage or treatment length) and unrestricted access to antibiotics, which encouraged imprudent AMU. Nevertheless, most farmers considered this AMU legitimate to guarantee herd productivity and showed unpreparedness and resistance to changing AMU practices, perceiving limitations (economic, sanitary and inspection) more easily than alternatives to reduce AMU. Agro-industries and foreign markets were mentioned, and internal consumers dismissed as potential motivators for behavioral changes. Importantly, farmers' economic, technical and social factors may limit their autonomy to change practices. We conclude that the observed distancing of pig farmers from the AMU/AMR problem limits the efficiency of policies aiming for a prudent AMU. Our study indicates a need for education, training and behavior change nudging that should include other stakeholders beyond farmers.