Combating Antimicrobial Resistance A One Health Approach to a Global Threat: Proceedings of a Workshop (2017) / Chapter Skim
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4 Applying Social and Behavioral Sciences to Combating Antimicrobial Resistance
4 Applying Social and Behavioral Sciences to Combating Antimicrobial Resistance
Pages 39-68
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From page 39... ...
Helen Boucher, professor of medicine and director of the infectious diseases fellowship program at Tufts Medical Center, discussed effective guidance for reducing antimicrobials use in health care. David Sjeklocha, operations manager of animal health and welfare at Cattle Empire, surveyed guidelines for antimicrobial usage in the beef industry, and Randall Singer, professor of epidemiology at the University of Minnesota, explored the changing paradigm of antimicrobial use in veterinary medicine.
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From page 40... ...
REDUCING ANTIMICROBIAL USE: STEWARDSHIP PROGRAMS, INCENTIVES, AND POLICY Effective Guidance for Reducing the Use of Antimicrobials in Health Care Boucher focused on effective guidance for reducing antimicrobial use in health care settings. She began by defining antimicrobial stewardship as involving the optimal selection, dose, and duration of an antibiotic resulting in the cure or prevention of infection with minimal unintended consequences to the patient including emergence of resistance, adverse drug events, and cost.1 The goals of antimicrobial stewardship, said Boucher, are patient focused: improving care and health care outcomes.
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From page 41... ...
According to a nationwide survey on antimicrobial stewardship program characteristics, Boucher said, institutions with formal antimicrobial stewardship programs are more likely to have antibiograms,4 infectious disease consultation services, fellowship programs, and higher admissions (Doron et al., 2013; see Box 4-1 for more about the survey)
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From page 42... ...
Core Elements of Hospital Antibiotic Stewardship Programs Boucher summarized guidance from the U.S. Centers for Disease Control and Prevention (CDC)
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From page 43... ...
It recommends implementing efforts to promote adoption of antibiotic stewardship in curricula by faculty in colleges of human and veterinary medicine. It aims to promote a culture of stewardship as an integral part of continuing education and clinical practice, she said.
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From page 44... ...
The VFD does track sales data, but Sjeklocha was unsure of its value because there is not enough verifiable data to use as a benchmark base. For example, knowing the amount of antibiotics sold does not capture the effect on animal health and welfare, he said.5 Gaining Producer Buy-In to Antimicrobial Use Guidelines Beef producers can be reluctant to buy into guidelines, Sjeklocha explained, for both economic and cultural reasons.
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From page 45... ...
He used the practice of calf preconditioning to illustrate why it can be difficult to gain producer buy-in to antimicrobial stewardship programs and practices (see Box 4-2)
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From page 46... ...
When he was told that he would be surprised by how many consumers want antibiotic-free beef or organic beef, his reply was: You'd be surprised how many consumers say they want antibiotic-free beef or organic beef, but they get into the grocery store and they have sticker shock, and they say, "I'm going do my good deed and buy it this one time, and then I'm back to the stuff that's a little cheaper." He emphasized that producers must receive a premium to bring them to these niche markets, and he predicted that ultimately, the majority of producers will provide what consumers want, even if those are niche markets, but only if the return on investment makes it worth their time and effort. Changing Paradigm of Antimicrobial Use in Veterinary Medicine Antimicrobial use practices in animal agriculture are changing rapidly, said Singer, due in part to FDA policy changes that Sjeklocha discussed earlier, but also to consumer and customer demands.
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From page 47... ...
Singer explained that it specifically limited the use of medically important drugs in food-producing animals to those that are considered necessary for ensuring animal health and that include veterinary oversight or consultation. Guidance for Industry #213 followed in 2013 and was fully enacted in January 2017, he said, providing more detail on implementing those key principles.
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From page 48... ...
However, pen trials are too limited in scope because they do not necessarily represent all the diversity found on farms and are restricted to the litter used in the pens. Broiler Meat On-Farm Antimicrobial Resistance Surveillance Program Singer also runs an on-farm antimicrobial resistance surveillance and monitoring program in the poultry sector, initially funded by FDA as a pilot.
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From page 49... ...
The survey is designed to capture on-farm usage data on indication, route, dose, and duration,9 and it is organized by how the antibiotic is used (in the hatchery, for growth promotion, for disease prevention, and for treatment and control)
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From page 50... ...
In the industry "all in" category, human-use-approved -- also called shared-use -- antibiotics are used in hatcheries and in feed for growth promotion or disease prevention; this category also uses ionophores as well as shared-use antibiotics for treatment, control, and targeted prevention in sick flocks. In the gray area ("no human")
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From page 51... ...
Perdue Farms is currently rolling out organic animal husbandry rules to their nonorganic flocks, he said. He concluded by encouraging a focus on engaging farmers: "Those are the ones that are raising the animals, they've got to buy in .
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From page 52... ...
Lonnie King, professor and dean emeritus of The Ohio State University College of Veterinary Medicine, asked Boucher about the core element of leadership in stewardship programs. According to Boucher, the leadership component of stewardship cannot be overemphasized because leaders are responsible for negotiating for high-level support, running the programs, and influencing people not to use antibiotics.
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From page 53... ...
Scott observed: We use the term antibiotic stewardship, but if you were talking about stewardhip of other natural resources like forests, you wouldn't talk s about chainsaw stewardship. You would actually refer to the trees .
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From page 54... ...
