Antimicrobial Resistance Action Plan Research Articles

Starved of ACTION: A Critical Look at the Antimicrobial Resistance Action Plans of African Countries.

The urgent need for Africa, as a continent, to start galvanizing resources and strengthening its capacity to win the fight against the looming threat of antimicrobial resistance (AMR) was once again brought to the limelight by the recent study on the "Global Burden of Bacterial Antimicrobial Resistance" (The Lancet 2022, 399, 629). According to the study, western sub-Saharan Africa is a super-region for AMR, with overall mortality rates due to and associated with AMR standing at 27.3 and 114.8 per 100 000 people, respectively. Putting this in perspective, if the leaders of this region do not take effective action, Africa will indeed be one of the two worst-affected regions, along with Asia, with the possibility of over 4.1 million people dying annually from AMR by 2050. The development of a National Action Plan, as directed by the World Health Organization, provides an important framework for addressing the complex and multi-faceted nature of the rise and spread of drug-resistant bacteria. This paper reviews the AMR National Action Plans of African countries and calls on the leaders of this region to move from paper to action and to look beyond just the reduction of antibiotic consumption and, as a more comprehensive response to the threat of AMR, focus also on expanding access to safe drinking water, bettering sanitary conditions, maintaining effective leadership at all levels of governance, increasing government spending on healthcare services, and strengthening regulatory oversight.

The Next Pandemic

The Next Pandemic

P04 An evaluation of antimicrobial stewardship education in the School of Pharmacy of an Irish university—a mixed methods study

BackgroundAntimicrobial stewardship (AMS) is essential to control the emergence of antimicrobial resistance (AMR) which has become an international health priority. Education of undergraduate students on AMS and AMR is a strategic objective in the WHO Global Action Plan on AMR and Ireland's National Action Plan.1,2 Research on AMS/AMR education has focused primarily on medical students with less emphasis on those from other healthcare profession including pharmacy students.ObjectivesTo investigate AMS and AMR education in the Pharmacy undergraduate programme in the School of Pharmacy of an Irish University.MethodsA mixed methods study was conducted. Ten semi-structured interviews were conducted in October 2019 with academic staff to capture their views on AMS education. Participants included staff members from different disciplines, those identified as involved in teaching elements of infectious disease, antibiotics, AMS and related topics, and those involved in curriculum design and approval within the School of Pharmacy. Interview transcripts were analysed by thematic analysis. An electronic survey of 17 questions was emailed to all second to fifth year UCC Pharmacy students in October 2019 to gather students’ views and experiences of AMS education. The survey contained four sections which addressed demographics, AMS, resources and education using open-ended, closed-ended or Likert-scale questions. Ethical approval was obtained.ResultsSix key themes were identified from the ten interviews: (i) curriculum priorities and capacity; (ii) housing of the subject, fragmentation and cohesion; (iii) integration; (iv) communication; (v) teaching methods; and (vi) assessment methods. 113 students participated in the survey (32.3% response rate). 96% agree that a strong knowledge of antimicrobials for their future careers is important, and over 89% of students desire more education on AMR and AMS. Only 43% of students found their AMS education provided sufficient preparation for practice. Students felt most prepared to recognize clinical signs of infection and least prepared for IV to oral switching, interpreting biological marker and de-escalation of antimicrobials. Over 50% of students never used or were not familiar with the national primary care antimicrobial guidelines: www.antibioticprescribing.ie.ConclusionsPharmacy students and staff agree that AMS and AMR are important and need enhanced educational focus. Students feel there are gaps in their AMS education and expressed a desire for more education in this area. Improved communication and identification of curriculum priorities by staff could help to establish a more cohesive and comprehensive educational approach to this area.

Change in use of pediatric oral antibiotics in Japan, pre- and post-implementation of an antimicrobial resistance action plan.

