Antimicrobial Resistance
Call for actionable steps in response to the
rising threat of antimicrobial resistance
(AMR)
Antimicrobial resistance (AMR) is one of the top global public health and development threats. According to the World Health Organisation (WHO), an estimated 4.95 million deaths were associated with AMR in 2019, including 1.27 million deaths attributable to bacterial AMR. Limiting the emergence and spread of resistant pathogens is critical to preserving the world’s ability to treat human, animal and plant diseases, reduce food safety and security risks and maintain progress on the WHO's sustainable development goals. The AMR Multi-Stakeholder Partnership Platform has developed key recommendations for action on antimicrobial resistance for consideration by United Nations (UN) Member States in the UN General Assembly High-Level Meeting on AMR, which will take place on 26 September 2024 at the UN Headquarters in New York. As a member of the AMR Multi-Stakeholder Partnership Platform and active participant of the platform's Action Group, the German Center for Infection Research (DZIF) has contributed to the development of the key recommendations.
The following key recommendations are based on discussions facilitated by the Action Group of the AMR Multi-Stakeholder Partnership Platform on the UN High-Level Meeting on AMR. The stakeholders of the platform, representing diverse sectors (human, animal, agrifood, plant, environment), disciplines and backgrounds, call upon the UN Member States to agree upon actionable, measurable steps applying a One Health approach to ensure a healthier, more sustainable and resilient present and future where antimicrobials are preserved as critical life-saving medicines, equally accessible to everyone, everywhere.
1. Enhance One Health collaboration on AMR through effective cross-sectoral, transparent, inclusive, multilateral, multidisciplinary, multi-stakeholder coordination, communication and follow-through.
2. Accelerate the implementation of AMR National Action Plans (NAPs), building on country context, capacity and capabilities.
3. Strengthen capacity for AMR efforts by mobilising sustainable financing for research, infrastructure and AMR NAPs implementation.
4. Strengthen health systems through comprehensive primary and secondary prevention strategies, such as infection prevention and control (IPC), stewardship programmes, water, sanitation and hygiene (WASH), vaccination, early diagnosis and prompt treatment and environmental management of air, water, soil, food and vectors for better human, animal and environmental health.
5. Better leverage preventive measures such as vaccination by expanding the evidence base on their impact against AMR, developing mechanisms to increase access and utilisation of existing vaccines, improving regulatory pathways, facilitating market authorisation and distributing products across sectors and countries.
6. Strengthen sector-specific AMR and antimicrobial use (AMU) surveillance, building towards integrated surveillance for evidence-based action to reduce the risk and impact of AMR.
7. Transform agrifood systems to significantly reduce AMU while optimising animal health and welfare.
8. Ensure universal, equitable, affordable and sustainable access, including in rural areas, to quality essential medicines, vaccines and diagnostics for humans and animals.
9. Encourage high-income countries and other stakeholders to commit to taking an end-to-end approach to sustainable antimicrobial research and development (R&D), including by increasing public investment in push and pull incentives to catalyse the global R&D efforts necessary to deliver new treatments and tools that target global priority pathogens.
10. Prevent and address the drivers, sources and challenges of the environmental dimensions of AMR.
The AMR Multi-Stakeholder Partnership Platform was established in November 2022 by the Quadripartite organisations—the Food and Agriculture Organisation of the United Nations (FAO), the United Nations Environment Programme (UNEP), the World Health Organisation (WHO) and the World Organisation for Animal Health (WOAH)—as one of the global governance structures recommended by the United Nations Inter-Agency Coordination Group on AMR. It brings together relevant stakeholders across the human, animal, plant and environment sectors to assist in preserving antimicrobials and ensuring their responsible use through a One Health approach. It promotes a shared global vision, helps build consensus and takes action to contribute to the implementation of the Global Action Plan on AMR (GAP). Since its inaugural meeting in November 2023, the platform has grown to more than 200 members (organisations, networks and federations). The German Center for Infection Research (DZIF) is one of them.
Read the full recommendations (and their brief version), watch the public release event and join the AMR Multi-Stakeholder Partnership Platform's global movement for action against AMR.
Better medical record-keeping needed to
fight antibiotic overuse, studies suggest
Many who get antibiotics in clinics & emergency departments have no diagnosis or symptoms that might explain a prescription; improved diagnosis coding could help target efforts to optimize use & reduce risk
MICHIGAN MEDICINE - UNIVERSITY OF MICHIGAN
A lack of detailed record-keeping in clinics and emergency departments may be getting in the way of reducing the inappropriate use of antibiotics, a pair of new studies by a pair of University of Michigan physicians and their colleagues suggests.
