AMR Awareness Week November 18-26 (Part 3): how can we as individuals help reduce the risks?

Amongst other things, the WHO proposes that “World Antimicrobial Awareness Week (WAAW) is intended to encourage “best practices among the public”, so with this in mind we’ll discuss what ‘best practice’ might mean, and also what we can do ourselves to support it.

What follows isn’t exhaustive but we hope may be helpful (and we suspect that most of it will be quite familiar as well).

Personal management of antibiotics

Antibiotics are by far the most widely prescribed antimicrobial agent, and simply using them potentially exposes the drug to a mutated pathogen so could provoke fresh drug-resistance. The first step, therefore is to do what we safely can not to need them in the first place, and the second is to use them as sensibly as possible when we have to.

We should first add, however, that they can unquestionably be lifesaving (which adds to their value and why we should be so careful with them) and we are not for a second against their use. Many of us who read this blog may well only be doing so because of an intervention with an antibiotic sometime in the past. Nevertheless, they present inherent public health problems:

1. Generally, the first step is to minimise our need for using antibiotics at all by taking all practical steps we can to keep our immune systems strong. (We will be looking at this in more detail in the final blog in this series).

2. We can also prevent infections in the first place by washing our hands regularly and keeping up to date with appropriate vaccinations.

3. We can safely prevent food-borne infections by washing fruit and vegetables and cooking food properly.

4. We should always bear in mind that antibiotics only work against bacteria, so we shouldn’t ask for them (or accept them) if we’re sure that our infection is viral or parasitic, and if our doctor does offer them when we think this is the case we should ask her/him why, and if necessary refuse them.

5. If they are prescribed appropriately, we should make sure that that we complete the full treatment, and if the infection then doesn’t clear, we would be wise to go back to our doctor and ask for more investigations.

6. We should never store old unused antibiotics and never give them away to anyone else (or accept any either).

7. We should also be cautious about over-use of hand-sanitizers and anti-sceptic handwash because paradoxically these have been shown to actually promote potential for AMR to develop. Instead it's better to wash hands thoroughly with soap and rinse well with water whenever we can. Applying hand-sanitizer may be easier, but even those with sufficient alcohol content cannot remove all types of bacteria and viruses. Soap and water are far more effective at removing common disease-causing germs (including cryptosporidium, norovirus and even clostridium difficile). Soap effectively washes away both bacteria and viruses (including ones that are much tougher than coronaviruses) at the same time as cleaning our hands of any other contaminants.

8. Finally, we can pester our elected politicians, and share our concerns (please see below for more information regarding this).

DDD's

Of course, this issue isn't being played out globaslly on a level playing field, and access to a decent range of effective antibiotics may be limited in some low-income countries. In some nations, broad spectrum antibiotics can easily be bought across the counter (as in India for instance), while in other countries this threat is already being so well addressed by doctors who are being very careful about prescribing antibiotics that it can be quite hard to get a prescription at all.

Population-measurement of antibiotic prescribing is measured by ‘DDDs’ or ‘defined daily doses per 1,000 population per day’. We have been unable to find a good global table that offers readily accessible comparisons between countries, but we have found a Lancet report which exposed the following thought-provoking differences in antibiotic use in different countries.

It reported a global average antibiotic consumption rate of 14·3 defined daily doses per 1000 population per day during 2018, which itself revealed a significant increase of 46% from 9·8 DDD in 2000. Not a good sign. It further identified large geographical disparities, with antibiotic consumption rates varying from a lowly 5 DDD in the Philippines to 46 DDD in Greece.

Average Antibiotic use per country (the darker the colour, the higher the DDD)

This information is easier to find for Europe, it seems. Here, the better (lower prescribing) countries currently reporting are the Netherlands (with a lowly 11 DDD), followed by Germany and Sweden; the worse ones include Greece (with that shocking 46 DDD), along with France and Belgium where prescription rates are both over 28 DDD.

What this means is that if you live in the Netherlands your doctor will probably only prescribe antibiotics for you when she judges that it will almost certainly help (and you might even find it difficult to have them prescribed at all even if you’re sure you need them). Meanwhile, just a couple of kilometres over the border in Belgium you may find it hard to refuse them!

