Antimicrobial Resistance

Antimicrobials are medicines used to prevent and treat infections in humans, animals, and plants. Examples of such medicine include antibiotics, antivirals, antifungals, and antiparasitics.¹ Antimicrobial resistance (AMR) occurs when bacteria, viruses, fungi, and parasites evolve and are no longer responsive to these medicines.¹ This makes infections more difficult to treat, increasing the risk of disease spread, severe symptoms, and death.

Factors Contributing to AMR

AMR occurs naturally but can be accelerated and increased by several factors, including inappropriate use of antimicrobials in human and animal medicine and food production, poor sanitation and hygiene, and lack of access to clean water.¹ Additional factors include inaccessibility of quality medical products, including illegal production and sale of fake medical products, and limited knowledge and understanding of how AMR develops and spreads.

One of the main drivers of AMR is the misuse and overuse of antimicrobials in human medicine and the agricultural sector. Misuse and overuse in human medicine is driven by overprescribing by health providers, patients not completing the full course of prescribed medicines, and incorrect dosages. In agriculture, large volume of use, prolonged exposure to sub-therapeutic doses, use of multiple drugs, and policies approving the use of clinical drugs for animals drive AMR in food production. AMR from animal production can be transferred to humans via consumption of animal products and the environmental contamination of food crops that are eaten by humans.² Contamination of the environment and the spread of AMR also stems from human and animal waste contaminating soil and water systems.³ This includes contamination from flushing unused antibiotics down toilets or hospital discharge systems.³ Misuse and overuse of antimicrobial drugs in humans and animals cause the death of susceptible microbes, leaving resistant strains to multiply and become the predominant strains. Poor hygiene and infection prevention and control measures then lead to the further spread of these resistant organisms within communities and even globally with travel and movement.⁴

The Impact of AMR on Public Health, Healthcare Systems, Economies, and Communities

AMR is a growing global concern that threatens to reverse the gains in global health over the past decades. It strains the health system and communities, as well as national and global economies. At least 700,000 people (about half the population of Hawaii or Mauritius) die of AMR each year globally.⁵ This death toll could rise to as many as 10 million deaths annually by 2050 if urgent action is not taken.⁵

Infections that resist treatment result in extended hospital stays and increased healthcare costs where providers require additional resources to manage treatment with alternative drugs.⁶ As resistance increases, healthcare providers are left with fewer options for effective medications to treat infections. This delays recovery and leads to the spread of infections where some may become untreatable if no effective antimicrobials are left.¹ If simple infections become difficult to treat, lifesaving medical and surgical procedures become risky, impacting public health services.

Prolonged ill health and hospital stays result in decreased productivity of patients and their caretakers and increased expenditure on health care from the need for more expensive and intensive care.

Outbreaks of untreatable resistant infections in hospitals (known as nosocomial infections), nursing homes, and communities are challenging to control and contain without effective medications.⁷ This allows the infections to spread rapidly⁷ in settings amid a concentration of already vulnerable individuals and could contribute to epidemics or pandemics.

Combating AMR

Importance of Intersectoral Collaboration and One Health Approach

AMR is complex and driven by factors emanating from several sectors. Hence, successfully addressing AMR requires intersectoral coordination and collaboration. In 2016, world leaders attending the United Nations General Assembly committed to a “One Health Approach” to addressing AMR.¹ A One Health approach involves the coordination of multiple sectors and stakeholders engaged in human, animal, and plant health, food and feed production, and the environment in the design and implementation of programs, policies, and legislation integrating and addressing human, animal, and environmental factors contributing to AMR.¹

The global action plan on antimicrobial resistance was ratified by the 2015 World Health Assembly and provides a framework to guide development and implementation of national multisectoral plans. It emphasizes the need for intersectoral collaboration and a one health approach with coordination among international and national actors across numerous sectors including human and veterinary medicine, agriculture, environment amongst others. It also highlights the importance of well-informed consumers and lists communication to raise awareness about AMR as one of its five objectives.⁸

The Role of Healthcare Providers, Patients, the Agricultural Sector, and the Pharmaceutical Industry in Promoting Responsible Antimicrobial Use

One of the main drivers of AMR is the misuse and overuse of antimicrobials in human medicine and the agricultural sector. Misuse and overuse in human medicine is driven by overprescribing by health providers, nonprescription use by patients, and use of sub-therapeutic doses. In agriculture, large volume of use, prolonged exposure to sub-therapeutic doses, multiple drug use, and policies approving use of clinical drugs for animals are important drivers of AMR from food production. AMR from animal production can be transferred to humans via consumption of animal products and the environmental contamination of food crops which are eaten by humans.² Therefore, advocating for and optimizing antimicrobial use requires deliberate and focused action in the human and veterinary medicine sectors, agricultural sector, and the pharmaceutical industry.

Role of SBC in Addressing AMR

AMR is driven by human behavior and policies around the use and development of antimicrobials in humans and animals as well as hygiene and sanitation practices. This presents an opportunity to utilize SBC approaches to effectively tackle the global issue. Some opportunities to use SBC in combating AMR and achieving the objectives of the global action plan are shared below.

Risk Communication about AMR

One of the drivers of AMR is a lack of awareness or understanding of how it arises and the magnitude of the problem it poses. It can be difficult to frame the complex multisectoral factors giving rise to AMR in ways that are comprehensible and actionable to audiences at high risk or whose behaviors most impact its spread—particularly when the negative consequences of AMR can sometimes take a long time to become apparent. In addressing this, the first objective of the global action plan highlights the importance of effective communication, education, and training to raise awareness and understanding of AMR. Several audiences need to be reached on AMR, and each audience requires a different messaging emphasis. SBC approaches can help ensure communication campaigns or products are strategically designed with key audiences at the center and that messages are in tune with the knowledge needs and behavioral drivers at play for audience and context. As with SBC in other areas, SBC with any of these audiences should be grounded in formative research as a foundation for nuanced messaging and precise interventions.