In one of the studies, about 10% of children and 35% of adults who got an antibiotic prescription during an office visit had no specific reason for the antibiotic in their record.
The rate of this type of prescribing is especially high in adults treated seen in emergency departments and in adults seen in clinics who have Medicaid coverage or no insurance, the studies show. But the issue also occurs in children.
Without information about what drove these inappropriate prescriptions, it will be even harder for clinics, hospitals and health insurers to take steps to ensure that antibiotics are prescribed only when they’re really needed, the researchers say.
Overuse and misuse of antibiotics raise the risk that bacteria will evolve to resist the drugs and make them less useful for everyone. Inappropriately prescribed antibiotics may also end up doing more harm than good to patients.
“When clinicians don’t record why they are prescribing antibiotics, it makes it difficult to estimate how many of those prescriptions are truly inappropriate, and to focus on reducing inappropriate prescribing,” said Joseph Ladines-Lim, M.D., Ph.D., first author of both of the new studies and a combined internal medicine/pediatrics resident at Michigan Medicine, U-M’s academic medical center.
“Our studies help contextualize the estimates of inappropriate prescribing that have been published previously,” he added. “Those estimates don’t distinguish between antibiotic prescriptions that are considered inappropriate due to inadequate coding and antibiotic prescriptions truly prescribed for a condition that they can’t treat.”
Ladines-Lim worked with U-M pediatrician and health care researcher Kao-Ping Chua, M.D., Ph.D., on the new studies. The one on outpatient prescribing by insurance status is in the Journal of General Internal Medicine and the one on trends in emergency department prescribing is in Antimicrobial Stewardship and Healthcare Epidemiology.
Building on previous research
Chua and colleagues recently published findings about trends in inappropriate antibiotic prescribing in outpatients under age 65, suggesting about 25% were inappropriate. But that number includes antibiotic prescriptions written for infectious conditions that antibiotics don’t help, such as colds, and antibiotic prescriptions that aren’t associated with any diagnoses that could be a plausible antibiotic indication.
The new studies add more nuance to that finding, by looking more closely at these two different types of inappropriate prescriptions.
Most antibiotic stewardship efforts to date have focused on reducing the use of the first type of inappropriate prescription – those written for infectious but antibiotic-inappropriate conditions like colds. The new studies show such patients still account for 9% to 22% of all antibiotic prescriptions, depending on the setting and age group.
But since doctors and other prescribers aren’t required to run a test for a bacterial infection or list a specific diagnosis in order to prescribe antibiotics, symptoms provide potential clues to why they might have written a prescription anyway.
So some of those 9% to 22% of all people receiving antibiotics may have also had a secondary bacterial infection that the clinician suspected based on symptoms.
However, it’s impossible to know.
As for those with no infection-related diagnoses or symptoms in their records who got antibiotics, the researchers suggest that clinicians may not have bothered to add these diagnoses or symptoms to the patient record inadvertently – or even deliberately, to try to avoid the scrutiny of antibiotic watchdogs.
But the researchers also speculate that the lower rate of diagnosis documentation in patients in the healthcare safety net may also have to do with the way healthcare organizations are reimbursed.
Often, clinics and hospitals receive a fixed amount from Medicaid to care for all their patients with that type of coverage. So they aren’t incentivized to create records that are as detailed as for privately insured patients, whose care traditionally is reimbursed under a fee-for-service model.
“This could actually be a matter of health equity if people with low incomes or no insurance are being treated differently when it comes to antibiotics,” says Ladines-Lim, who has also studied antibiotic use related to immigrant and asylum-seeker health and will soon begin a fellowship in infectious diseases.
He said that private and public insurers, and health systems, may need to incentivize accurate diagnosis coding for antibiotic prescriptions – or at least make it easier for providers to document why they’re giving them.
That might even include steps such as requiring providers to record the reason for antibiotic prescribing before prescriptions can be sent to pharmacies through electronic health record systems.
After all, Ladines-Lim said, physicians often have to list a diagnosis that justifies tests they order, such as CT scans or x-rays. With antibiotic resistance posing an international threat to patients who have antibiotic-susceptible conditions, similar steps to justify prescriptions of antibiotics might be advisable.
In addition to Ladines-Lim and Chua, the other authors of the two articles are Michael A. Fischer, M.D., M.S. of Boston Medical Center and Boston University, and Jeffrey A. Linder, M.D., M.P.H. of Northwestern University Feinberg School of Medicine.
