Research into the biggest threats to human health - antimicrobial resistance
The Foundation team recently caught up with Prince of Wales Hospital Infectious Disease Specialist Dr Kristen Overton and spoke to her about her research into antimicrobial resistance (AMR) which threatens the effective prevention and treatment of an ever-increasing range of infections.
Q: How did you chose the topic of AMR for your research? Was there a personal experience or just general fascination/interest with the topic?
A: My motivation for my research has been a longstanding interest in AMR and global health, initially triggered by my experiences working in a refugee camp on the Thai–Myanmar border, and then fortified by my specialist training in Infectious Diseases. In early 2010 I was completing my medical elective at the Mae Sot clinic, Thailand, before starting my final year of medical school, and it was my experience working there that helped me decide to specialise in infectious diseases. It was there that I sadly witnessed children and adults dying from preventable and/or treatable infectious diseases, including measles, human immunodeficiency virus (HIV), tuberculosis (TB) and malaria. Being at the Mae Sot clinic also strengthened my interest in the social determinants of health, and in particular the impact of social inequality on the outcomes of patients with these preventable/treatable infectious diseases. The most striking feature of the living conditions of the people I worked with at the Mae Soot clinic was the lack of access to quality healthcare, seemingly worlds away from the plentiful resources available at Australian hospitals that are so often taken for granted.
Over the years that followed, I completed medical school, trained as an infectious diseases specialist and completed a Master’s of Tropical Medicine and Public Health. During this time, and while carrying out my clinical work, I have continued to witness the pathogenic role that inequality plays in people’s health. I have also seen and treated increasing numbers of patients with infections due to AMR bacteria. Unfortunately I have sadly also had patients die from these resistant bacteria when the limited treatment options available have been unsuccessful. This is where my two interests in the role of sociocultural factors and the development of AMR intersect. In order to examine these intersecting issues, I chose to focus on India, where the emergence and spread of AMR is a growing public-health challenge.
Q: AMR is considered one of the biggest threats to human health by the WHO. What is being done to address this?
A: A concerted global effort to address the issue of AMR has become truly evident only in the past 10 years. The WHO highlighted AMR as a major global threat in its 2014 report, the first global survey of AMR to be conducted. In 2010 a tripartite alliance was formed between the WHO, the World Organisation for Animal Health (OIE) and the Food and Agriculture Organization of the United Nations (FAO) to help drive the international response. The alliance epitomised the One Health (OH) approach to AMR, defined as the ‘collaborative efforts of multiple disciplines working locally, nationally, and globally, to attain optimal health for people, animals, and our environment’. In May of the same year, the 68th World Health Assembly adopted the Global action plan on antimicrobial resistance (GAP), mandating that each member state develop an AMR national action plan by May 2017. The GAP sets out five strategic objectives to address AMR centred around surveillance (of resistance and antimicrobial use), stewardship (to optimise antimicrobial use), education, public awareness, infection prevention overseen by national governance structures, and development of new antimicrobials, vaccines and diagnostics. Global action to counteract AMR gained further momentum in September 2016 when, for the first time, the United Nations (UN) member states unanimously committed to a collaborative approach to tackle AMR and support the GAP mandate. However, there is concern that the current COVID-19 crisis will decrease the momentum that was building.
Q: What are your hopes for the future around AMR or AMR research?
A: The internationally dominant discourse of implementing ‘greater regulation’, models focusing on behaviour change and education interventions focused on the transmission of knowledge based on pan-national guidelines are not helpful in optimising antimicrobial use and will continue to fail to decrease AMR. The greatest impact on AMR will be achieved by introducing polices that address social inequality, including but not limited to access for all to appropriate treatment with the right antimicrobials, and adequate healthcare and sanitation. I hope for strategies aimed at reducing inequality in healthcare by strengthening individuals, strengthening communities, improving living and working conditions, and implementing healthy macro policies that reduce inequality, poverty and violence, these will have the greatest impact on optimising the use of antimicrobials.
In terms of social research into AMR the field would be further aided by attention being placed on the specificities of locale and the importance of economic/political forces, including vast socio-economic inequality and a paucity of effective governance. If AMR is indeed to be addressed taking into consideration both the local and the global, then further exploration of these complex, nuanced contexts is vital. In addition, I feel now is the time for a genuine focus on the issues of the Global South, driven by (and for) the Global South rather than by elite institutions or outsiders looking in. If the status quo continues, we are likely to continue to fail to get any traction in the fight against AMR, and therefore against the future spread of AMR around the globe, an eventuality that must be avoided if at all possible.
Q: Is it correct that there is a lack of funding for the development of new antibiotics?