Most antimicrobials are prescribed to outpatients, making outpatient antibiotic prescription an important target for antibiotic stewardship. A national antimicrobial resistance (AMR) action plan was developed in 2016 by the Japanese government with various antimicrobials steawardship activities for pediatric outpatients. We aimed to evaluate changes in antibiotic use pre- and post-implementation of the AMR action plan. All antimicrobials prescribed to pediatric outpatients in Japan from 2011 to 2018 were retrospectively analyzed using data from a national database. Antimicrobials dispensed for patients aged ≤19 years were reviewed. Antimicrobial use was surveyed by age, year of use, type of antimicrobial prescribed, and prescribing facility. Five cities were selected as pilot areas to investigate the variations, based on the clinical specialties of the prescribing physicians. Antimicrobial usage varied with age. Specifically, usage decreased post-AMR in patients aged ≤8 years and increased in those aged >15 years. Further, antimicrobial prescriptions tended to decrease after 2016 in primary care clinics and hospitals. In the pilot areas of the study, 35% of all oral antimicrobials were prescribed in otolaryngology departments, and 8% were prescribed in dermatology clinics. Notably, antimicrobial prescriptions from both departments showed an upward trend from 2011 to 2018. The use of antimicrobial agents decreased in children younger than 8 years in pediatric clinics, hospitals, and internal medicine clinics. However, use increased in children older than 15 years and in other specialty clinics. Settings with an increasing use of antimicrobials are potential targets for the next antibiotic stewardship program and should be investigated in detail.

How to make noncoherent problems more productive: Towards an AMR management plan for low resource livestock sectors

Global policy for managing antimicrobial resistance (AMR) is underpinned by a standardised and coherent global framework for reducing antibiotic use in clinical health, veterinary health, and food production sectors. Within the framework, problematic antibiotic use (a significant driver of AMR) is treated as a knowledge deficit on the part of users and prescribers, which can be remedied by educating them to make better informed treatment decisions. This narrow approach to AMR management conceals the socioeconomic and material drivers of antibiotic decision-making, creating challenges for low resource regions that rely on antibiotic therapies to manage uncertainty and precarity. Thus, there is a need for a global AMR policy that acknowledges the diversity of sociomaterial arrangements and practices that antibiotics form part of, if their use is to be reduced without undermining productivity or the attainment of poverty reduction indicators. Drawing upon research of antibiotic use in West Africa’s livestock sector, this article analyses the interrelation of antibiotics, AMR action plans, and production management strategies in ecologies of livestock breeding practices. We apply the STS-influenced perspective of noncoherence to analyse how seemingly contradictory practices and institutional logics productively coalesce. We argue that observing noncoherent practices increases our understanding of antibiotic use in relation to local breeding conditions that are frequently not of the producers’ making, whilst drawing attention to context-specific possibilities for improving livestock management capacities and reducing reliance on antibiotic therapies in low-resource settings. The article concludes by calling for an AMR global policy that is more responsive to local specificity rather than enforcing universal standardisation.

A Strategy for Hospital Pharmacists to Control Antimicrobial Resistance (AMR) in Japan.

In Japan, there is concern regarding the relation between the inappropriate use of antibiotics and antibiotic resistance (AMR). Increased bacterial resistance is due in part to the inappropriate use of antimicrobial agents. The support of the pharmacist becomes important, and there is growing interest in antimicrobial stewardship to promote the appropriate and safe use of antimicrobials needed for the optimal selection of drugs, doses, durations of therapy, therapeutic drug monitoring (TDM), and implementations of cost containment strategies in Japan. Pharmacists should strive to disseminate the concept of “choosing wisely” in relation to all medicines, implement further interventions, and put them into practice. In this article, we present data for antimicrobial stewardship and Japan’s AMR action plan, focusing on how pharmacists should be involved in enabling physicians to choose antimicrobials wisely.

Antibacterial Activity of Kaolin-Silver Nanomaterials: Alternative Approach to the Use of Antibiotics in Animal Production.

