Workshop Six: Antimicrobial resistance and rational use of antibiotics
Convenors Mary Murray, Niyada Kiatying‐AngsuleeRapporteursMichael Chai, Debra Rowett
Workshop Participants from Indonesia, Australia, India, Kiribati, American Samoa, Samoa,
Vanuatu, Tonga, Cook Islands, Tuvalu, India, Netherlands, Nepal, New Zealand, Philippines,
Bangladesh, Korea, China, Mongolia, and Malaysia (37 participants)
Antimicrobial resistance occurs with antiviral (HIV), antiparasitic(malaria) and antibacterial
medicines(TB and common bacterial diseases). While resistance has been addressed to an
extent in HIV, Malaria and TB, resistance to antibiotics for other bacterial diseases has had
relatively little attention. The workshopfocused onantibiotic resistance (ABR).
ABR is not a specific disease but a problem concerning a medicine that is no longer working
against bacteria that cause many common diseases. For example, blood infections,
gonorrhoea, typhoid fever, pneumonia and various surgical infections are becoming
untreatable due to increasing resistance. In some parts of the world, the situation is already
critical. Resistance also threatens many medical procedures such as major surgery, safe
childbirth, care of preterm neonates, and cancer treatment. ABR is a global problem affecting
everyone, but vulnerable populations with the highest infectious disease burden pay the
highest price having least access to current and future interventions to manage ABR. As first
line antibiotics fail, the cost for treatment by second or third line antibiotics increases
dramatically. For example the cost for treating resistant typhoid in Pakistan in 2004roseby
200‐3,000% depending on the antibiotic, using up the annual hospital drug budget in 2 weeks.
How did we get to this position? Antibiotics have been used inappropriately for a long time in
humans, animals and plants. Bacteria are very adaptive. To develop resistant genes is a
natural response to survive. The more we use antibiotics, especially unnecessarily and in a
wrong manner, the more pressure on bacteria to develop resistance. Resistance genes travel.
Bacteria actively share their genes and hence resistance moves through ecosystems, ESBL
even being found in migratory birds in the Antarctica. Global travel and trade increases the
rate of spread of resistance genes. Poor sanitation and hygiene also contribute to the spread
of infection and resistance.
The extent of the problem and burden associated with AMR has been underestimated due to
limitations of available data. Complicating and increasing the urgency of the problem is the
fact that there are almost no new antibiotics in the present R&D pipeline. So, as resistance
grows, we are literally running out of effective treatments. Should solutions to the
development of new antibiotics be found, they are likely to be extremely expensive and how
will they become accessible to all those that need them?. More fundamentally, what will
guarantee that they can be preserved for a reasonable time to treat infection if the present
way we use antibiotics continues? At societal level there seems to have been little or no
planning around how the cost structures involved for using existing second or third line, last
resort or future new antibiotics will be managed.
The effort of the past 20 years highlights that there has been growing awareness of the
problem of AMR but that, like an iceberg, only the tip was visible, but perhapsonlynow a sense
of the depth of the problem is being realised. The ‘timeline of endeavour’ representing years
of hard work across many countries on AMR shows a recent concentration of effort.
Workshop participants were encouraged to think differently and innovatively ‐ tostop
spinning within the circle (Thai saying), unlike ‘think outside the square’ (western saying) but
both imploring those in this field to think differently if we are to find a timely solution.
“If change is to occur then it will need to occur at the community, professional and policy
levels and there will need to be strong advocacy if the system is to change. We need to
galvanise the community to hold us all accountable for AMR.”
To strengthen attention to AMR as an issue to be implemented within NMP.
To identify the main challenges/barriers/gaps to developing and implementing effective
strategies to contain AMR, and integrate AMR into NMP.
What are the AMR challenges participants face in their countries?
Participants were invited to provide individual written responses to the following questions:
Describe one main challenge you face in taking action on AMR.
Why did you choose this challenge to share?
Which country are you from?
