Special Issue "Tackling Challenges Associated with Antibiotic Resistance: Social, Economic and Policy Perspectives"

A special issue of Antibiotics (ISSN 2079-6382). This special issue belongs to the section "Antibiotics Use and Antimicrobial Stewardship".

Deadline for manuscript submissions: closed (31 December 2018)

Special Issue Editors

Guest Editor
Prof. Dr. Richard Smith

Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London WC1H 9SH, UK
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Guest Editor
Dr. Johanna Hanefeld

Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London WC1H 9SH, UK
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Guest Editor
Prof. Dr. Joanna Coast

School of Social and Community Medicine, University of Bristol, Bristol BS8 2PR, UK
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Guest Editor
Prof. Dr. Helen Lambert

School of Social and Community Medicine, University of Bristol, Bristol BS8 2PS, UK
Website | E-Mail

Special Issue Information

Dear Colleagues,

A forthcoming Special Issue of Antibiotics will focus on the Social, Economic and Policy aspects of antibiotic resistance (ABR). Guest Editors, Professor Richard Smith and Dr. Johanna Hanefeld, London School of Hygiene & Tropical Medicine, and Professor Joanna Coast and Professor Helen Lambert, University of Bristol, UK, invite you to contribute a paper on this important topic.

ABR is high on national and global agendas. It is recognized as threatening the very foundations of modern healthcare, reversing the decline in mortality and morbidity from infectious diseases, and posing potentially crippling financial effects. Although intrinsically a biological phenomenon, the conditions promoting, or mitigating against, ABR are deeply social, shaped by cultural, political, and economic processes. As a social problem, ABR demands a social solution, one based on greater understanding, measurement, appraisal and modelling, and ultimately (re)shaping of the social, political, and economic environments in which resistance develops and antibiotics are used.

There is currently very limited evidence on these aspects of ABR. For instance, on the ways that farmers, vets, and regulatory systems manage the use of antibiotics in livestock production; how regulatory and fiscal frameworks incentivize or deter antibiotic development, production, and use; how diverse publics and healthcare professionals understand, value, and use antibiotics; what the future costs of resistance might be, and how they should be incorporated into decision making; and how to reconcile antibiotic stewardship with the need to ensure equitable access to these essential drugs. The Special Issue of Antibiotics will address issues such as these. The aim is to publish rigorous empirical original research and reviews, but also substantive contributions to the conceptual and methodological basis of such research. We are especially interested in papers that deploy sociological, anthropological, economic, organizational, policy or health systems perspectives to consider issues including (but not limited to):

  • Economic impact of ABR in specific settings—countries, regions, health care facilities;
  • Economic evaluation of interventions to control or reduce ABR;
  • Policy analysis related to availability of antibiotics and/or the development of new antibiotics;
  • Analysis of the “value chain” for antibiotics in specific settings;
  • Work focused on low- and middle-income countries;
  • Conceptual analysis of innovative ways to reduce use of antibiotics or develop alternative therapies;
  • Analysis of links between agricultural and human antibiotics and AMR;
  • Empirical research and analysis of sociocultural or economic drivers of ABR;
  • Health systems responses to ABR and/or the effects of regulatory change.

We encourage you to submit a paper on any of these issues, or to contact Professor Richard Smith ([email protected]) in the first instance to discuss a proposed submission.

Prof. Dr. Richard Smith
Dr. Johanna Hanefeld
Prof. Dr. Joanna Coast
Prof. Dr. Helen Lambert
Guest Editors

Manuscript Submission Information

Manuscripts should be submitted online at www.mdpi.com by registering and logging in to this website. Once you are registered, click here to go to the submission form. Manuscripts can be submitted until the deadline. All papers will be peer-reviewed. Accepted papers will be published continuously in the journal (as soon as accepted) and will be listed together on the special issue website. Research articles, review articles as well as short communications are invited. For planned papers, a title and short abstract (about 100 words) can be sent to the Editorial Office for announcement on this website.