Chua is a member of the Susan B. Meister Child Health Evaluation and Research Center, and the U-M Institute for Healthcare Policy and Innovation.
The research was funded by a Resident Research Grant from the American Academy of Pediatrics, a Physician Investigator Award from Blue Cross Blue Shield Foundation of Michigan, and a Research Grant from the National Med-Peds Residents’ Association.
Prevalence of Inappropriate Antibiotic Prescribing with or without a Plausible Antibiotic Indication among Safety-Net and Non-Safety Net Populations, Journal of General Internal Medicine - https://link.springer.com/article/10.1007/s11606-024-08757-z
Appropriateness of Antibiotic Prescribing in US Emergency Department Visits, 2016–2021; Antimicrobial Stewardship and Healthcare Epidemiology https://doi.org/10.1017/ash.2024.79
JOURNAL
Antimicrobial Stewardship & Healthcare Epidemiology
METHOD OF RESEARCH
Data/statistical analysis
SUBJECT OF RESEARCH
People
ARTICLE TITLE
Appropriateness of Antibiotic Prescribing in US Emergency Department Visits, 2016–2021
ARTICLE PUBLICATION DATE
17-May-2024
AI reveals critical gaps in global Antimicrobial Resistance research
Artificial Intelligence (AI) has helped identify knowledge, methodological and communication gaps in global Antimicrobial Resistance (AMR) research.
In a new study carried out by the Chinese Academy of Sciences and Newcastle University under the co-leadership of Professor Yong-Guan Zhu and Professor David W Graham, respectively, experts compiled a comprehensive database of 254,738 articles spanning two decades, shedding light on patterns of AMR research worldwide.
They found that the terminology and methods used in AMR research significantly differ across the medical, veterinary, food safety, plant agriculture, and environmental sectors. The semantic and methodological differences result in limited valuation work between sectors and limited cross-sectoral communication, resulting in inconsistent messages to decision-makers.
Through sophisticated AI-based analysis, the team developed global maps showcasing regional, methodological, and sectoral AMR research activities. The findings confirm a stark lack of interdisciplinary collaboration, particularly in low-income countries, where the burden of increasing AMR is most acute.
Published in the journal Environment International, the findings explain why solutions to AMR based on One Health are not developing as needed. The results could play a critical role in providing guidance on how and where to better integrate AMR surveillance across sectors and regions worldwide.
Professor David W Graham, Emeritus Professor of Engineering at Newcastle University, said: “The findings highlight the urgent need for greater coordination in research methods across sectors and regions. For instance, the medical and veterinary communities need information about living AMR infectious pathogens to prioritise decisions, whereas environmental researchers often focus on genetic targets. Our work shows that culturing microbiology and isolate sequencing, and metagenomics must be performed in tandem in all future work, and more context data must be collected to relate results from different sectors.
“Our paper's findings support key messages from UN Environment Programme and World Health Organization that emphasise the best way to mitigate AMR is through prevention and integrated surveillance, which is key to prioritising solutions.”
This is being addressed by the United Nations Quadripartite Technical Group on Integrated Surveillance on Antimicrobial Use and Resistance on which both Prof Zhu and Graham are members.
Graham further said, “this work was only possible due its novel use of Artificial Intelligence and Natural Language Processing to intelligently search an extensive and living database, an archive we make openly available for public use and contributions. This paper represents the first in a series of joint manuscripts leveraging AI to guide future AMR and other research agenda.”
Professor Yong-Guan Zhu, Professor of Environmental Sciences, Chinese Academy of Sciences, added: “the framework of One Health is of critical importance in safeguarding human and ecosystem health, but it needs roadmaps to implement, this study timely identifies path forward. The study also demonstrates that multidisciplinary and international collaboration is essential in solving global challenges, and we should embrace emerging technologies, such as AI”.
Both scientists recommend future research and increased investment in capacity development, especially in low-income countries, to address the pressing AMR challenges in these regions.
Funding: This work is financially supported by the National Natural Science Foundation of China and the Ningbo Municipality.
Reference
Chen, C., Li, S.-L., Xu, Y.-Y., Liu, J., Graham, D. W., & Zhu, Y.-G. (2024). Characterising global antimicrobial resistance research explains why one health solutions are slow in development: An application of AI-based Gap Analysis. Environment International, 187, 108680. doi:10.1016/j.envint.2024.108680
JOURNAL
Environment International
METHOD OF RESEARCH
Computational simulation/modeling
ARTICLE TITLE
Characterising global antimicrobial resistance research explains why One Health solutions are slow in development: An application of AI-based gap analysis
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