SBC and Engaging Healthcare Providers

For myriad reasons, health care providers may default on following the guidelines for the prescription of antimicrobials, despite their knowledge about AMR and the availability of these guidelines. Using a social and behavior change (SBC) approach to understand and improve provider behavior can play a crucial role in combating AMR.

SBC interventions directed at health care providers provide an opportunity for meaningful engagement to understand contextual drivers of antimicrobial over-prescription and deviation from guidelines leading to effective design of interventions to address these drivers, whether they are related to the provider’s personal experiences, prevalent cultural and social preferences, influences from peer providers, or factors within the workplace or health facility environment. Designing interventions based on this nuanced analysis, in combination with education and training on the appropriate practices for prescribing drugs as well as the risks of overprescribing can increase knowledge and create shifts in antimicrobial prescription and use. Other examples of provider behaviors where implementers have used SBC to address AMR are handwashing and reporting antimicrobial-resistant infections to surveillance teams (Antibiotic resistance).

SBC and Engaging Animal Health and Agricultural Sector

Just as in human health, misuse and overuse of antimicrobials in veterinary medicine and in agriculture during food production drives antimicrobial resistance. SBC interventions can optimize antimicrobial use, uptake of vaccinations of animals to reduce the need for antimicrobials and improve biosecurity in the agricultural sector through hygiene and animal welfare practices which facilitate infection prevention.^1,10 Stakeholders important to reach might include veterinarians and animal health workers, wildlife control professionals, forestry and park rangers, farmers and animal husbandry specialists, and pet owners, among others.

Engaging Consumers and Communities

There are several community or consumer factors which drive antimicrobial resistance. Examples are indiscriminate use of antibiotics without prescription, defaulting on required dose or duration of treatment, low uptake of vaccinations, and poor hygiene practices. SBC helps with understanding what drives these practices and in addressing them through implementation of interventions to aid rational antimicrobial use, vaccinations, and better hygiene practices.^1,10 Patient or community outreach campaigns, mass and digital media, and partnerships with patient and consumer advocacy groups can all support effective dissemination of research-based messaging around AMR.

SBC and Advocacy Efforts

Advocacy can play a significant role in preventing AMR. Increasing knowledge and awareness of AMR will not automatically result in the uptake of desired behaviors. An enabling environment is needed to allow action on knowledge acquired and drive behavioral change.¹⁰ Policies and funding are important in shaping an enabling environment and SBC implementers are well placed to make advocacy relevant with governing bodies and stakeholders, especially on a complex issue requiring action from many different stakeholders with different interests. To be effective, AMR advocacy should be targeted, time-limited, and make a specific “ask” of a specific decision maker, which could include, for example, allocation of budgetary resources or making a public statement regarding the issue.

Conclusion

AMR is a global health and development challenge with several behavioral drivers. There are many opportunities for SBC to strengthen ongoing efforts to combat AMR. This trending topic brings together a curated collection of resources to aid understanding of the role of SBC in mitigating AMR. If you have related materials you would like to share with us, please upload the items, or contact us at info@thecompassforsbc.org.

References

1. World Health Organization. (2021). Antimicrobial resistance.
   https://www.who.int/news-room/fact-sheets/detail/antimicrobial-resistance
2. Silbergeld, E., Aidara-Kane, A., & Dailey, J. (2017). Agriculture and food Production as drivers of global emergence and dissemination of antimicrobial resistance. AMR Control.
   http://resistancecontrol.info/2017/agriculture-and-food-production-as-drivers-of-the-global-emergence-and-dissemination-of-antimicrobial-resistance
3. Centers for Disease Control and Prevention. (n.d.). Where resistance spreads: Water, soil, & the environment. https://www.cdc.gov/drugresistance/environment.html
4. Australian Government (n.d.). What causes AMR? AMR Initiative. https://www.amr.gov.au/about-initiative
5. The World Bank (2021). Antimicrobial resistance (AMR). https://www.worldbank.org/en/topic/health/brief/antimicrobial-resistance-amr
6. Roberts, R. R., Hota, B., Ahmad, I., Scott R. D., Foster, S. D., Abbasi, F., Schabowski, S., Kampe, L. M., Ciavarella, G. G., Supino, M., Naples, J., Cordell, R., Levy, S. B., & Weinstein. R. A. (2009). Hospital and societal costs of antimicrobial-resistant infections in a Chicago teaching hospital: implications for antibiotic stewardship. Clinical Infectious Diseases, 49(8), 1175-1184. https://doi.org/10.1086/605630
7. Lee, C. R., Cho, I. H., Jeong, B. C., & Lee, S. H. (2013). Strategies to minimize antibiotic resistance. International Journal of Environmental Research and Public Health, 10(9), 4274-4305. https://doi.org/10.3390/ijerph10094274
8. World Health Organization. (2016 January 1). Global action plan on antimicrobial resistance. https://www.who.int/publications/i/item/9789241509763
9. World Health Organization. (2020 July 30). Antimicrobial resistance. https://www.who.int/news-room/fact-sheets/detail/antibiotic-resistance
10. Uppsala Health Summit. (n.d.). Managing antimicrobial resistance through behavior change: Preconference report. https://www.uppsalahealthsummit.se/digitalAssets/931/c_931080-l_1-k_uppsala-health-summit-preconference-report-2021.pdf