Submitted manuscripts should not have been published previously, nor be under consideration for publication elsewhere (except conference proceedings papers). All manuscripts are thoroughly refereed through a single-blind peer-review process. A guide for authors and other relevant information for submission of manuscripts is available on the Instructions for Authors page. Antibiotics is an international peer-reviewed open access quarterly journal published by MDPI.

Please visit the Instructions for Authors page before submitting a manuscript. The Article Processing Charge (APC) for publication in this open access journal is 550 CHF (Swiss Francs). Submitted papers should be well formatted and use good English. Authors may use MDPI's English editing service prior to publication or during author revisions.

Published Papers (9 papers)

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Research

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Open AccessArticle Characterizing Antimicrobial Use in the Livestock Sector in Three South East Asian Countries (Indonesia, Thailand, and Vietnam)
Antibiotics 2019, 8(1), 33; https://doi.org/10.3390/antibiotics8010033 (registering DOI)
Received: 31 January 2019 / Revised: 5 March 2019 / Accepted: 15 March 2019 / Published: 25 March 2019
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Abstract
A framework was developed to characterize the antimicrobial use/antimicrobial resistance complex in livestock systems in Indonesia, Vietnam, and Thailand. Farm profitability, disease prevention, and mortality rate reduction were identified as drivers toward antimicrobial use in livestock systems. It revealed that antimicrobial use was [...] Read more.
A framework was developed to characterize the antimicrobial use/antimicrobial resistance complex in livestock systems in Indonesia, Vietnam, and Thailand. Farm profitability, disease prevention, and mortality rate reduction were identified as drivers toward antimicrobial use in livestock systems. It revealed that antimicrobial use was high in all sectors studied, and that routine preventative use was of particular importance to broiler production systems. Misleading feed labeling was identified as a hurdle to the collection of accurate antimicrobial use data, with farmers being unaware of the antimicrobials contained in some commercial feed. Economic analysis found that the cost of antimicrobials was low relative to other farm inputs, and that farm profitability was precariously balanced. High disease and poor prices were identified as potential drivers toward economic loss. The research indicates that antimicrobial use in small-scale poultry production systems improves feed conversion ratios and overall productivity. However, data were limited to quantify adequately these potential gains and their impacts on the food supply. During the study, all countries embraced and implemented policies on better management of antimicrobial use in livestock and surveillance of antimicrobial resistance. Future policies need to consider farm-level economics and livestock food supply issues when developing further antimicrobial use interventions in the region. Full article
Open AccessArticle Mapping and Analysing Potential Sources and Transmission Routes of Antimicrobial Resistant Organisms in the Environment using Geographic Information Systems—An Exploratory Study
Antibiotics 2019, 8(1), 16; https://doi.org/10.3390/antibiotics8010016
Received: 21 December 2018 / Revised: 21 January 2019 / Accepted: 25 February 2019 / Published: 27 February 2019
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Abstract
Antimicrobial resistance (AMR) is one of the leading threats to human health worldwide. The identification of potential sources of antimicrobial resistant organisms (AROs) and their transmission routes in the environment is important for improving our understanding of AMR and to inform and improve [...] Read more.
Antimicrobial resistance (AMR) is one of the leading threats to human health worldwide. The identification of potential sources of antimicrobial resistant organisms (AROs) and their transmission routes in the environment is important for improving our understanding of AMR and to inform and improve policy and monitoring systems, as well as the identification of suitable sampling locations and potential intervention points. This exploratory study uses geographic information systems (GIS) to analyse the spatial distribution of likely ARO sources and transmission routes in four local authority areas (LAAs) in Ireland. A review of relevant spatial data in each LAA, grouped into themes, and categorised into sources and transmission routes, was undertaken. A range of GIS techniques was used to extract, organise, and collate the spatial data into final products in the form of thematic maps for visual and spatial analysis. The results highlight the location of ‘clusters’ at increased risk of harbouring AMR in each LAA. They also demonstrate the relevance of aquatic transmission routes for ARO mobility and risk of human exposure. The integration of a GIS approach with expert knowledge of AMR is shown to be a useful tool to gain insights into the spatial dimension of AMR and to guide sampling campaigns and intervention points. Full article
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Open AccessArticle The State of Education and Training for Antimicrobial Stewardship Programs in Indian Hospitals―A Qualitative and Quantitative Assessment
Antibiotics 2019, 8(1), 11; https://doi.org/10.3390/antibiotics8010011
Received: 14 December 2018 / Revised: 20 January 2019 / Accepted: 23 January 2019 / Published: 30 January 2019
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Abstract
Background: To understand the role of infrastructure, manpower, and education and training (E&T) in relation to Antimicrobial Stewardship (AMS) in Indian healthcare organizations. Methods: Mixed method approach using quantitative survey and qualitative interviews was applied. Through key informants, healthcare professionals from [...] Read more.
