Educating Medical Students on Antimicrobial Resistance

For World Antibiotic Awareness Week, PLOS ONE Academic Editor Dr. Pathiyil Ravi Shankar discussed his perspective on this year’s theme, “Preventing antimicrobial resistance together“.

---

Dr. P Ravi Shankar is a faculty member at the International Kuala Lumpur, Malaysia. He has 772 publications in various national and international journals. He was among the top 2% of scientists globally for the years 2019, 2020, 2021 and 2022. He has reviewed over 860 research papers for various journals. He is a member of the TLM Global Counterspace program and of the ORCID Research Advisory Council (ORAC). He is a member of the World Association of Medical Editors (WAME). He is an academic editor of PLOS ONE and an editorial board member of the Journal of Asthma and Allergy. He has been involved in teaching rational use of medicine to health science students for over two decades. His areas of research interest are the health humanities, rational use of medicines, pharmacovigilance, and small group learning among others. He enjoys traveling and is a creative writer and photographer.

---

Antibiotics have brought about a revolution in human health. Infections that were once untreatable can today be treated easily. These medicines have saved millions of human lives. The threat of antibiotic or antimicrobial resistance has been associated with antibiotics from the very beginning. Within a few years of their introduction, bacteria became resistant to sulfonamides (a group of antibiotics). Antimicrobial resistance (AMR) is a global health and development threat and is included among the top ten threats facing humanity [1]. Overuse and misuse of antibiotics are key factors promoting AMR. AMR can take us back to an era without effective antibiotics and place the foundations of modern medicine at risk.

AMR may be inevitable and can only be slowed down through proper and judicious use of antimicrobials. Each time we use an antimicrobial we are exerting selective pressure on microorganisms. Susceptible organisms are destroyed, providing space and resources for resistant strains of microbes to multiply and thrive. Eventually, the resistant organisms will become dominant. Microbes also have a variety of mechanisms to transmit the acquired resistance among themselves. AMR occurs when microbes can adapt and grow in the presence of medicines that once impacted them [2]. Misuse and overuse of antibiotics, increase in income levels, easier global and domestic travel, and gaps in our knowledge about AMR may all be responsible [3].       

Cost of AMR

AMR has a huge cost in terms of illness and productivity. In the United States (US) the cost estimated by the Centers for Disease Control and Prevention (CDC) was USD 55 billion. Multidrug-resistant (MDR) TB could cost the world USD 16.1 trillion by 2050 [4]. Less privileged nations and individuals may bear a disproportionate amount of the burden. AMR will significantly impact global trade and livestock production, especially in low and middle-income countries. A recently published systematic analysis mentions an estimated 4.95 million deaths may have been associated with AMR in 2019 and the highest impact was in sub-Saharan Africa [5].

Pharmacists play an important role in delivering healthcare and properly trained pharmacists can be part of the solution to combat the global problem of AMR [6]. The World Health Organization’s (WHO) global action plan on AMR highlights avoiding overuse and misuse of antibiotics (requiring healthcare professionals’ awareness and understanding of AMR through effective communication, education, and training) [7]. Comprehensive training and education on antibiotics and AMR are important for pharmacists to play an important role in combating AMR. The Organization for Economic Cooperation and Development (OECD) estimates that investing as little as US$2 per person per year could avoid 75% of deaths caused by infections from resistant microorganisms. The report mentions five simple measures to reduce resistance: better hygiene, fewer antibiotic prescriptions, rapid testing to distinguish bacterial from viral infections, delayed antibiotic prescriptions, and educating the public through media campaigns [8].

Educating medical students about AMR

Medical students, residents, and fellows should be aware of AMR and the serious threat it poses to human health. In many countries, students learn about antimicrobials and AMR during the basic sciences phase of the undergraduate medical course. Using newer antimicrobials that are more expensive may be incentivized. A recent article mentions a possible misalignment of incentives between the government and healthcare organizations on the one hand and the pharmaceutical industry on the other [9]. Governments and healthcare organizations are incentivized to restrict and promote the rational use of antibiotics while the industry is incentivized to promote sales and boost profit. Realigning bonuses to maintain the susceptibility of antibiotics over time can be considered. Though the situation is changing, Medicine and Therapeutics Committees and Antimicrobial Stewardship are still absent in many hospitals, especially in developing nations. The use of antimicrobials in hospitals and other settings may be inappropriate as shown by several studies. Newer antibiotics are expensive and may be aggressively promoted and prescribed and their overuse and misuse can lead to AMR. To combat this issue,  we need to provide training in clinical pharmacology during the clinical years and residency for medical students . Clinician educators should act as role models for the appropriate use of antimicrobials. Medical students should be aware of the proper use of antimicrobials and learn how to investigate medicine use in different settings, as well as stewardship.

Challenges faced in using antimicrobials rationally

We are slowly realizing that there should be a balance of consideration of profit and of the greater good. AMR is a problem that affects  anyone including the top executives of pharmaceutical companies and preserving the power of antimicrobials may be in everyone’s best interest.