According to the search for alternatives to replace antibiotics in animal production suggested in the antimicrobial resistance action plans around the world, the objective of this work was to evaluate the bactericidal effect of kaolin–silver nanomaterial for its possible inclusion as an additive in animal feed. The antibacterial activity of the C3 (kaolin–silver nanomaterial) product was tested against a wide spectrum of Gram-negative and Gram-positive bacteria (including multidrug resistant strains) by performing antibiograms, minimal inhibitory concentration (MIC) and minimal bactericidal concentration (MBC), as well as growth inhibition curves against seven strains causing infections in animals. The C3 product generated inhibition halos in all the tested strains, and a higher activity against Gram-negative bacteria was found, with MBC values ranged from 7.8 µg/mL (P. aeruginosa) to 15.6 µg/mL (E. coli and Salmonella). In contrast, it was necessary to increase the concentration to 31.3 µg/mL or 250 µg/mL to eliminate 99.9% of the initial population of S. aureus ATCC 6538 and E. faecium ATCC 19434, respectively. Conversely, the inhibition growth curves showed a faster bactericidal activity against Gram-negative bacteria (between 2 and 4 h), while it took at least 24 h to observe a reduction in cell viability of S. aureus ATCC 6538. In short, this study shows that the kaolin–silver nanomaterials developed in the framework of the INTERREG POCTEFA EFA183/16/OUTBIOTICS project exhibit antibacterial activity against a wide spectrum of bacteria. However, additional studies on animal safety and environmental impact are necessary to evaluate the effectiveness of the proposed alternative in the context of One Health.

Estimating the Economic and Clinical Value of Reducing Antimicrobial Resistance to Three Gram-negative Pathogens in Japan.

Background: Antimicrobial resistance (AMR) represents a significant global public health crisis. Despite ample availability of Gram-positive antibiotics, there is a distinct lack of agents against Gram-negative pathogens, including carbapenem-resistant Enterobacterales, which remains a real threat in Japan. The AMR Action Plans aim to mitigate the growing public health concern posed by AMR.Objective: This study aims to estimate the clinical and economic outcomes of drug-resistant Gram-negative pathogens forecasts for Japan to guide resource allocation defined within the upcoming National AMR Action Plan.Methods: A previously published and validated dynamic health economic model was adapted to the Japanese setting. The model used a 10-year time horizon with a willingness-to-pay threshold of ¥5 000 000 (US $46 827) and discounting was applied at a rate of 2% to costs and benefits. Clinical and economic outcomes were assessed as a function of varying AMR levels of three Gram-negative pathogens in Japan by up to 100% of the current level.Results: Reducing drug-resistant Gram-negative pathogens in Japan has the potential to save 4 249 096 life years, corresponding to 3 602 311 quality-adjusted life years. The associated maximum clinical and economic gains were estimated at up to 4 422 284 bed days saved, up to 3 645 480 defined daily doses of antibiotics avoided, up to ¥117.6 billion (US $1.1 billion) saved in hospitalization costs, and a net monetary benefit of up to ¥18.1 trillion (US $169.8 billion).Discussion: Learnings from this study can be used by the Japanese government to help inform decision-making on the strategies that may be included in the upcoming National AMR Action Plan and facilitate allocation of the required budget.Conclusions: This analysis demonstrated the considerable economic and clinical value of reducing AMR levels of three Gram-negative pathogens in Japan and could be utilized to support the valuation of antimicrobial treatment and resistance in Japan and more broadly.

Estimating the Economic and Clinical Value of Reducing Antimicrobial Resistance to Three Gram-negative Pathogens in Japan

