Optimising antimicrobial use in humans – review of current evidence and an interdisciplinary consensus on key priorities for research

Abstract

Addressing the silent pandemic of antimicrobial resistance (AMR) is a focus of the 2021 G7 meeting. A major driver of AMR and poor clinical outcomes is suboptimal antimicrobial use. Current research in AMR is inequitably focused on new drug development. To achieve antimicrobial security we need to balance AMR research efforts between development of new agents and strategies to preserve the efficacy and maximise effectiveness of existing agents. Combining a review of current evidence and multistage engagement with diverse international stakeholders (including those in healthcare, public health, research, patient advocacy and policy) we identified research priorities for optimising antimicrobial use in humans across four broad themes: policy and strategic planning; medicines management and prescribing systems; technology to optimise prescribing; and context, culture and behaviours. Sustainable progress depends on: developing economic and contextually appropriate interventions; facilitating better use of data and prescribing systems across healthcare settings; supporting appropriate and scalable technological innovation. Implementing this strategy for AMR research on the optimisation of antimicrobial use in humans could contribute to equitable global health security.

Knowledge Gaps in the Understanding of Antimicrobial Resistance in Canada

“…Various knowledge gap assessments ( 16 , 109 ) and action plans have been developed regarding AMR, including the WHO Global Action Plan ( 3 ) and the Federal action plan on antimicrobial resistance and use in Canada ( 99 ). Most requirements detailed in this review ( Figure 2 ), developed for the three key areas (treatment optimization, surveillance, and transmission), are logical continuations of described action plans with focus on the Canadian context.…”

“…Prioritization of required activities is needed to focus efforts and available resources; however, without answers to some of these knowledge gaps, it is difficult to identify the most pressing areas to act (i.e., restrict AMU, prescribing best practices, environmental containment, etc.). Although, in general, AMR understanding and mitigation attempts should follow the following roadmap: (1) detailed understanding of missing data required to inform realistic policies and best management practices, (2) implementation and ongoing evaluation of policies and recommendations at the community, provincial/territorial, and national levels, (3) sustainable implementation with ongoing evaluation to account for new innovations and AMU/AMR surveillance findings ( 16 ). Additionally, to lay the groundwork for changes in antimicrobial prescribing and use, must be accompanied by public educational campaigns to improve general understanding of the risks associated with AMR and unnecessary AMU, but also to increase social responsibility.…”

“…Specific societal and cultural factors in human medicine include-short term benefits, such as positive clinical outcomes and avoidance of clinical risks, maintaining prescriber-patient relationships, societal pressures and prescriber expectation outweighing long-term AMR community risks, and thus hampering judicious AMU ( 34 ). Antimicrobial prescribing can also be influenced by social hierarchies in the both the human ( 16 ) and veterinary medical settings ( 35 ). Even when AMS strategies in human hospitals were developed, they often did not include who should act and failed to account for multi-professional care teams and details on when to start/stop antimicrobials ( 36 ).…”

“…Stewardship efforts can be supported by further development and availability of rapid diagnostic technology, to decrease empirical prescribing and increase appropriate antimicrobial treatment response times ( 16 ). An impediment to optimal dosing is the knowledge gap regarding quantitative relationships between AMU and AMR development, and interactions of resistant bacteria at the human, animal, and environmental interface ( Table 1 ).…”

“…The extent of selection of resistant bacteria often reflects the degree of AMU, the type of antimicrobials used, and the effectiveness of infection prevention and control ( 13 ). The COVID-19 pandemic exacerbated the problem, as antimicrobial stewardship (AMS) efforts were often disregarded, with substantial AMU in COVID-19 patients for bacterial infections or prophylaxis ( 14 – 16 ). Furthermore, disinfectant use has dramatically increased, affecting the microbiome and potentially exacerbating AMR development ( 17 , 18 ).…”