Understanding these aspects of AMR has to be a vital part of what increasing ‘awareness’ of ‘best practice’ is all about, because it means that citizens of certain countries (the darker ones in the map above) can choose to take it on themselves to be watchful of their doctors’ prescribing practices, but also advocate with their politicians and health authorities for much better practice to help reduce the risk of AMR developing in their countries.

But we want to take this a step further.

Information that could be of use if you decide to pester your politicians

If we do decide to pester our politicians (see #8 above - and if we live in Greece or Belgium or France or any country that uses antibiotics as part of animal husbandry we should consider doing so) we could identify any or all of the following principles which need to be driven, and driven hard by national health authorities. (What follows is courtesy of FEMA - the Federation of European Microbiological Societies).

Any of us can write and ask that all or any of the following become much higher political priorities:

1. Improve sanitation and so prevent the spread of infection It is estimated that improving sanitation in low-income countries would decrease the use of antibiotics to treat diarrhoea by 60%, for instance.

2. Reduce unnecessary use of antimicrobials in agriculture and their dissemination into the environment In the USA over 70% of medically important antibiotics are used in agriculture. This use of antibiotics is almost entirely for infection prevention in animals and (more importantly) for growth promotion. This practice should be highlighted as being both dangerous and unnecessary, and arguably this practice should be banned. What's more, other recent data has suggested that 75-90% of antibiotics are excreted from animals in an unmetabolized form, and so leak into the environment to do what they will in the soil and have potentially devastating effect on other lifeforms down the waste chain with consequential further significant risks to public health.

3. Improve global surveillance of drug resistance and microbial consumption Three areas require better information and action: antibiotic consumption among both humans and animals, resistance rates for the available drugs (particulatly the most critically important ones) and better research knowledge on the molecular foundations of AMR.

4. Promote new and rapid diagnostics Every year, 67% of all prescribed antimicrobial therapies in the U.S. are estimated to be incorrectly prescribed. These data are shocking, and it is only the technical development of rapid and accurate diagnostic tests that will allow doctors to target antimicrobials to those patients who actually need them, and to do so by accurately identifying and targeting the specific organisms concerned in every case.

5. Promote development and judicial use of vaccines and alternatives With judicious vaccination, the number of infected people needing antibiotic treatment theoretically reduce. Alternatives to antibiotics are also being developed but lack adequate funding support and so should be better supported. These include phage therapy, probiotics, antibodies and lysins, to name a few – (and of course moxa!).

6. Improve the number and 'recognition value' of people working with infectious disease There is a shortage of key professional figures such as microbiologists, infectious disease specialists, infection control specialists, pharmacists, nurses, veterinarians and epidemiologists. Countries need to invest in more training and better rewarding for these specialists because of their inherent value in this field.

7. Develop a global innovation fund for early stage and non-commercial research Given the reluctance of the pharma industry to invest in less commercially attractive research, and the apparent capture of many university research establishment by the same industry, this anomaly needs reviewing urgently, and a global innovation fund for support of less commercially attractive research is probably needed.

8. Develop better incentives to promote investment for new drugs and improving existing ones The development of new antibiotics is not attractive for pharmaceutical companies since there are still (relatively) effective antimicrobial compounds on the market. (We will be looking at this in more detail on Day 6 because this is not a simple issue)

9. Build a global coalition for real action Global action is essential to make meaningful progress in tackling AMR. Putting AMR on the international political agenda is important for impacting change. Encouraging and maintaining better active engagement of Civil Society with the G20 or the United Nations could help to put AMR higher up on the political agenda.

Finally...

We hope that these blogs are proving to be both interesting and useful, and we actively encourage you (in the spirit of the aims of WAAW) to take the step of doing everything you can in respect of any of the above.

In the next blog, we will be discussing what is officially termed the ‘One Health Approach’ and how this applies to AMR as part of the solution, along with identifying who these so-called ‘One Health Stakeholders’ who are being called upon to take action on AMR actually are.