Antimicrobial resistance as a social dilemma: Approaches to reducing broad-spectrum antibiotic use in acute medical patients internationally

Antimicrobial resistance is one of the largest and most widely-acknowledged problems in 21st century medicine. Attempts to change the ways antibiotics are prescribed, in order to tackle the problem of antimicrobial resistance, have met with variable success. This is partly because the prescription of antibiotics is influenced by many social, cultural and organisational factors, and those prescribing antibiotics have to balance competing interests, values and short and long term benefits when making decisions. Healthcare providers have a responsibility both to individual patients and to "society at large", and since there is often not a "technical" solution to problems with prescribing, decisions are usually based on moral values and the customs of the healthcare community. Therefore attempts to change the ways antibiotics are prescribed will be more effective if they take these social factors into account.
These social factors, and thus decisions made by individuals about prescribing antibiotics, are strongly influenced by the local and national context. By comparing attitudes to prescribing antibiotics in England, Sri Lanka, and South Africa this study will consider and predict the influence of different contextual factors on various attempts to change the ways antibiotics are prescribed. This will make it easier to assess which attempts will be successful and could be repeated in different international contexts. Models, which take these factors into account, can be used to predict how changes in individual behaviour, social, cultural, or economic factors will impact on decisions about prescribing antibiotics, and the broader problem of antimicrobial resistance.
The project has three main aims:
1. To develop an international group of academics and clinicians who will work together to use social science theory and methods to look at the use of antibiotics in treating seriously ill patients. Close collaboration will make sure that the work of the project will be relevant to many contexts in which people are trying to improve antimicrobial resistance, particularly in non-high income countries.
2. To use theory to build a model that describes the use of broad spectrum antibiotics in treating seriously ill patients. The model will identify the risks, tensions, and elements of social and cultural context that effect the way antibiotics are prescribed. To find ways to improve antibiotic prescribing, and to consider the potential of various actions to address problems with the use of antibiotics in treating seriously ill patients in different parts of the world.
3. To begin work on a future proposal which would use two types of mathematical models to predict the effect of various attempts to try and improve the use of antibiotics in different contexts.
The model or models developed within the grant could be used to improve the success of attempts to influence antibiotic prescription, by making it clearer which actions have the best chance of success in different contexts, particularly in non-high income countries. This would reduce the risk of investing finances, time, and energy in unsuccessful projects.
The work will lay the ground work for future international collaborations, and for the development of larger projects to research and test attempts to improve the way antibiotics are prescribed. This might involve a study which interviews patients to explore their role in the prescription of antibiotics. The study will also involve training local researchers in Sri Lanka and South Africa in interviewing skills

Who will benefit from this research?
Antimicrobial resistance (AMR) is a significant threat to society, being highlighted in a recent World Economic Forum report as a global risk on the scale of global economic meltdown or severe climate change. Efforts to avoid overuse of existing antibiotics and preserve their efficacy are critical in mitigating this threat. Our research has potential benefit to patients; clinicians and those involved in delivering antimicrobial stewardship programmes; hospital managers; and policy makers . The immediate impact will be within the three participating countries but the outputs from the research will have international significance; through dissemination we will maximise the reach of the learning from this project.
How will they benefit from the research?
We will engage with clinicians involved in stewardship activities and in developing and implementing policies and guideline related to broad spectrum antibiotics. Our research has the potential to feed into the development and implementation of guidelines. The study will contribute to the theory-base around the design of context-specific interventions targeted at reducing the use of broad spectrum antibiotics. This will enable those involved in stewardship programmes to select, design, and implement interventions that are more effectively tailored to their local organisational and cultural context, and hence more likely to be effective and efficient. Our work will also help clinicians to reflect on the tensions and influences on their prescribing behaviour, and to gain insight into their own practices. In addition, we will support networking between researchers, clinicians and policy-makers within each country with an interest in the use of broad spectrum antimicrobials. The study will build research capacity in the participating middle-income countries by training local researchers.
How will we provide opportunities to engage?
We will establish links with key stakeholders internationally through the visits proposed as the first stage of the study; key stakeholders will be invited to be involved in a virtual advisory stakeholder group and will be kept informed by email at regular intervals. We will involve established contacts in organisations involved in national stewardship research and practice, including the British Society for Antimicrobial Chemotherapy, which has global links. We will maintain a project website and will upload interim updates, a full final report and a plain English summary. We will promote the website widely on social media and at workshops and conferences. We have costed for a small amount of time for a communications assistant to set up the advisory group, website and social media presence, and communication plan. We will provide training in qualitative methods to researchers in participating middle income countries, helping to build capacity for future local research into optimising the use of antibiotics. We will run a national post-project workshop in each of the three participating countries, bringing together researchers, policymakers and clinicians with an interest in reducing broad spectrum antibiotic use in acute medical patients, to disseminate findings of the project, to discuss implications for practice, and to facilitate the development of future collaboration around developing and implementing interventions. As well as presenting findings at an academic conference to disseminate our application of the specific theoretical perspective to the problem of antimicrobial stewardship, we will present the findings at two international conferences aimed at practitioner audiences involved in stewardship and quality improvement, such as the International Forum for Quality and Safety in Healthcare, and the European Congress of Clinical Microbiology and Infectious Diseases. We will aim to publish one output from the study in a practice-oriented academic journal such as the Journal of Hospital Infection.