Applying Social Psychology to Antimicrobial Prescribing Practices To frame antimicrobial prescribing and use in a theoretical context, Scott applied the theory of planned behavior (TPB) from social psychology to intensive production animal agriculture, noting that the TPB model has already been applied to physician prescribing behavior and patient compliance.
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From page 55... ...
After three years, the use of antibiotics among the group that received the structural animal health intervention was shown to have declined over the entire study period. Leveraging Social and Behavioral Interventions to Achieve Appropriate Antibiotic Prescribing Practices in Health Care Linder opened by arguing that improved diagnostics will not resolve the problem of inappropriate antibiotic use in human health.
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From page 56... ...
. He reported that for ambulatory visits, there are 506 antibiotic prescriptions per 1,000 people in the United States; at least 30 percent of overall antibiotic prescribing is unnecessary and half of the antibiotics prescribed for acute respiratory infections are unnecessary (Fleming-Dutra et al., 2016)
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From page 57... ...
. He noted that this effect was replicated by athenahealth, in a study that found the antibiotic prescribing rate for acute respiratory infections increased over the course of the day as the number of appointments accrued (see Figure 4-1)
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From page 58... ...
The third intervention -- peer comparison -- involves a different form of social motivation, he explained. Everyone receives a monthly email that stratifies clinicians into top performers with the lowest inappropriate antibiotic prescribing rate, and non-top-performers (all others)
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From page 59... ...
In summary, Linder noted that these studies suggest that doctors' behaviors are influenced by social factors so insights from social and behavioral sciences can facilitate the development of interventions to influence doctors' prescribing behavior for acute respiratory infections. The Role of Academic Veterinary Medicine in Combating Antimicrobial Resistance Maccabe described initiatives to combat antimicrobial resistance by AAVMC, an association of all veterinary medical colleges in Canada and the United States, as well as colleges of veterinary medicine worldwide, facilitating an international approach with a global footprint.
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From page 60... ...
Definition Define antimicrobial drug stewardship Societal Recognize that there Recognize that there Describe specific resource is increasing societal is increasing societal examples of resistance concern about concern about in pathogenic and bacterial resistance bacterial resistance nonpathogenic bacteria to antimicrobials to antimicrobials that are commonly and potential and potential found in a specific reduction or loss of reduction or loss animal species and effectiveness of effectiveness. in important human Cite examples pathogens of antimicrobial stewardship that might be helpful
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From page 61... ...
students) Definition Define antimicrobial drug stewardship Common Identify common Recognize that Distinguish common or uses of situations in which there are common important situations in antimicrobial antimicrobials are situations in which which antimicrobials drugs needed to address antimicrobials are are needed to address animal health and needed to address animal health and welfare and minimize animal health welfare and minimize suffering and welfare and suffering and those in minimize suffering which antimicrobial and those in which drugs will not make a antimicrobial drugs difference will not make a difference Complexity Recognize that Recognize that Describe the of bacterial infectious diseases infectious diseases epidemiology and infections can be caused can be caused pathogenesis of the by a variety of by a variety of most common and microorganisms, and microorganisms, the most significant that disease risks can and describe bacterial disease vary among different how disease risks challenges in major animals can vary among domestic species of different animals animals; describe the organism or patient factors that may effect treatment options Need for Recognize that there Recognize that Explain to animal antimicrobial may be a need to there is a need to owner or manager why drugs use antimicrobial use antimicrobial an antimicrobial drug is drugs in cases of drugs in cases of or is not recommended infectious disease infectious disease based on the perceived where subsequent where subsequent need and benefit to health and life or health and life or the animal, including lives of animals are lives of animals are differentiating an threatened threatened, and infection requiring understand that treatment and a antimicrobial drugs contaminant not may not be required requiring treatment NOTE: 4-H = U.S.
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From page 62... ...
Maccabe explained that the Antimicrobial Resistance Learning Site is a project that provides open-source teaching modules for instructors in veterinary medical education on antimicrobial resistance with modules in pharmacology, microbiology, public health, and species-specific medicine.14 According to Maccabe, the AAVMC's education and outreach efforts also involve developing key messages and communication strategies for engaging decision makers at all levels. Informational materials will be made available to producers and veterinarians (e.g., FDA VFD guidance, disease prevention strategies, and antimicrobial stewardship)
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From page 63... ...
The complexity of clinical decision making will only continue to accelerate, said Kirch, while human cognitive capacity remains static. Unlike decades ago, he said, a single clinician can no longer accumulate all the relevant knowledge required to make clinical decisions.
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From page 64... ...
The Path to Mastery in Addressing Antimicrobial Resistance Practice-based learning and communication are particularly relevant to mastery in antibiotic stewardship, Kirch said. He offered a sketch of a four-step pathway to mastery in addressing antimicrobial resistance.
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From page 65... ...
After looking at the difference between people who did and did not enroll in the trial, he found that the people who enrolled had a lower baseline antibiotic prescribing rate than those that did not. Linder said that this set the bar higher for the interventions that they tested, as well as highlighting the need to engage people who are not prescribing well and may be aware that they are not.
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From page 66... ...
Medical societies in the United States have developed specialty-specific consensus lists consisting of five practices that reflect overutilization or misutilization of diagnostic tests and treatments. He said that many of the lists include inappropriate antibiotic prescribing.
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From page 67... ...
. They found that the intervention reduced inappropriate antibiotic prescribing by around 20 percent, he said.
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