Background: Antimicrobial resistance (AMR) represents a significant global public health crisis. Despite ample availability of Gram-positive antibiotics, there is a distinct lack of agents against Gram-negative pathogens, including carbapenem-resistant Enterobacterales, which remains a real threat in Japan. The AMR Action Plans aim to mitigate the growing public health concern posed by AMR. Objective: This study aims to estimate the clinical and economic outcomes of drug-resistant Gram-negative pathogens forecasts for Japan to guide resource allocation defined within the upcoming National AMR Action Plan. Methods: A previously published and validated dynamic health economic model was adapted to the Japanese setting. The model used a 10-year time horizon with a willingness-to-pay threshold of ¥5 000 000 (US $46 827) and discounting was applied at a rate of 2% to costs and benefits. Clinical and economic outcomes were assessed as a function of varying AMR levels of three Gram-negative pathogens in Japan by up to 100% of the current level. Results: Reducing drug-resistant Gram-negative pathogens in Japan has the potential to save 4 249 096 life years, corresponding to 3 602 311 quality-adjusted life years. The associated maximum clinical and economic gains were estimated at up to 4 422 284 bed days saved, up to 3 645 480 defined daily doses of antibiotics avoided, up to ¥117.6 billion (US $1.1 billion) saved in hospitalization costs, and a net monetary benefit of up to ¥18.1 trillion (US $169.8 billion). Discussion: Learnings from this study can be used by the Japanese government to help inform decision-making on the strategies that may be included in the upcoming National AMR Action Plan and facilitate allocation of the required budget. Conclusions: This analysis demonstrated the considerable economic and clinical value of reducing AMR levels of three Gram-negative pathogens in Japan and could be utilized to support the valuation of antimicrobial treatment and resistance in Japan and more broadly.

An insight into the implementation of the global action plan on antimicrobial resistance in the WHO African region: A roadmap for action

IntroductionThe Global Action Plan (GAP) on antimicrobial resistance (AMR) delivers a ‘One Health’ strategy for the development of the national action plan. It encourages the optimal use of antimicrobials and strengthens the evidence base through surveillance and research. MethodsThis study evaluated the current status of implementation of the GAP on AMR in World Health Organization (WHO) African countries via a retrospective, cross-sectional analysis of routinely collected data on AMR. A SWOT analysis was used to identify the strengths, weaknesses, opportunities and threats involved in the GAP implementation. A roadmap for action was proposed. ResultsThe overall mean GAP performance score across all the countries that were assessed was 32% ± SD12 (95% CI 27–36%). The mean thematic scores were 59% ± 12 (53–65%) for multi-sector and One Health collaboration; 50% ± 22 (42–58%) for developing national AMR action plans; 38% ± 12 (33–42%) for awareness and training; 18% ± 13 (13–23%) for surveillance; 33% ± 13 (29–38%) for infection prevention and control; and 28% ± 23 (20–37%) for optimal use of antimicrobial medicines in human, animal and plant health. The difference in GAP performance scores between African sub-regions and between income categories was not statistically significant (P > 0.05). While seven countries exhibited strengths in two themes, 25 countries exhibited weaknesses across all themes. Six threats and six opportunities were identified to inform a practical roadmap for AMR action. ConclusionThe findings from this study indicate that the overall GAP implementation on AMR in the WHO African region is inadequate. Some thematic GAP scores appeared to be relatively good, but on closer inspection, individual indicators revealed a lack of progress and implementation, requiring action.

Learnings from select Indian public welfare programs to catalyze the implementation of India’s national actional plan on antimicrobial resistance

Antibiotics are an easy, rapid and quick replacement to improved care within fragmented health systems with poor access and infection control measures in many countries, including India. India announced its national action plan for antimicrobial resistance (NAP-AMR) 2017-2021 but has made limited progress. Successful public welfare programs (Delhi metro rail corporation DMRC, swachh bharat mission (SBM), beti bachao beti padao (B3P) and national green tribunal NGT) were reviewed that had addressed critical national concerns similar to AMR. Valuable lessons from their implementation provide the opportunity to improve the governance and operationalization of the NAP-AMR. Unique features of the four programs identified above include resilient leadership, multi-stakeholder coordination with oversight and accountability of partnerships, innovation in program design and implementation and data-driven real-time monitoring for sustained behavior change. Incorporating these strategies into the program design and implementation of India's NAP-AMR will reinvigorate the program to accelerate the achievement of program targets.

Conflicts of interest: an invisible force shaping health systems and policies

Conflicts of interest: an invisible force shaping health systems and policies

Three-Dimensional Micropatterning Deters Early Bacterial Adherence and Can Eliminate Colonization.

