Antimicrobial Resistance Policies Research Articles

Gender and equity considerations in AMR research: a systematic scoping review.

Research on gender and antimicrobial resistance (AMR) beyond women's biological susceptibility is limited. A gender and equity lens in AMR research is necessary to promote gender equality and support the effectiveness, uptake, and sustainability of real-world AMR solutions. We argue that it is an ethical and social justice imperative to include gender and related intersectional issues in AMR research and implementation. An intersectional exploration of the interplay between people's diverse identities and experiences, including their gender, socio-economic status, race, disability, age, and sexuality, may help us understand how these factors reinforce AMR risk and vulnerability and ensure that interventions to reduce the risk of AMR do not impact unevenly. This paper reports on the findings of a systematic scoping review on the interlinkages between AMR, gender and other socio-behavioural characteristics to identify priority knowledge gaps in human and animal health in LMICs. The review focused on peer-reviewed and grey literature published between 2017 and 2022. Three overarching themes were gendered division of caregiving roles and responsibilities, gender power relations in decision-making, and interactions between gender norms and health-seeking behaviours. Research that fails to account for gender and its intersections with other lines of disadvantage, such as race, class and ability, risks being irrelevant and will have little impact on the continued and dangerous spread of AMR. We provide recommendations for integrating an intersectional gender lens in AMR research, policy and practice.

Global antimicrobial resistance and use surveillance system (GLASS 2022): Investigating the relationship between antimicrobial resistance and antimicrobial consumption data across the participating countries.

For the first time since 2015, the World Health Organization's (WHO) global Antimicrobial Resistance and Use Surveillance (GLASS) featured both global reports for antimicrobial resistance (AMR) and antimicrobial consumption (AMC) data in its annual reports. In this study we investigated the relationship of AMR with AMC within participating countries reported in the GLASS 2022 report. Our analysis found a statistically significant correlation between beta-lactam/cephalosporin and fluoroquinolones consumption and AMR to these antimicrobials associated with bloodstream E. coli and Klebsiella pneumoniae among the participating countries (P<0.05). We observed that for every 1 unit increase in defined daily dose DDD of beta-lactam/cephalosporins and quinolone consumptions among the countries, increased the recoveries of bloodstream-associated beta-lactam/cephalosporins-resistant E. coli/Klebsiella spp. by 11-22% and quinolone-resistant E. coli/Klebsiella spp. by 31-40%. When we compared the antimicrobial consumptions between the antimicrobial ATC (Alphanumeric codes developed by WHO) groups and countries, we observed a statistically significant higher daily consumption of beta-lactam-penicillins (J01C, DDD difference range: 5.23-8.13) and cephalosporins (J01D, DDD difference range: 2.57-5.13) compared to other antimicrobial groups among the countries (adjusted for multiple comparisons using Tukey's method). Between the participating countries, we observed a statistically significant higher daily consumption of antimicrobial groups in Iran (DDD difference range: 3.63-4.84) and Uganda (DDD difference range: 3.79-5.01) compared to other participating countries (adjusted for multiple comparisons using Tukey's method). Understanding AMC and how it relates to AMR at the global scale is critical in the global AMR policy development and implementation of global antimicrobial stewardship.

The challenges of implementing antibiotic stewardship in diverse poultry value chains in Kenya

This paper investigates the challenges of implementing antibiotic stewardship – reducing and optimizing the use of antibiotics – in agricultural settings of Low- and Middle-Income Countries (LMICs) as a strategic part of addressing the global problem of antimicrobial resistance (AMR). It does so through analysis of the rapidly transforming yet diverse Kenyan poultry sector, characterized by growing commercial operations alongside traditional smallholder farming. Our research involves interviews with farmers, processors, policymakers, and agro-veterinary stores in these settings. We blend Chandler’s (2019, p. 8) notion of “antibiotics as infrastructure” with value chain frameworks to understand how the structural role of antibiotics in agriculture plays out through contrasting value chains, with different implications for stewardship. Weak regulation and intense market-based pressures are shown to drive widespread antibiotic use in poultry value chains involving small- and medium-sized farms supplying open markets. Antibiotic stewardship through adherence to agricultural and food safety standards is more evident, though unevenly observed, in value chains involving large commercial farms and processors supplying corporate buyers. Our findings reveal the complex structural roles of antibiotics in maintaining producer livelihoods in an intensely competitive and heterogeneous Kenyan poultry sector. This highlights challenges with applying global AMR policy to transforming food systems in LMICs without appropriate translation. We argue that attempts to reduce and optimize the use of antibiotics in agriculture must be informed by nuanced understandings of the roles of antibiotics in food systems in specific places including where very different scales and models of farming and value chain co-exist.