What are the main issues regarding AMR in your country?
The responses below, in the participants own words as far as possible, show the range of
issues and have been grouped under broad headings.
Having the public (ie the community and media) believe it is a real and urgent problem that is
important for them
o Lack of knowledge, attitude and practice of the community towards antimicrobial use
o Getting consumers to understand why AB are not often needed
o Real issue vs conspiracy theory vs boring topic
o Surveillance of antibiotic use in the community (both human and animals)
o Communicatingand implementing findings of research
Lack of expertise of prescribers / Standard Treatment Guidelines
o Unavailability of antimicrobial use guidelines at a local level at the point of care/clinical
o Prescribers prescribe irrespective of guidelines
o Ensuring principles are applied consistently for all prescribers including non medical
o Prescribers are concerned about complaints by patients in case infections not cured
o Indiscriminate use of AB by physicians as well as unauthorised prescribers
lack of laboratory microbiology and expertise in microbiology in health providers
Promotion of rational use to policy makers
o Cannot convince Ministry of Agriculture to reduce AB use in cattle
o Requires intersectoral commitment, coordination, partnership
o Requires evidence of impact of AMR and also success of interventions to change AB use and
o That AMR is seen as a potential problem rather than as a real and actual problem facing
patients and practice
o Lack of regulatory power and resistance of Governments to regulate
o Development of a funded national AMR policy that is comprehensive an includes use of AB in
o Coordinated action so that opportunities in the health system can be used to address rational
use of AB eg when decision support systems being built (eg hospital approval processes are
included in the design phase)
o Maintaining old patent expired AB on the register to ensure supply plus actual maintenance of
o Prescribing practices which are very much influenced by pharmaceutical promotion
o Limited Budgets and adequate funding for public education and awareness
Participants highlighted different reasons as to why they had chosen a particular challenge to
share, for many it was based on the extent of the problem and the potential for change. It was
emphasized that this needs to be a community led change with greater data collected to
provide the evidence on antibiotic use (misuse) to inform intervention programs.
“One group/sector alone cannot achieve adequate impact and sustained activity”
“The time is right to make a change”
A review of the responses regarding the main issues of AMR in the respondent’s country
revealed many similarities. There were consistent issues relating to the high rates of
prescribing by qualified doctors and non medical prescribers alike, accessibility of antibiotics
without a prescription over the counter, community expectation for a ‘quick fix’, veterinary
use of antibiotics – perverse incentives and no control, antibiotics in agriculture, no database
for antibiotic use in the community
Three work groups each focused on one level of society/health system. Community, Policy,
and Professional (hospital/academic/research) levels were each conceptualised as interacting
systems as described below in the headings introducing each work group) The workshop
participants joined one of three groups depending on their interest and expertise. They were
encouraged to brainstorm the issues but then to choose one to delve intomore deeply in
regard to barriers and ways forward for real change, rather than simply identifying a range of
barriers and general solutiosn..The following reflects the feedback from each of the groups.
Community level – key stakeholder groups and individuals and the interactions
at the community and primary care level.
7 Participants (Indonesia,
Australia, India, Kiribati)
including those who had
contributed posters on
consumer and health
practices and perceptions of
AB use in the community.
This group emphasised the ongoing challenges of AB overuse and misuse in both public and
private sectors including wrong indication, wrong AB, wrong dose and wrong duration. The
impact of over‐the‐counter (OTC)ABs (without prescription) from private retail pharmacistsin
the developing world was ongoing. Pharmacists copy GP prescribing patterns – if a GP is giving
ciprofloxacin for diarrhoea then pharmacists copy their model and give ciprofloxacin OTC to
patients. Hence the doctor’s behaviour is a strong influence on the practice of otherhealth
providers (multiplier effect). This includes nurses who give paracetamol and amoxycillin when
a patient presents with a fever. There is limited or no time for counselling patients that they
don’t need an AB for acute diarrhea or fever. Theperception is that it takes less time to just
give the AB.