Developing strategies to prevent bacterial infections that do not rely on the use of drugs is regarded globally as an important means to stem the tide of antimicrobial resistance, as argued by the World Health Organization (WHO) (Mendelson, M.; Matsoso, M. P. The World Health Organization Global Action Plan for Antimicrobial Resistance. S. Afr. Med. J. 2015, 105 (5), 325-325. DOI: 10.7196/SAMJ.9644). Given that many antimicrobial-resistant infections are caused by the bacterial colonization of indwelling medical devices such as catheters and ventilators, the use of microengineered surfaces to prevent the initial attachment of microbes to these devices is a promising solution. In this work, it is demonstrated that 3D engineered surfaces can inhibit the initial phases of surface colonization for Escherichia coli, Klebsiella pneumoniae, and Pseudomonas aeruginosa, representing the three most common catheter-associated urinary tract bacterial infections, identified by the WHO as urgent threats. A variety of designs including 11 different topographies and configurations that exhibited random distributions, sharp protrusions, and/or curvilinear shapes with dimensions ranging between 500 nm and 2 μm were tested to better understand the initial stages of surface colonization and how to optimize the design of fabricated surfaces for improved inhibition. These topographies were fabricated in two configurations to obtain either a standard 2D cross section or a 3D engineered topography using a novel UV lithography process enabling cost-efficient high-throughput manufacturing. Evaluating both the number of adhered bacteria and microcolonies formed by all three bacterial pathogens on the different surfaces provides insight into the initial colonization phase of bacterial growth on the various surfaces. The results demonstrate that both initial attachment and subsequent colonization can be significantly reduced on concrete 3D engineered patterns when compared to flat substrates and standard 2D micropatterns. Thus, this technology has great potential to reduce the colonization of bacteria on surfaces in clinical settings without the need for chemical treatments that might enhance antimicrobial resistance.

Antibiotics prescriptions for pneumonia analyzed by claim information in Japan

OBJECTIVE Japan is an aging society, and pneumonia is the leading cause of death, but the suitability of antibiotics for treating community-acquired pneumonia (CAP) in Japan is not clear. The purpose of this study was to investigate antibacterial drugs for treating CAP according to age. MATERIALS AND METHODS Using the Japanese national database from 2011 to 2014, we analyzed the usage of antibiotics for CAP according to age. RESULTS The numbers of claim information were 9,386, and 70% of the patients were aged ≥ 75 years. Sulbactam/ampicillin (SBT/ABPC) or ceftriaxone (CTRX) was used in 60%, but broad-spectrum antibiotics, combination therapy, and anti-mycoplasma antibiotics were used in 15 - 28% of all age groups. The 30-day survival rate did not differ between SBT/ABPC or CTRX vs. others. There was no difference in 30-day mortality and risk in any group between the ages of 15 and 64 years. On the other hand, the use of anti-mycoplasma antibiotics reduced the 30-day mortality by 0.50 times (p < 0.01), and the use of two or more antibiotics increased the 30-day mortality by 1.45 times (p = 0.02) at age ≥ 65 years. CONCLUSION Approximately half of the antibiotics used for CAP requiring hospitalization consisted of CTRX or SBT/ABPC as recommended by the Japanese Respiratory Society (JRS) guidelines. On the other hand, the usage of broad-spectrum antibiotics and combination therapy were relatively frequent at all ages, although their use does not always contribute to survival. Our data provide basic information for analyzing the outcome of pneumonia treatment in terms of an antimicrobial resistance action plan in Japan.