What and how can we learn from complex global problems for antimicrobial resistance policy? A comparative study combining historical and foresight approaches

To (i) develop a methodology for using historical and comparative perspectives to inform policy and (ii) provide evidence for antimicrobial-resistance (AMR) policymaking by drawing on lessons from climate change and tobacco control. Using a qualitative design, we systematically examined two other complex, large-scale policy issues-climate change and tobacco control-to identify what relevance to AMR can be learned from how these issues have evolved over time. During 2018-2020, we employed a five-stage approach to conducting an exploratory study involving a review of secondary historical analysis, identification of drivers of change, prioritisation of the identified drivers, scenario generation and elicitation of possible policy responses. We sought to disrupt more 'traditional' policy and research spaces to create an alternative where, stimulated by historical analysis, academics (including historians) and policymakers could come together to challenge norms and practices and think creatively about AMR policy design. An iterative process of analysis and engagement resulted in lessons for AMR policy concerning persistent evidence gaps and uncertainty, the need for cross-sector involvement and a collective effort through global governance, the demand for new interventions through more investment in research and innovation, and recognising the dynamic relationship between social change and policy to change people's attitudes and behaviours are crucial towards tackling AMR. We draw on new methodological lessons around the pragmatism of future- and policy-oriented approaches incorporating robust historical and comparative analysis. The study demonstrates proof of concept and offers a reproducible method to advance further methodology, including transferrable policies that could tackle health problems, such as AMR.

Development, roll-out and implementation of an antimicrobial resistance training curriculum harmonizes delivery of in-service training to healthcare workers in Kenya.

Antimicrobial resistance (AMR) is an increasingly severe threat to global public health that requires action across different sectors. Selection of appropriate antimicrobials is an urgent challenge due to the emergence of drug resistance. In 2017, Kenya developed an AMR policy and National Action Plan to drive prevention and containment of AMR. A priority activity under AMR surveillance strategic objective was to develop a national AMR training curriculum for in-service healthcare workers. In this paper we discuss the development process, gains achieved through implementation across the country and lessons learned. An initial stakeholders' forum was convened to brainstorm on the process for developing the curriculum and some issues deliberated upon include the design approach, development roadmap, curriculum outline and scope, delivery, and evaluation methodologies. A dedicated team of subject matter experts (SMEs), drawn from the project and government ministries, compiled the initial draft of the curriculum and later the training materials. A series of other stakeholders' meetings were convened to review these materials. The National Antimicrobial Stewardship Interagency Committee (NASIC) of the MOH in Kenya identified a team of experts from academia, research, and government to work with the SMEs in reviewing and providing valuable inputs to the curriculum. Additionally, principles of adult learning and a One Health approach for development were considered as AMR has drivers and impacts across sectors. A validation workshop was held to finalize the documents with a formal launch conducted during the World Antibiotics Awareness Week of 2020. A multisectoral AMR surveillance training curriculum and facilitator and trainee manuals were developed and endorsed by MOH and Ministry of Agriculture, Livestock, Fisheries and Cooperatives within one year. Over 500 healthcare workers in 19 counties were trained, with overwhelming adoption by other stakeholders in Kenya and beyond. This curriculum was developed to standardize training for AMR detection and surveillance. The central role played by the MOH ensured expeditious development and roll-out of this curriculum. The in-service curriculum, now available on an e-learning platform, provides a ready opportunity to build capacity of healthcare professionals. Additional resources are needed to standardize and scale these efforts to reach all healthcare workers.

Antibiotics online: digital pharmacy marketplaces and pastiche medicine

The internet enables access to information and the purchasing of medical products of various quality and legality. Research and regulatory attention have focused on the trafficking of illicit substances, potential...

