Six Healths

5 min read March 6, 2018 at 12:00pm on Infection

I went to Brisbane recently, where I was asked to speak at Antimicrobials 2018 - the annual scientific meeting of the Australian Society for Antimicrobials. I've posted my presentation here. It will also be up on ASA's website soon.

I was given the not-at-all-broad topic of "2017: The year in antimicrobial therapy and resistance".  It was the third of three "year in review" talks, and after hearing the first two, I was feeling incredibly under-prepared. Sally Roberts and Kirsty Buising presented "here's 30 great papers I read last year" talks with what felt like hundreds of slides and thousands of references, while my talk was more of a helicopter view of what I'd seen as the big issues of the year. Feeling like you've got imposter syndrome for your first invited conference presentation is normal, right?

As well as presenting some of the data that I'd helped wrangle into the AURA 2017 report, I spent a bit of time speaking about one of my hobby-horses, which is how we communicate information about drug-resistant infection. 

The most recent AGAR report also launched around the time of the conference, and one of the headline findings was a significant increase in fluoroquinolone resistance in E. coli and Shigella sp. 

Whenever anybody talks about drug-resistance, it is immediately followed by one of the following questions:

  • Isn't that because there's too much antibiotic use in hospitals? (from GPs) 
  • Isn't that because there's too much antibiotic use in the community? (from hospital docs) 
  • Isn't that because there's unrestrained use in agriculture? (all human doctors and much of the public) 
  • It's nothing to do with us, it's because of human and animal use, right? (from farmers - just kidding, I've never been able to get an agriculturalist to come to one of my talks) 
  • It's because you can buy antibiotics over the counter in the developing world isn't it? (everybody in Australia) 
  • It's because patients demand antibiotics from their doctors. (doctors, not a question) 
  • It's because doctors give antibiotics to patients when they don't need them (other doctors, also not a question)
  • Antimicrobial resistance is a clinical management issue, so an infectious diseases problem (a significant number of public health physicians) 

For examples of many of these comments, see the replies to this article I wrote in 2012. 

And then this reply to the Commission tweeting about the resistance report (and especially this reply to Evan's reply). Nothing much changes over the years. 


This drives me absolutely insane and you can all get the hell in the bin. 


People a lot more familar with social science than me can tell you all about "othering" much better than I do. But that's exactly what all these people are doing.

"Resistance is predominantly caused by someone else, therefore I will keep doing exactly what I'm doing because I know better than you what works for my patients" 

In hospital, I hear this a lot - "my patients are special, therefore I shouldn't have to follow the antimicrobial guidelines". It's not particular to any one specialty. Renal, Paeds, ICU, Haematology, Diabetes. They're all special and "high risk of infection" (by high-risk, doctors mean "I don't need to follow the guidelines" rather than "I'm more likely to need to follow the guidelines", by the way).

It's exactly what the government does about climate change, and probably half a dozen other issues that I'm not as engaged with. - Irresponsibility
Irresponsibility - from - believed fair use

We all need to accept that we live in a connected world. Antimicrobial resistance occurs naturally, it is enhanced by antibiotic use - whether that be community practice, hospital practice, veterinary practice or agricultural practice. Global travel spreads resistance as well as influenza. I really would have thought that the concept of One Health had been around long enough that people would be familiar with it - particularly since it's already spawned an iteration including the ecologists - Planetary Health. Instead, we persist on living in our own little silo, throwing rocks at the terrible people over there who should know better, because of course General Practice is nothing like hospital medicine. Overseas is nothing like Australia, and veterinary medicine is nothing like human. Not One Health, but six. Or maybe more if you're a splitter, not a lumper.

There are quite a number of things we don't know - is it antibiotic volume (GP) or density (hospital) that is the most important factor in development of resistance?; what's the mechanism of increasing fluoroquinolone resistance despite our very low usage of these agents (yes, in hospital as well as the community).

Sure, it's terrible that companies put colistin in their animal feeds to boost yields, and that doctors give patients in [the health sector you don't work in] too many antibiotics. Although I hate airline industry metaphors in medicine, I think this is one thing that they have done well - move beyond individual blame to focus on the systems factors that contribute to error.

Rather than attacking the data because you don't like the message, or then moving on to blame those hopeless morons over there for dragging down the average on your "perfect" prescribing, perhaps the thing that will ensure your patients stay well into the future would be to realise that every little thing we all do can contribute to holding back the flood of drug-resistance.

Remember, also that the data is pretty even-handed in showing that we're all terrible - 25% of surgical prophylaxis continues for too long, 60% of patients presenting to GPs with URTIs get antibiotics and antibiotics are fed to animals measured in tonnes. Every prescription is contributing to the problem, regardless of how well-meaning.

This is part of the reason that I think behavioural science research of the sort done by Alex and Jennifer Broom (and others; CoI: including me, on one paper) is so important. We know what we're doing wrong, we know how we can improve it, but the implementation of better stewardship is going to hinge on how we can change attitudes and beliefs beyond just presenting walls of data and accepting that this will some how bring about change. In hospitals, we know that one of the keys to successful stewardship is building relationships between prescribers and stewards.

I've a feeling that shouting at each other on twitter is unlikely to be the answer.

Featured image:  Fragments by CarolSandra via Flikr - CC-BY-NC-2.0