“Patients demand AB because they paid money or travelled long distances –‘ we need somestrong
medicine so we can go to back to work as quickly as possible’”
It is important to understand that the patient is not necessarily asking for AB –people’s
practical reality,their ‘fear’ about infection/microbes and cultural belief about how to keep
going and be protected are also involved. The group considered it important to implement
standard treatment guidelines (STG), pharmacist education and encourage political
commitment and a multidisciplinary approach.However the most important area was to make
the issue real and personal for consumers/citizens either through story or pictorial
approaches which touch people’s emotions – resistance is in the bug, not in you, so if your
child is sick and the bug is resistant to AB then your child may not get well and die.
The group emphasized the need to educate patients to ask at least onequestion of the doctor
and pharmacist: “Do I really need an AB?”Strengthen the confidence of consumers/citizens to
ask this question with posters in doctor’s surgeries, in outpatients department and clinics
reminding them to ask this question. The group noted the example of polio which is more
straight forward as people can see the need. Therefore we need to make resistance more real
to the community, to make it a more visible problem.
Professional secondary and tertiary health institution level – key stakeholder
groups and individuals and the interactions at the hospital, academic teaching
and research level.
13 Participants (American
Samoa, Samoa, Vanuatu,
Tonga, Cook Islands, Tuvalu,
India, Netherlands, Nepal,
This groupacknowledged much overlap with the previous group comments but emphasised
that in many countries there was no monitoring for antimicrobial use, no microbiology
laboratory support, no AMR data to inform policies and procedures, and, in some countries,
there were no AB treatment guidelines at all. They restated that there was both under
treatment with a lack of expertise and knowledge of the service provider (microbiology, AB
dose, duration, selection, form) and also inappropriate use of antibiotics whereby prescribers
are resistant to evidence‐based practice and continue to do what they have always done.
The patient demand for antibiotics was significant also and reflected their perceptions and
health beliefs.“I need amoxycillin, or cotrimoxazole based on previous experience when AB fixed the
infection in 2 days”
Other issues included: availability of AB without prescription in both community and hospital
and no restriction of sellers of antibiotics; AB use in animal feeds, e.g. poultry; no infection
control committee in place; sanitation, hygiene can still be a problem with inappropriate
disposal of infected materials; limited development of new Abs; Surgical prophylaxis;
unavailability of first line drugs forcing use of quinolone and cepaholsporin, for example;
Influence of pharmaceutical companies; strengthen regulatory & Ministry of Health strategies.
Having local sensitivity data – informs drug choice selection and patterns of AMR
Strong microbiology department, Infection Control policy makers, active DTC
Making AB treatment guidelines available in every country
Evidence base to support management treatment guidelines
Prescribing restriction levels for access to AB (ie Level 4 ID specialist)
Empirical escalation and de‐escalation
Research into innovative practices to change behaviour
Regular auditing and monitoring of AM use and of how strategies are working
Education for all stakeholders including patients
Policy to govern public and private prescribing – expanded to regional and global levels.
National or central government level (and decentralised state or province) –
key stakeholder agencies and individuals,including business,and the
interactions in the political and policy machinery process.
This group identified similar points to those of the other groups but emphasised the
importance of encouraging people to do what they know they should do but don’t!
Professionals need to understand that they do not act in isolation and that their actions can
have far reaching impacts at all three levels. The goal is to strengthen the ethos that no
physician practises in isolation. Their practice influences others –physicians and patients alike.
There is a clear need for a National committee on AMR which has resources (dollars and
political will) to coordinate activities, to conduct surveillance, provide education to help
people to do the right thing. Then at a local/regional level areneeded local Infection control
committees, surveillance, education, AB guidelines. Policy needs to be linked into incentives
and sanctions, as education,while useful,doesn’t work for all.Surveillance needs to be linked in
to practice incentive payments and sanctions (professional and financial). Similarly, if AB are
being offered/sold by pharmacists then those pharmacists need to be accredited and part of
ongoing monitoring and audit processes
National education health promotion campaigns need to be conducted under the auspices of
national policy. A regulatory process regarding AB use also needs to apply in veterinary
practice and agriculture, to ensure that different classes of AB are used. It was acknowledged
that this is not simple, but that this area still needs policy, surveillance, regulation and
sanctions; Industry less of a problem more responsible.