Antimicrobial resistance and karst groundwater systems: A policy gap analysis for addressing water quality and contaminants of emerging concern

Aquifers are a significant drinking water source for the United States. Although vital to human well-being, development, and economies, these systems, specifically karst, either have minimal protections or are entirely overlooked in federal and state-level water quality policies and regulations. A lack of policies and regulations for the protection of karst groundwater resources is problematic, especially because these systems are characterized by distinctive landforms such as interconnected networks of underground rivers, sinkholes, springs and caves, and are extremely susceptible to contamination from polluted overland flows. This study considers policy approaches to improve water quality in groundwater, specifically karst systems, especially with regard to emerging contaminants of concern (CECs) and health threats, such as antimicrobial resistance (AMR). The study reviews and evaluates groundwater and karst groundwater quality and AMR policy gaps in federal water legislation (including the U.S. Clean Water Act and the Safe Drinking Water Act), and state-level programs in 44 states to provide recommendations for future policy development. Presently, there is limited federal and state-level protection for groundwater systems and minimal state-level for karst throughout the U.S. Also, there are neither federal nor state regulations for AMR mitigation in water resources. There is a need for policies and monitoring and regulatory programs that support water quality protection and management strategies for water resources with distinctive hydrology. Addressing water quality policy gaps for groundwater resources – especially karst aquifers – and prioritizing emerging contaminants in research, monitoring, and policymaking, are critical to safeguard the public against nascent public and environmental health threats.

Use of antibiotics in poultry and poultry farmers- a cross-sectional survey in Pakistan.

Antimicrobial resistance (AMR) which has been ascribed to be due to community carriage of antibiotic-resistant bacteria is highly prevalent in the WHO South-East Asia region. One of the major reasons for this is the misuse of antibiotics in animal farming practices and at the community level, which threatens both human and animal health. However, this problem of antibiotic misuse in poultry farms and in respective farmers is not well studied in countries like Pakistan. We conducted a cross-sectional study in rural Punjab to explore the current practices of antibiotic use in poultry and poultry farmers, associated factors, their healthcare-seeking behavior and biosecurity practices. In the context of antibiotic use for poultry, 60% comprised of Colistin sulfate and Amoxicillin trihydrate whereas Colistin is considered as the last resort antibiotic. In addition, the significant consumption of antibiotics in poultry farms (60%) and poultry farmers (50%) was without prescription by either human health physicians or veterinarians. Most of the farms (85%) had no wastewater drainage system, which resulted in the direct shedding of poultry waste and antibiotic residue into the surrounding environment. The lack of farmers' education, professional farm training and farming experience were the most significant factors associated with antibiotic use and knowledge of AMR. Our study findings show that it is necessary for an integrated AMR policy with the inclusion of all poultry farmers to be educated, a mass awareness program to be undertaken and that strict antibiotic usage guidelines be available to them. Such initiatives are also important to ensure food safety and farm biosecurity practices.

One Health Surveillance of Antimicrobial Use and Resistance: Challenges and Successes of Implementing Surveillance Programs in Sri Lanka.

Sri Lanka is a low-income country, as defined by the World Bank. The country suffered further economic downturn during the COVID-19 pandemic. This situation adversely affected the prioritization of policies and programs around healthcare and public health. In particular, inflation, fuel prices, and shortage of food supplies increased struggles to implement antimicrobial resistance (AMR) programs. However, in the long run, it is crucial to gather data and evidence to plan AMR policies and track interventions. (1) Aim: To establish and reiterate the importance of prioritizing AMR programs in the One Health framework, the Fleming Fellows collected and studied antimicrobial use/consumption (AMU/AMC) and resistance (AMR) in humans, food-producing animals, and the environment. (2) Methods: A systematic and cross-sectional study was conducted between 2019 and 2021. By way of coordinating an AMU/AMC and AMR prevalence study across six agencies from human health and food-producing animal sectors, the authors established a field epidemiology study, laboratory testing, and data processing at their institutions. AMU/AMC patterns were surveyed using questionnaires and interviews, while AMR samples were collected for antibiotic susceptibility tests and genomic tests. Samples were tested for phenotypic and genotypic resistance. (3) Results: In human samples, resistance was highest to beta-lactam antibiotics. In non-human samples, resistance was highest to erythromycin, a highest-priority, critically important antibiotic defined by the World Health Organization. From government records, tylosin was sold the most in the food-producing animal sector. (4) Conclusions: Sri Lanka AMU and AMR trends in human and non-human sectors can be ascertained by a One Health framework. Further coordinated, consistent, and sustainable planning is feasible, and can help implement an AMU/AMR surveillance system in Sri Lanka.