A: Development of new antimicrobials has not been sufficient to tackle the growing problem of AMR. From 1960 to 1990 the pharmaceutical industry developed multiple new antibiotics, temporarily addressing the problem of AMR, but since then development of new antimicrobials has stalled. In the past 10 years, only eight new antibiotics have received approval in the US for marketing. There are numerous reasons for the lack of development of new antimicrobials. These drugs are taken for only a short period of time, are often curative and are relatively cheap in comparison to other medicines required for chronic illness (e.g. for hypertension, hypercholesterolemia, rheumatoid arthritis or diabetes) and are therefore not as profitable to pharmaceutical companies as these other drugs. The second factor is scientific; more than 100 antimicrobial agents have been developed since the 1940s and are said to represent the ‘low-hanging fruit’ or easier-to-discover agents. Thus, discovery and development of successive generations of antimicrobials is technically more complex, more expensive and more time consuming than previous discoveries. Finally, the lengthy research and development phase is exacerbated by challenging regulatory requirements. It can be up to 10 years from when development begins before the drug finally appears for sale on the market, which highlights the role of policy and the state in limiting the development of new antimicrobials.
Q: What would your advice today be for the use of antibiotics?
A: Antibiotic resistance is happening now in Australia and around the world. The more we use antibiotics, the more chance bacteria have to develop resistance to them. People don’t become resistant to antibiotics, bacteria do. These resistant bacteria can then spread to other people.
Antibiotics will not make you better if you have an infection caused by a virus. This includes most sore throats, ear infections, coughs and colds. If you are prescribed antibiotics for a bacterial infection, use them as directed by your health professional. Only take antibiotics when they are prescribed for you, don’t use or share leftover antibiotics.
Q: Do we need to change/review hospital policies?
A: In response to AMR there has been widespread development of hospital antimicrobial stewardship (AMS) programmes, the majority of which include antibiotic approval systems, including at Prince of Wales Hospital. Despite these programs inappropriate antibiotic use in hospitals continues, suggesting potential disjunctions between advice and the logics of antibiotic use within hospitals. One reason noted for this in previous research has been that prescribing improvement strategies which are driven outside of specialties (by infectious diseases) are reported to result in disengagement. I feel that embedding quality improvement strategies within, and as driven by, specialties or individual teams is a potential logical step for consistent and sustainable prescribing changes in other areas of AMS.
Q: What can an individual do to help address AMR?
A: Preventing infections and their spread helps stop antibiotic resistance by reducing the need for antibiotics. You can help prevent infections by regularly washing your hands, keeping up to date with vaccinations and preventing food-borne infections by washing fruits and vegetables and cooking food properly.
Only taking antibiotics when necessary. Understanding that colds and flu are caused by viruses, and that antibiotics treat bacterial infections, not viruses. Tell your doctor you only want an antibiotic if it is really necessary. Take the right dose of your antibiotic at the right time, as prescribed by your doctor. Take your antibiotic for as long as your doctor tells you to.
Q: Will AMR have an impact on the current pandemic?
A: Since the emergence of COVID-19, date collected from around the world has demonstrated an increase in antibiotic use, even though most of the initial illnesses being treated have been from COVID-19 viral infection. While the use of antibiotics in hospitalised COVID-19 patients with secondary bacterial infection is appropriate, the possibility of antibiotic prescribing in a large number of patients without established secondary infection is common. The resulting increased exposure to healthcare facilities, invasive procedures, along with marked increase in antibiotic use, amplified the opportunity for multidrug resistant (MDR) bacteria to emerge and spread.
There is also concern that the current COVID-19 crisis will decrease the momentum that was building in AMR policy and appropriate antibiotic use.
Q: Lastly, who is the star researcher or strongest advocate around this topic? This could be someone whose work you admire or someone who has brought the topic into the spotlight.
A: Dr Paul Farmer is an infectious diseases specialists, medical anthropologist (social science researcher) and cofounder of Partners in Health, an organisation whose mission is to bring modern medical care to those in need around the world. Although his work and research does not specifically focus on AMR his work is based on the premise that you cannot relieve health inequality without addressing poverty and social inequality.
In terms of AMR research, some of the most exciting work in the field has recently been published (Tompson & Chandler, 2021); it acknowledges the importance of social structures and networks into which antimicrobial use is intertwined, and frames this as a better target for antimicrobial stewardship activities than individual-behaviour-change-based models. As well as work by Alex and Jennifer Broom based in Australia looking at the social influences on antibiotic prescribing and then attempting to address these to improve surgical antibiotic prescribing in hospitals (J. Broom et at, 2021).