Story, media and evidence
o Surveillance and good data are needed and then to be translated into human stories –
ie a routine hip replacement resistance organism might lead to implant removal and
pus oozing for months, useless floppy leg as a result
Media will need to play an important role – disaster stories help make get issue onto the
front page. In India the NDM story made the front pages of newspapers and was linked to
medical tourism – people come to India for surgery. This resulted in a task force being set
up.Public policy to reinforce AMR
AMR needs to be in the school curriculum so children go home to discuss with parents and
doctors as part of public education
Need to engage not only the Minister for Health butalso the Minister for Education
Policy in Philippines is‘no prescription no AB’ but is not followed by the pharmacy; needs
local level commitment by local officials
Data about financial burden to Government needs to cost the side effects of AMR – need
better data on financial burden of AMR
Who will advocate? All in the room!
A conceptual map of a worldwide network based on ReAct’s network and its connections with
other networks was displayed. Participants wanted to be connected in a network.
Conclusions from discussion of group work results:
Countries represented in the workshop were very diverse. They reported different types of
barriers at different levels within the countries. Where enablers exist (such as surveillance
data, treatment guidelines, regulations) theyare not adequately connected on common
platforms locally or nationally. There is little or no policy support. Even where there is policy,
there is little or no commitment, resources or machinery for implementation or enforcement.
In many of the Pacific island nations, there are no guidelines available. In many places there
are no microbiological facilities present and so even if guidelines exist, there is no possibility
to gather local sensitivity data and match local guidelines to results.
Stronger efforts to engage and strengthen community understanding and advocacy was
proposed including empowering people to ask their doctor and pharmacists whether they
really needed antibiotics. Likewise efforts are needed to make doctors aware of how their
prescribing for symptoms such as fever may set the pattern that will be copied for years to
come for similar symptoms by patients and pharmacists alike for self‐purchased medicines,
including antibiotics. Proposals made in the workshop included:
Build partnerships, raise awareness and strengthen collaboration among all stakeholders
to address the growing challenge of antibiotic resistance. Simple and easy programs to
educate the public regarding resistance and the use of antibiotics through various media at
specific locations – tell stories that engage people emotionally – make resistance VISIBLE.
Encourage people to ask ‘Do I really need antibiotics?’
National Prescribing Service, Australia, is running a 5 year campaign on resistance encouraging
every Australian to become a resistance fighter.
Strengthen the ethos that no physician is practising in isolation but that their practice
influences others: physicians and patients alike
Build networks to join people together. ReAct and other global
networks are beginning to collaborate in regions. There was a
strong feeling in the room that it is important to be part of a
‘How can we get the pacific islands onto the networking
map?’ asks Natane fromTuvalu after the workshop
Link researchprojects with research training in order topromote
research in the field of ABR for necessary evidence.
Review and revise all undergraduate health related education programs with the aim of
increasing students' skills in rational prescribing and dispensing of antibiotics.
Develop an ethos of independent continuing education amongst health professionals.
Institute government (MoH) regulation of the interactions between pharmaceutical
industries, doctors and pharmacists.
Focus on the mechanism for action– the national policy platform, represented by the
community of stakeholders serving as a review panel, agreeing upon the monitoring and
evaluation methodology and time frame to measure outcomes and impacts and propose
course corrections. Replicate this at local/regional levels.
Policy needs to be linked into incentives and sanctions because education,while
useful,doesn’t work for all.Surveillance needs to be linked in to practice incentive payments
and sanctions (professional and financial).Accredit, and audit pharmacists who sell ABs.