Multi-Sectoral Involvement in the National Action Plan on Anti-Microbial Resistance in Bangladesh: A Qualitative Study

Background To combat anti-microbial resistance in Bangladesh, a national action plan is designed with the involvement of multiple sectors. Methods Sixteen participants were interviewed virtually due to the COVID-19 pandemic. Semi-structured, pre-tested questionnaires were used for data collection using the Key-Informant Interview (KII) technique. Qualitative and quantitative analysis was carried out of relevant information. Results Bangladesh has no specific monitoring body for antibiotic prescription, and professionals do not follow national guidelines. Most healthcare settings don't have any protocol for Infection Prevention and Control (IPC), Standard Operating Procedure (SOP), and monitoring facilities. The main factor of Anti-Microbial Resistance (AMR) is the availability and accessibility of antibiotics and the dealers who supply antibiotics. Patients consume antibiotics without consulting any qualified doctor. The COVID-19 pandemic and the occurrence of AMR have escalated the use of antibiotics. Abuse of antibiotics in the animal industry is a worrying trend. The Bangladesh National Action Plan 2017 on AMR (BNAP), however, persuaded the top court to issue a ruling restricting the sale of antibiotics without a prescription and to establish an antibiotic surveillance system across the nation. The BNAP on AMR policy has been more effectively implemented thanks to multi-sectoral cooperation. Conclusion To monitor current facilities and spot trends in antibiotic resistance, a multi-sectoral regulatory organization specifically focused on AMR is desperately needed.

Antimicrobial susceptibility of bacterial isolates from clinical specimens in four Pacific Island countries, 2017–2021

There are limited antimicrobial resistance (AMR) surveillance data from low- and middle-income countries, especially from the Pacific Islands region. AMR surveillance data is essential to inform strategies for AMR pathogen control. We performed a retrospective analysis of antimicrobial susceptibility results from the national microbiology laboratories of four Pacific Island countries - the Cook Islands, Kiribati, Samoa and Tonga - between 2017 and 2021. We focused on four bacteria that have been identified as 'Priority Pathogens' by the World Health Organization: Staphylococcus aureus, Escherichia coli, Klebsiella pneumoniae and Pseudomonas aeruginosa. Following deduplication, a total of 20,902 bacterial isolates was included in the analysis. The most common organism was E.coli (n=8455) followed by S.aureus (n=7830), K.pneumoniae (n=2689) and P.aeruginosa (n=1928). The prevalence of methicillin resistance among S.aureus isolates varied between countries, ranging from 8% to 26% in the Cook Islands and Kiribati, to 43% in both Samoa and Tonga. Ceftriaxone susceptibility remained high to moderate among E.coli (87%-94%) and K.pneumoniae (72%-90%), whereas amoxicillin+clavulanate susceptibility was low against these two organisms (50%-54% and 43%-61%, respectively). High susceptibility was observed for all anti-pseudomonal agents (83%-99%). Despite challenges, these Pacific Island laboratories were able to conduct AMR surveillance. These data provide valuable contemporary estimates of AMR prevalence, which will inform local antibiotic formularies, treatment guidelines, and national priorities for AMR policy. Supported by the National Health and Medical Research Council.