Addressing antimicrobial resistance in Nigerian hospitals: exploring physicians prescribing behavior, knowledge, and perception of antimicrobial resistance and stewardship programs

ABSTRACT Introduction We assessed the knowledge of, attitude toward antimicrobial resistance (AMR) and practice of antimicrobial stewardship (AMS) among physicians in Nigeria to provide future guidance to the Nigerian National Action Plan for AMR. Methods A descriptive cross-sectional questionnaire-based study explored the physicians’ self-reported practice of antibiotic prescribing, knowledge, attitude, and practice of AMR and components of ASPs. Results The majority (217; 67.2%) of respondents prescribed antibiotics daily in their clinical practice AMR was recognized as a global and local problem by 308 (95.4%) and 262 (81.1%) respondents, respectively. Only 91 (28.2%) of respondents have ever heard of antibiotic stewardship. The median AMR knowledge score was 40 (19–45)out of 45while that for ASP was 46.0(32–57) out of 60. There was significant statistical difference between the ASP median scores among the medical specialties category (P value <0.0001) More respondents had good knowledge of AMR than ASPs (82.7% versus 36.5%; p < 0.0001). Conclusion Respondents in this study were more knowledgeable about AMR than AMS and its core components.

Tackling AMR crisis in India: Changing paradigm

Antimicrobial resistance (AMR) is an important public health concern globally. For India, undoubtedly, AMR has had profound impact on its health &amp; socioeconomic parameters. Several hospital and community-based surveys have indicated alarming rise in incidence of multidrug resistant microbes, especially ‘superbugs’, having direct links with antibiotic use/misuse. Additionally, paucity in data with regards to quantification of AMR crisis &amp; its determinants has been concerning. However, the national commitment to address AMR has steadily increased of late, with an oft-restated realization – it is time to act. Recent initiatives like National Policy for Containment of AMR (2011), Chennai Declaration (2012), Anti-microbial Resistance Surveillance and Research Network (2013), The Red Line Campaign (2016), National Action Plan (NAP) for AMR (2017), ICMR Treatment Guidelines for Antimicrobial Use in Common Syndromes (2019) are promising measures expected to have positive impact on both clinical and economic outcome in India. This paper provides a snapshot of major strategies proposed in recent years, including educational and awareness initiatives, infection control guidelines, audit and feedback, antimicrobial stewardship, surveillance projects etc. It also identifies technical challenges &amp; opportunities for improved AMR mitigation in India.

National Consumption of Antimicrobials in Tanzania: 2017-2019.

Objective: Surveillance of antimicrobial consumption is essential to the national action plan for antimicrobial resistance (AMR) as stipulated in the Global Action Plan on AMR and the Tanzanian National Action Plan on AMR. Given the paucity of antimicrobial consumption data in sub-Saharan Africa region, the objective of this study was to measure antimicrobial consumption in Tanzania. Methods: From 2017 to 2019, data on all antimicrobials imported into Tanzania were obtained from the Tanzania Medicines and Medical Devices Authority Data, augmented with purchasing data from the Medical Stores Department and data from local manufacturers. Data were collected and analyzed in accordance with the World Health Organization Anatomical Therapeutic Chemical and defined daily doses (DDD) methodology. Results: The average DDD per 1,000 inhabitants per day (DDD/1,000/D) for all antimicrobials was 80.8 ± 39.35. The DDD/1,000/D declined from 136.41 in 2017 to 54.98 in 2018 and 51.02 in 2019. Doxycycline, amoxicillin, and trimethoprim-sulfamethoxazole were the most frequently consumed antibiotics during these years, accounting for 20.01, 16.75, and 12.42 DDD/1,000/D, respectively. The majority of antimicrobial consumption in Tanzania occurred in the private sector, with the proportion of private-sector antibiotic consumption increasing annually from 2017 to 2019. Based on AWaRe classification >90% of antimicrobial consumption was Access class medications, with Watch and Reserve class medications accounting for <10% and <1%, respectively. Conclusion: The private sector use of antimicrobials is significantly increasing and should be carefully monitored in accordance with national policies. Future work is necessary to increase reporting of antimicrobial consumption patterns in sub-Saharan Africa.