Background: To understand the role of infrastructure, manpower, and education and training (E&T) in relation to Antimicrobial Stewardship (AMS) in Indian healthcare organizations. Methods: Mixed method approach using quantitative survey and qualitative interviews was applied. Through key informants, healthcare professionals from 69 hospitals (public & private) were invited to participate in online survey and follow up qualitative interviews. Thematic analysis was applied to identify the key emerging themes from the interviews. The survey data were analyzed using descriptive statistics. Results: 60 healthcare professionals from 51 hospitals responded to the survey. Eight doctors participated in semi-structured telephone interviews. 69% (27/39) of the respondents received E&T on AMS during undergraduate or postgraduate training. 88% (15/17) had not received any E&T at induction or during employment. In the qualitative interviews three key areas of concern were identified: (1) need for government level endorsement of AMS activities; (2) lack of AMS programs in hospitals; and, (3) lack of postgraduate E&T in AMS for staff. Conclusion: No structured provision of E&T for AMS currently exists in India. Stakeholder engagement is essential to the sustainable design and implementation of bespoke E&T for hospital AMS in India. Full article
Open AccessArticle Cost-Effectiveness Analysis of the Use of Point-of-Care C-Reactive Protein Testing to Reduce Antibiotic Prescribing in Primary Care
Antibiotics 2018, 7(4), 106; https://doi.org/10.3390/antibiotics7040106
Received: 19 October 2018 / Revised: 20 November 2018 / Accepted: 3 December 2018 / Published: 7 December 2018
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Abstract
More appropriate and measured use of antibiotics may be achieved using point-of-care (POC) C-reactive protein (CRP) testing, but there is limited evidence of cost-effectiveness in routine practice. A decision analytic model was developed to estimate the cost-effectiveness of testing, compared with standard care, [...] Read more.
More appropriate and measured use of antibiotics may be achieved using point-of-care (POC) C-reactive protein (CRP) testing, but there is limited evidence of cost-effectiveness in routine practice. A decision analytic model was developed to estimate the cost-effectiveness of testing, compared with standard care, in adults presenting in primary care with symptoms of acute respiratory tract infection (ARTI). Analyses considered (1) pragmatic use of testing, reflective of routine clinical practice, and (2) testing according to clinical guidelines. Threshold and scenario analysis were performed to identify cost-effective scenarios. In patients with symptoms of ARTI and based on routine practice, the incremental cost-effectiveness ratios of CRP testing were £19,705 per quality-adjusted-life-year (QALY) gained and £16.07 per antibiotic prescription avoided. Following clinical guideline, CRP testing in patients with lower respiratory tract infections (LRTIs) cost £4390 per QALY gained and £9.31 per antibiotic prescription avoided. At a threshold of £20,000 per QALY, the probabilities of POC CRP testing being cost-effective were 0.49 (ARTI) and 0.84 (LRTI). POC CRP testing as implemented in routine practice is appreciably less cost-effective than when adhering to clinical guidelines. The implications for antibiotic resistance and Clostridium difficile infection warrant further investigation. Full article
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Open AccessArticle The Consequences of AMR Education and Awareness Raising: Outputs, Outcomes, and Behavioural Impacts of an Antibiotic-Related Educational Activity in Lao PDR
Antibiotics 2018, 7(4), 95; https://doi.org/10.3390/antibiotics7040095
Received: 2 September 2018 / Revised: 19 October 2018 / Accepted: 30 October 2018 / Published: 1 November 2018
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Abstract
Education and awareness raising are the primary tools of global health policy to change public behaviour and tackle antimicrobial resistance. Considering the limitations of an awareness agenda, and the lack of social research to inform alternative approaches, our objective was to generate new [...] Read more.
Education and awareness raising are the primary tools of global health policy to change public behaviour and tackle antimicrobial resistance. Considering the limitations of an awareness agenda, and the lack of social research to inform alternative approaches, our objective was to generate new empirical evidence on the consequences of antibiotic-related awareness raising in a low-income country context. We implemented an educational activity in two Lao villages to share general antibiotic-related messages and also to learn about people’s conceptions and health behaviours. Two rounds of census survey data enabled us to assess the activity’s outputs, its knowledge outcomes, and its immediate behavioural impacts in a difference-in-difference design. Our panel data covered 1130 adults over two rounds, including 58 activity participants and 208 villagers exposed indirectly via conversations in the village. We found that activity-related communication circulated among more privileged groups, which limited its indirect effects. Among participants, the educational activity influenced the awareness and understanding of “drug resistance”, whereas the effects on attitudes were minor. The evidence on the behavioural impacts was sparse and mixed, but the range of possible consequences included a disproportionate uptake of antibiotics from formal healthcare providers. Our study casts doubt on the continued dominance of awareness raising as a behavioural tool to address antibiotic resistance. Full article
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Review

