What can science and policy do to tackle AMR?

Tracking and tackling antibiotic resistance requires a joined-up global effort, and new scientific innovations to help us to stay one step ahead. Colin Brown is an infectious disease clinician at the UK Health Security Agency, and a leading expert on AMR. What does he think we need to be prioritising?

Colin - So I think there are multiple areas where science can help. Number one is new drugs. As the drugs we have cease to be effective, we need new drugs to replace them that are effective. And we in the UK have a scheme to try and incentivise drug companies - often referred to as the "Netflix model" - whereby we pay a subscription fee, as it were, for companies. Regardless of whether we watch something once or watch it a million times, or whether we use the drug once or use it a million times, we give them the same price point. That is because antibiotics have very - unfortunately -  poor investment potential, because once we have a new antibiotic, we don’t want to use it widely - we want to restrict it for cases where it’s absolutely necessary.

And that is not a very attractive prospect if you're trying to develop a drug, whereas you could be investing money, for example, in a new anti-cancer drug, or a new heart drug, or a new weight loss drug that you might be able to give to lots and lots and lots of different people, as much as possible. We also really need to understand best where resistance is developing and where it’s being transmitted. We know that as people get exposed to antibiotics, resistance will develop, but that happens also in the environment. It happens in animals that we eat or interact with.

And trying to ascertain where do you get the best bang for buck in prevention efforts? Is it about screening people so that you pick up drug resistance early in healthcare settings, and you prevent it transmitting from one patient to another patient to another patient? Is it about better drug awareness and people only taking if they definitely need them as prescribed, and perhaps investing more in diagnostic tools that really help us to find where the best use of antibiotics is only in those people that really need them? So there’s a variety of different things that we need to do. Some artificial intelligence will definitely help us with; a lot of modelling and looking at where of all the different interventions we could do, we will get that best bang for buck. And some of it is about what's coming down the line and how do we invest in new antimicrobials so we have new antibiotics when we need them?

Chris - This is arguably a big problem in hospitals. Once you get people into hospital, because of the close contact - just as we were hearing earlier in the programme in Niger - when kids come into hospital, close contact means they’re more likely to acquire these things. So are we also looking at the behaviours of hospitals, how we manage patients, how we manage staff, to minimise the opportunity for these bugs to spread among patients and staff?

Colin - Most definitely. Infection prevention and control efforts in hospitals are key to preventing that spread. People have large amounts of bacteria that have been exposed to very broad-spectrum antibiotics that are sort of blunderbusses that treat all manner of both infections and normal bacteria. There’s lots of patients who are very unwell, who don’t have control over their bowel movements. There's lots of potential routes whereby there's both the resistant antibiotics and the means of them spreading around.

In places like Niger, it’s all the more difficult because they also don't have the water and sanitation and hygiene practices we often take for granted in the UK. One big aspect is helping hospitals with their infection prevention and control, and some of that is modelling work and identifying what is it about practice that is likely to interrupt the spread? Is it screening people and isolating them if they carry resistant bacteria? Is it hand hygiene - which we know throughout the world we could improve on? Is it around patients meeting each other in different areas of the wards and interacting and spreading bacteria that way? Is it the cleaning of toilets, showers, and washrooms? For example, we're trying to look at: can we do with waterless toilets and waterless sinks to try and prevent splash of bacteria that may transmit from person to person? So at every stage of that, there is a range of different science advances.

Chris - This is arguably a global problem, and global problems need global solutions. Is everybody everywhere on the same page with this, or do we have a fragmented landscape? No joined-up thinking and therefore - because the weakest link in the chain is always the place it's going to break - as soon as one bit breaks down, we’ve got a problem and it’s a problem everywhere.

Colin - I think everyone is broadly on the same page for what we want to do. There clearly is a difference in resources. The UK has provided significant assistance to many countries and continues to do so through things like GAMRIF - the Global Antimicrobial Resistance Innovation Fund. We work closely with countries as part of the UK Health Security Agency, particularly in Nigeria, Ethiopia, and Zambia, do a range of development work, which does include antimicrobial resistance. And we do the same also in the Caribbean with some of our UK overseas territories. There are lots of countries that want to be doing really good work here, but they have multiple challenges facing their health systems, of which AMR is only one.

And there are some basics that are difficult to access, for example, clean water. They also have less in the way of access to novel drug agents to be able to help where there are resistant bacteria to treat. So there are a wide number of problems that parts of the world face. So in that way, it is a global effort. A lot of the work that we are doing as an organisation has direct relevance to any setting.

So, where best to invest your money? How do you best prevent transmission of resistance once it develops, and prevent the development of resistances either in people, animals, or the environment? All of that has got real global applicability once we identify some of the key learning. So in that way, the work that we are doing really is trying to help the globe. But we do need to recognise this is an interconnected problem, and that if a part of the world that we see regular travel from or regular healthcare from has got a problem, then all too soon we will have a problem.  That fits in with some of the screening recommendations that we recommend nationally, whereby if we know people are coming from areas where there is more antimicrobial resistance, we do recommend that particularly if they've been exposed to healthcare environments there, they get screened.