Jennifer Broom

Much has been written about the problem of antimicrobial resistance (AMR) and the action required to rein in this emerging global health threat. Addressing AMR is often operationalised as requiring ‘behavior change’ of clinicians and of patients, in combination with improving the drug development pipeline. Few have approached AMR as a challenge fundamentally embedded within the cultural fabric of modern societies and the (varied) ways they are organised economically, socially and politically. Here, drawing on a decade of work across a range of health contexts, we approach the problem of AMR as one of values and culture rather than of individual behavior. We reframe AMR as a social and political concern resulting from a confluence of factors and practices including: temporal myopia, individualisation, marketisation, and human exceptionalism. To effectively tackle AMR, we advocate solidaristic models that espouse collective responsibility and recognise relative opportunity to act rather than a continuation of the individualistic behavioural models that have, so far, proven largely ineffective.

OBJECTIVES: Escalating antimicrobial resistance worldwide necessitates urgent optimization of antimicrobial prescribing to preserve antibiotics for future generations. Early intravenous (iv) to oral switch campaigns are one strategy that hospital-based antimicrobial stewardship programmes can incorporate to minimize inappropriate antibiotic use. Yet, iv antibiotics continue to be offered for longer than is clinically indicated, increasing hospital length of stay, increasing costs and placing patients at risk (e.g. cannula-related infections). This study aims to identify why this inappropriate prescribing trend continues. METHODS: Twenty doctors (9 females and 11 males) working at a teaching hospital in north-east England participated in semi-structured interviews about their experiences of antibiotic use. NVivo10 software was used to conduct a thematic content analysis of the full interview transcripts driven by the framework approach. Results are reported according to COREQ guidelines. RESULTS: Decisions around the choice of iv over oral antibiotics were influenced by three key issues: (i) consumerism, i.e. participants were concerned about the risk of litigation or complaints if patient expectations were not met; (ii) hierarchy of the medical team structure limited opportunities for de-escalation of antibiotics; and (iii) iv antibiotics were perceived as more potent and having significant mythical qualities, which participants acknowledged were not necessarily evidence based. CONCLUSIONS: The iv to oral switch interventions should tailor strategies to demystify iv versus oral antibiotic efficacy, engage consumers around the negative effects of iv antibiotic overuse and examine strategies to streamline team decision-making. Addressing these issues has the potential to reduce inappropriate antibiotic use and resistance.