An agent-based model for collaborative learning to combat antimicrobial resistance: proof of concept based on broiler production in Senegal

Antimicrobial resistance (AMR) is a substantial global One Health problem. This paper reports on initial, proof-of-concept development of an agent-based model (ABM) as part of wider modelling efforts to support collaborations between groups interested in policy development for animal health and food systems. The model simulates AMR in poultry production in Senegal. It simultaneously addresses current policy issues, builds on existing modelling in the domain and describes AMR in the broiler chicken production cycle as seen by producers and veterinarians. This enables implementation and assessment of producer antimicrobial use and infection prevention and control strategies in terms of immediate economic incentives, potentially helping to advance conversations by addressing national policy priorities. Our model is presented as a flexible tool with promise for extension as part of AMR policy development in Senegal and West Africa, using participatory approaches. This work indicates that ABM can potentially play a useful role in fostering counter-AMR initiatives driven by food system actor behaviour in lower- and middle-income countries more generally.

960. Optimizing the report of antimicrobial resistance in Mexican hospitals: An unfinished business.

Abstract Background One of the aims of antimicrobial stewardship programs (ASP) in hospitals is to make an efficient use of the available infrastructure to enhance surveillance and antimicrobial resistance (AMR) reporting. In this study, we aimed to explore specific AMR reporting mechanisms in ASPs in Mexican hospitals in order to highlight potential areas of improvement. Methods An online survey was applied to a purposive sample of 40 hospitals who performed regular antimicrobial stewardship activities in Mexico. Answers regarding a subset of questions on antimicrobial susceptibility monitoring and reporting practices were provided by ASP professionals. Results A total of 39 hospitals (14 private and 25 public hospitals) in 13 states in Mexico answered the subset of the survey. Thirty-three of those (85%) expressed that their databases allowed periodically monitoring of changes in susceptibility and resistance patterns for specific pathogens. As many as 17 hospitals (44%) reported to two external national academic networks and none reported to international ones. Only 10 reported to the National Hospital Network for Epidemiological Surveillance (RHOVE) in charge of AMR data (29%). Thirty hospitals (77%) declared reporting their AMR consolidated results internally to either the epidemiology department, an ASP leader, or other hospital committee. Twenty percent of the surveyed hospitals issued AMR reports to two entities, an additional 10% of them to 3 entities and 5% more to 4 different entities; reporting to &amp;gt;3 entities was observed only in public hospitals. Two hospitals (5%) declared not submitting AMR reports at all. Conclusion The adoption of reporting commitments without guiding national AMR policies derives into the duplicity of processes (reporting to different networks or entities) requiring additional human and financial resources. It also reflects the unavailability of a functional national reporting system allowing all hospitals to monitor and access the reported information nationally or internationally (GLASS). Optimizing AMR surveillance and reporting in Mexico must incorporate the simplification and standardization of reporting processes into an articulated system in line with the National Strategy against AMR. Disclosures Anahí Dreser, PhD, MSD: Grant/Research Support.

Governing Antibiotic Risks in Australian Agriculture: Sustaining Conflicting Common Goods Through Competing Compliance Mechanisms

Abstract The One Health approach to antimicrobial resistance (AMR) requires stakeholders to contribute to cross-sectoral efforts to improve antimicrobial stewardship (AMS). One Health AMR policy implementation is challenging in livestock farming because of the infrastructural role of antibiotics in production systems. Mitigating AMR may require the development of more stringent stewardship obligations and the future limitation of established entitlements. Drawing on Amatai Etzioni’s compliance theory, regulatory analyses and qualitative studies with stakeholder groups we examine the structural and socio-cultural dimension of antibiotic use and AMS compliance in Australian beef and dairy production. We found a disconnect between how antibiotic use is conceptualised by farmers and the way in which AMS policies construe agricultural AMR risks. Under the umbrella of food safety standards and national-level prescribing restrictions, farmers and veterinarians interact around antibiotic use with different operating logics and compliance mechanisms. These parallel regimes service distinct and sometimes competing common goods of food security and antibiotic preservation. Further reforms to mitigate AMR need to account for the value orientations of different groups and the embeddedness of the constraints imposed by existing systems. Advocacy for greater AMR precaution in agriculture should acknowledge and compensate for erosions in competing common goods and the cost of proposed interventions.