While medical students have a broad understanding of AMR and its implications, lack of appropriate role-modeling by clinicians and inappropriate use of antibiotics in clinical facilities can influence their future prescribing behavior. A study in the United Kingdom found that foundation-year doctors made complex antibiotic-prescribing decisions. They mentioned workplace cultures often failed to promote learning and feedback and that hierarchy sometimes worked against rational antimicrobial prescribing [10]. In surgery, a study found that the responsibility for antimicrobial decision-making is uncoordinated and diffuse with it being often delegated to junior team members [11].

A challenge is the amount of money spent on developing newer antimicrobials and the high probability that these will be kept in reserve for treating resistant infections. Pharmaceutical companies would like the newly developed antimicrobials to be used widely while governments and public health experts would like to restrict their use to resistant infections. The lack of suitable financial reward is one of the reasons why newer antimicrobials are not being developed. A recent article proposes alternative models to finance antibiotic development including substantial investment by government and not-for-profit agencies [12].  

Effective strategies in promoting rational use of antimicrobials among the next generation of doctors

Rational use of antimicrobials should be introduced during the basic science years and should continue to be promoted by clinicians during the clinical years of study. Serious games have been used to teach medical students about antibiotics [13]. Antibiogame is based on gamification techniques and cartoon graphics and seems a promising strategy to educate students. This can easily be included in multifaceted training [13]. Games have been used among different segments of the population including students, healthcare workers, and the general public [14]. Teaching hospitals have a responsibility to use medicines rationally and should have regulatory and other mechanisms including a medicine and therapeutics committee, infection control committee, a well-regulated hospital pharmacy, academic detailing, regulated pharmaceutical promotion, and antimicrobial stewardship. Role modeling by clinical teachers is important.  

Combating antimicrobial resistance requires teamwork and collaboration among a multitude of stakeholders including governments, healthcare professionals, the media, pharmaceutical industry, research scientists, patients and caregivers. In this article, we focused on medical students who will be future prescribers. They must work in concert with different stakeholders as mentioned. Preserving the power of antimicrobials is vital to ensure the continued growth, prosperity, and safety of future generations.

---

References

1. World Health Organization. Antibiotic Resistance. 2020 [cited 2023 Oct 9]. Available from: https://www.who.int/news-room/fact-sheets/detail/antibiotic-resistance

2. Founou RC, Founou LL, Essack SY. Clinical and economic impact of antibiotic resistance in developing countries: a systematic review and meta-analysis. PLoS One. 2017;12: e0189621.

3. Dadgostar P. Antimicrobial resistance: implications and costs. Infect Drug Resist. 2019;12: 3903-3910.

4. Drug-resistant tuberculosis: worth the investment why drug-resistant tuberculosis? n.d. [cited 2023 Oct 9]. Available from: https://www.eiu.com/graphics/market ing/pdf/Drug-resistant-tuberculosis-Article.pdf .

5. Murray CJ, Ikuta KS, Sharara F, Swetschinski L, Aguilar GR, Gray A, et al. Global burden of bacterial antimicrobial resistance in 2019: a systematic analysis. The Lancet. 2022;399(10325): 629-655.

6. Sakeena MH, Bennett AA, McLachlan AJ. Enhancing pharmacists’ role in developing countries to overcome the challenge of antimicrobial resistance: a narrative review. Antimicrob Resist Infect Control. 2018;7: 63.

7. WHO. Global action plan on antimicrobial resistance. 2015 [cited 2023 Oct 9]; Available from: http://apps.who.int/iris/bitstream/10665/193736/1/ 9789241509763_eng.pdf?ua=1   

8. Hofer, U. The cost of antimicrobial resistance. Nat Rev Microbiol. 2019;17: 3 doi: 10.1038/s41579-018-0125-x

9. Morel CM, Lindahl O, Harbarth S, de Kraker ME, Edwards S, Hollis A. Industry incentives and antibiotic resistance: an introduction to the antibiotic susceptibility bonus. J Antibiot (Tokyo). 2020;73(7): 421-428.

10.  Mattick K, Kelly N, Rees C. A window into the lives of junior doctors: narrative interviews exploring antimicrobial prescribing experiences. J Antimicrob Chemother. 2014;69(8): 2274-2283.

11.  Charani E, Tarrant C, Moorthy K, Sevdalis N, Brennan L, Holmes AH. Understanding antibiotic decision making in surgery—a qualitative analysis. Clin Microbiol Infect. 2017;23(10): 752-760.

12.  Klug DM, Idiris FI, Blaskovich MA, von Delft F, Dowson CG, Kirchhelle C, et al. There is no market for new antibiotics: this allows an open approach to research and development. Wellcome Open Res. 2021;6: 146.

13.  Tsopra R, Courtine M, Sedki K, Eap D, Cabal M, Cohen S, et al. AntibioGame®: A serious game for teaching medical students about antibiotic use. Int J Med Inform. 2020;136: 104074.14.  Molnar A, Molnar I. Learning Theories in Games That Teach Responsible Antibiotic Use: A Literature Review. Sustainability. 2023;15(5): 4643.

14. Molnar A, Molnar I. Learning Theories in Games That Teach Responsible Antibiotic Use: A Literature Review. Sustainability. 2023;15(5): 4643.

---

Disclaimer: Views expressed by contributors are solely those of individual contributors, and not necessarily those of PLOS.