Improving educator’s knowledge and confidence to teach infection prevention and antimicrobial resistance

Objective: e-Bug is a teaching resource that addresses the UK 5-year National Action Plan on antimicrobial resistance (AMR) that pledges to work with educators and local authorities to ensure young people understand infection prevention and control (IPC) and AMR. This study aimed to evaluate the effectiveness and acceptability of the e-Bug face-to-face train-the-trainer intervention with school and community educators. Design: Service evaluation of an educational intervention via surveys. Setting: Workshops were organised by Public Health England (PHE) and collaborators in seven regions of the UK during 2018–2019. Method: Pre- and post-intervention surveys measured satisfaction with training, knowledge of IPC and AMR, and confidence to teach others. Statistical analyses included multilevel and ordinal logistic regression models to measure change in educator knowledge and confidence. Results: In all, 262 educators participated: primary (46%), secondary (17%), college (2%), healthcare (29%) and community (7%). Educators had high pre-intervention knowledge of topics, with significant improvement ( p &lt; .05) in confidence to teach all topics and some significant IPC knowledge improvement, post-intervention. There was strong evidence for a difference in confidence change between educator types, with primary educators improving the most. Ninety-five percent of educators rated the train-the-trainer workshop positively, valued the interactive workshops and felt confident to use the resources. Conclusion: Confident and knowledgeable educators, achieved via e-Bug train-the-trainer workshops, will enhance education of IPC and AMR topics in schools and communities, and therefore support the UK 5-year AMR action plan. The intervention will be monitored with long-term follow-up surveys to explore how training has been disseminated and to evaluate long-term benefits.

What are the barriers to implementing national antimicrobial resistance action plans? A novel mixed-methods policy analysis in Pakistan

Despite political commitment to address antimicrobial resistance (AMR), countries are facing challenges to implementing policies to reduce inappropriate use of antibiotics. Critical factors to the success of policy implementation in low- and middle-income countries (LMIC), such as capacity for enforcement, contestation by influential stakeholders and financial interests, have been insufficiently considered. Using Pakistan as a case study representing a populous country with extremely high antibiotic usage, we identified 195 actors who affect policies on antibiotic use in humans and animals through a snowballing process and interviewed 48 of these who were nominated as most influential. We used a novel card game-based methodology to investigate policy actors' support for implementation of different regulatory approaches addressing actions of frontline healthcare providers and antibiotic producers across the One Health spectrum. We found that there was only widespread support for implementing hard regulations (prohibiting certain actions) against antibiotic suppliers with little power-such as unqualified/informal healthcare providers and animal feed producers-but not to target more powerful groups such as doctors, farmers and pharmaceutical companies. Policy actors had limited knowledge to develop implementation plans to address inappropriate use of antibiotics in animals, even though this was recognized as a critical driver of AMR. Our results indicate that local political and economic dynamics may be more salient to policy actors influencing implementation of AMR national action plans than solutions presented in global guidelines that rely on implementation of hard regulations. This highlights a disconnect between AMR action plans and the local contexts where implementation takes place. Thus if the global strategies to tackle AMR are to become implementable policies in LMIC, they will need greater appreciation of the power dynamics and systemic constraints that relate to many of the strategies proposed.

Antibiotic literacy among Japanese medical students

Antimicrobial resistance (AMR) is an urgent global issue. After the AMR action plan was introduced in 2016, a study on antibiotic literacy (i.e., awareness, knowledge, and attitude relating to antimicrobial use) among clinicians and lay people was conducted in Japan. However, no studies have hitherto targeted medical students who are expected to have a high level of antibiotic literacy. The present study was conducted between September 2019 and February 2020, enrolling undergraduate students at Okayama University Medical School. We collected data using a paper-based questionnaire form with 11 questions about antibiotic literacy. The response rate was 93.8% (661/705 students). Overall, 92.6% of the students knew that antibiotics inhibit the growth of bacteria. Student reporting that antibiotics could treat the common cold accounted for 77.0% (Year 1), 50.9% (Year 2), 48.2% (Year 3), 49.1% (Year 4), 23.8% (Year 5), and 26.2% (Year 6). Only 43 (6.5%) had heard about the AMR action plan. The study data suggested that medical students' level of literacy on antimicrobial use should be further enhanced to address AMR and promote antimicrobial stewardship.