Development of a target product profile for a One Health antimicrobial resistance surveillance service

Abstract We developed a target product profile (TPP) for an interoperable, nationally hosted surveillance service that can automatically aggregate One Health antimicrobial resistance (AMR) data from numerous sources. The service described would provide a customized view of national level data in low- and middle-income countries. A draft TPP was reviewed through online survey by experts with broad knowledge across AMR policy, microbiology, surveillance and data management. The TPP included 51 characteristics with minimal and optimal requirements relating to overall information technology (IT) vision of effective AMR surveillance, data characteristics, data storage and use, interoperability, data security, system management and governance and non-functional requirements. The agreement for all characteristics in Round 1 was high (≥85%). Ten characteristics for which comments highlighted a need for clarification were amended and circulated for further review among 28 non-commercial and 15 commercial reviewers who responded to Round 1. The agreement with these characteristics during Round 2 was ≥88%. The final TPP will serve as an informative tool for a variety of stakeholders including diagnostic and software developers, governments and policymakers. The TPP aims to promote development of effective AMR surveillance information technology approaches to support policy decisions and implementation across human health, animal health and other sectors.

Regulating Antimicrobial usage in Livestock Farming: Innovative and Interdisciplinary Solutions

Antimicrobials have been used extensively in Livestock production. The overuse and misuse of antimicrobials has resulted in the development of drug resistant pathogens that is Antimicrobial Resistance (AMR). The emergence and spread of drug resistant pathogens have resulted into AMR and has continued to threaten our veterinary and health care systems. The most alarming situations include the rapid global spread of multi-and pan-resistant bacteria which have been referred to as “superbugs”. These have caused infections that are un-treatable with the available medicines in our health care and veterinary settings. AMR is one of the top ten global health and development threats facing humans and animals according to the World Health Organization hence the need for urgent multisectoral action. Antimicrobials are medicines used for prophylaxis, treatment and prevention of infections in animals, humans and plants. They comprise of antibiotics, antiviral, antifungal and antiparasitics. Antibiotics are increasingly losing their effectiveness as drug-resistance spreads globally resulting into difficulty in treating infections, death of animals and humans. In this paper, we addressed some of the innovative solutions based on an interdisciplinary perspective. We discussed the fundamental concerns for defining policies and strategies to mitigate AMR in Livestock farming, structured a basis for AMR policies and strategies and the key actors in Antimicrobial decision systems.

Antimicrobial Resistance Policy Protagonists and Processes-A Qualitative Study of Policy Advocacy and Implementation.

Antimicrobial resistance (AMR) fundamentally weakens societal foundations economically and in health care. The development of well-considered policies against AMR is important. However, in many places, AMR policy implementation remains elusive. This study aims to identify enablers and deterrents as well as processes and conditions in AMR policy advocacy. It also aims to identify AMR implementation conditions where AMR national policies are adopted and, to a certain extent, formulated and implemented. This study adopts qualitative research methodology and applies the Grounded Theory Framework to identify thematic findings from interviews conducted in China, Japan, Norway, the United Kingdom (UK), and the United States of America (US). It was identified that AMR policy protagonists are critical to filtering AMR issues and identifying policies “fit to prioritize” and “fit to implement”. They have helped move policy prioritization needles in the UK and the US and engaged in diplomatic efforts in the UK. In these cases, no clientelism was considered. In the US, protagonists who talked to the right decision-makers in the right office at the right time both moved AMR issues from individuals to institutional agenda and from social norms to policy agenda. To conclude, there are three thematic policy conditions that are significant to AMR policy advocacy and implementation: committed personal championship, institutionalization of policies, and social norms facilitate AMR policy advocacy and implementation.

A cross-sectional study of antimicrobial use among self-medicating COVID-19 cases in Nyeri County, Kenya