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Open AccessReview Antibiotic Stewardship—Twenty Years in the Making
Received: 5 December 2018 / Revised: 9 January 2019 / Accepted: 21 January 2019 / Published: 24 January 2019
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Abstract
In the last 20 years, efforts were made to optimize antibiotic use in hospitals across the world as a means of addressing the increasing threat of antibiotic resistance. Despite robust evidence supporting optimal practice, antibiotic decision-making remains sub-optimal in many settings, including in [...] Read more.
In the last 20 years, efforts were made to optimize antibiotic use in hospitals across the world as a means of addressing the increasing threat of antibiotic resistance. Despite robust evidence supporting optimal practice, antibiotic decision-making remains sub-optimal in many settings, including in hospitals. Globally, resources remain a limiting factor in the implementation of antibiotic stewardship programs. In addition, antibiotic decision-making is a social process dependent on cultural and contextual factors. Cultural boundaries in healthcare and across specialties still limit the involvement of allied healthcare professionals in stewardship interventions. There is variation in the social norms and antibiotic-prescribing behaviors between specialties in hospitals. The cultural differences between specialties and healthcare professionals (1) shape the shared knowledge within and across specialties in the patient pathway, and (2) result in variation in care, thus impacting patient outcomes. Bespoke stewardship interventions that account for contextual variation in practice are necessary. Full article
Open AccessReview Something Borrowed, Something New: A Governance and Social Construction Framework to Investigate Power Relations and Responses of Diverse Stakeholders to Policies Addressing Antimicrobial Resistance
Received: 6 December 2018 / Revised: 14 December 2018 / Accepted: 19 December 2018 / Published: 24 December 2018
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Abstract
While antimicrobial resistance (AMR) has rapidly ascended the political agenda in numerous high-income countries, developing effective and sustainable policy responses in low- and middle-income countries (LMIC) is far from straightforward, as AMR could be described as a classic ‘wicked problem’. Effective policy responses [...] Read more.
While antimicrobial resistance (AMR) has rapidly ascended the political agenda in numerous high-income countries, developing effective and sustainable policy responses in low- and middle-income countries (LMIC) is far from straightforward, as AMR could be described as a classic ‘wicked problem’. Effective policy responses to combat AMR in LMIC will require a deeper knowledge of the policy process and its actors at all levels—global, regional and national—and their motivations for supporting or opposing policies to combat AMR. The influence of personal interests and connections between for-profit organisations—such as pharmaceutical companies and food producers—and policy actors in these settings is complex and very rarely addressed. In this paper, the authors describe the role of policy analysis focusing on social constructions, governance and power relations in soliciting a better understanding of support and opposition by key stakeholders for alternative AMR mitigation policies. Owing to the lack of conceptual frameworks on the policy process addressing AMR, we propose an approach to researching policy processes relating to AMR currently tested through our empirical programme of research in Cambodia, Pakistan, Indonesia and Tanzania. This new conceptualisation is based on theories of governance and a social construction framework and describes how the framework is being operationalised in several settings. Full article
Open AccessReview Interventions to Reduce Antibiotic Prescribing in LMICs: A Scoping Review of Evidence from Human and Animal Health Systems
Received: 1 November 2018 / Revised: 17 December 2018 / Accepted: 18 December 2018 / Published: 22 December 2018
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Abstract
This review identifies evidence on supply-side interventions to change the practices of antibiotic prescribers and gatekeepers in low- and middle-income countries (LMICs). A total of 102 studies met the inclusion criteria, of which 70 studies evaluated interventions and 32 provided insight into prescribing [...] Read more.
This review identifies evidence on supply-side interventions to change the practices of antibiotic prescribers and gatekeepers in low- and middle-income countries (LMICs). A total of 102 studies met the inclusion criteria, of which 70 studies evaluated interventions and 32 provided insight into prescribing contexts. All intervention studies were from human healthcare settings, none were from animal health. Only one context study examined antibiotic use in animal health. The evidence base is uneven, with the strongest evidence on knowledge and stewardship interventions. The review found that multiplex interventions that combine different strategies to influence behaviour tend to have a higher success rate than interventions based on single strategies. Evidence on prescribing contexts highlights interacting influences including health system quality, education, perceptions of patient demand, bureaucratic processes, profit, competition, and cultures of care. Most interventions took place within one health setting. Very few studies targeted interventions across different kinds of providers and settings. Interventions in hospitals were the most commonly evaluated. There is much less evidence on private and informal private providers who play a major role in drug distribution in LMICs. There were no interventions involving drug detailers or the pharmaceutical companies despite their prominent role in the contextual studies. Full article
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Other