BackgroundDuring the COVID-19 pandemic, Nyeri County in Kenya was among the regions reporting a high number of confirmed cases. This exemplified the increased need of addressing potential antimicrobial resistance (AMR) and self-medication during disease outbreaks. This study examined the extent of self-medication with antimicrobials among COVID-19 confirmed cases in the County.MethodsA cross-sectional survey using phone-based interviews was conducted in August 2021 among a sample of 280 out of 2317 confirmed COVID-19 cases in the County using a pre-coded questionnaire. Descriptive analyses of frequencies and causal logistic regression were conducted using STATA version 13.ResultsA total of 193 (68.9%) of the respondents indicated developing COVID-19 related symptoms-mainly cough (41.5%), headache (38.3%), and fatigue (34.7%). Over one-fifth (23.4%) of the respondents had self-medicated with antibiotics, 60.6% of whom did so at the onset of symptoms before the confirmatory test, and 51.5% self-medicating more than once. Common antibiotics used were Azithromycin (40.0%) and Amoxycilline (23.3%), with a considerable 21.7% having difficulty remembering the name of the drugs. Only half (50.4%) of the respondents (128/254) were aware of regulations towards self-medication with antibiotics. Age was the only socio-demographic variable significantly related to reduced self-medication, with older persons less likely to self-medicate. On the other hand, developing COVID-19 symptoms, awareness of COVID regulations, and appreciation of the need for self-medication awareness were related to increased self-medication.ConclusionBeing older, developing COVID-19 symptoms, and appreciating self-medication awareness have influential effects on the use of antimicrobials. Public health interventions should be timely during infectious disease outbreaks to prevent undesirable health-seeking behavior such as irrational antimicrobial use. AMR policies should enhance awareness of the risks of self-medication and address barriers that deter people from timely access of health services during disease outbreaks. Further research should be conducted on the self-medication and AMR nexus, especially during health emergencies.

Closing the GAP in Antimicrobial Resistance Policy in Benin and Burkina Faso.

ABSTRACTAntimicrobial resistance (AMR) is a global concern that is geographically unevenly distributed, with low- and middle-income countries and African countries suffering in particular. The World Health Organization (WHO) Global Action Plan (GAP) for antimicrobial resistance identified five key objectives that aim to ensure the continued treatment and prevention of infectious diseases with the use of antibiotics. Countries signatory to the WHO GAP are expected to develop their own national action plans (NAPs) based on the global model. How low-income countries are able to achieve the GAP objectives is not well understood. This paper analyzes the progress of two West African countries in achieving the GAP targets, Benin and Burkina Faso, countries among the lowest bracket in the World Development Index. We present qualitative data from interviews and focus group discussions with local policy-makers, nurses, doctors, animal breeders, veterinarians, and laboratory researchers, supported by participant observations and surveys within rural communities. The analysis is organized according to the five WHO GAP objectives to show the countries’ challenges in fulfilling them. The analysis shows that there are shortcomings in all of the WHO GAP areas in the two countries, making it a compounded and multifactorial problem—a stacking of lacks. In such contexts, calibrating a society toward AMR resilience/prevention requires overall development and attention to interdependencies. Active local research and policy communities with international, sustained financial support are essential for achieving the targets.IMPORTANCE The burden of antimicrobial resistance (AMR) is unequally distributed across the globe. Low-income countries face a more severe AMR situation and have fewer means to solve the problem. This paper brings out the voices of local experts, policy-makers, and members of the community in Benin and Burkina Faso across human health, animal health, and food production sectors, where the majority of antibiotic use is concentrated. We describe the difficulties that they face in implementing global action plans, targets set by the World Health Organization, for securing antibiotics and preventing the spread of antimicrobial resistance. This paper argues that the various deficits in implementation are stacked, multisectoral, and compounded. We highlight the role of active local scientists and policy-maker networks in setting priorities to address the AMR problem; however, their activities need technical and financial support from international partners.

Hardwiring antimicrobial resistance mitigation into global policy.

In the wake of COVID-19, antimicrobial resistance (AMR) has become termed the ‘silent pandemic’, with a growing number of editorials warning that international momentum for AMR mitigation is being lost amidst the global turmoil of COVID-19, economic crises and the climate emergency. Yet, is it sufficient to now simply turn the volume of the pre-existing AMR policy discourse back up? Although existing AMR initiatives have previously achieved high levels of international attention, their impact remains limited. We believe it is time to critically reflect on the achievements of the past 7 years and adapt our AMR policies based on the substantial literature and evidence base that exists on the socioecological drivers of AMR. We argue that developing a more sustainable and impactful response requires a shift away from framing AMR as a unique threat in competition with other global challenges. Instead, we need to move towards an approach that emphasizes AMR as inherently interlinked and consciously hardwires upstream interventions into broader global developmental agendas.