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Open AccessConcept Paper Combatting Antibiotic Resistance Together: How Can We Enlist the Help of Industry?
Antibiotics 2018, 7(4), 111; https://doi.org/10.3390/antibiotics7040111
Received: 15 November 2018 / Revised: 11 December 2018 / Accepted: 13 December 2018 / Published: 18 December 2018
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Abstract
The development of antibiotics needs to be supported through new financial stimuli, including help from the public sector. In exchange for public support, industry should be asked to do what is in their power to help curb the inappropriate use of antibiotics. This [...] Read more.
The development of antibiotics needs to be supported through new financial stimuli, including help from the public sector. In exchange for public support, industry should be asked to do what is in their power to help curb the inappropriate use of antibiotics. This work discusses key areas through which industry has an important influence on antibiotic consumption and where agreements can be made alongside financial incentives, even those intended to stimulate very early research. As long as the traditional unit sale-based business model for antibiotics remains in place, profit-making incentives will likely undermine efforts to sell and utilize antibiotics in a sustainable manner. In the short-term, while we try to come to a consensus on how best to fix the market, we need measures to prevent major over-selling and inappropriate promotion—especially for new, badly needed antibiotics that reach the market. This paper explores ways in which the pharmaceutical industry could help buttress sustainable antibiotic use while we search for more long-term, constructive, mutually-beneficial ways to organize the market. Full article
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