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Stanford’s efforts to combat antibiotic resistance move to global stage

In this Q&A, Stanford physician-scientists Stanley Deresinski and Marisa Holubar explain why responsible use of antibiotics is so important worldwide.

The discovery of antibiotics like penicillin in the late 1920s revolutionized medicine, making surgeries safer and common bacterial infections less deadly. But the overuse and misuse of these life-saving drugs has evolved into a global public health emergency: many microorganisms naturally develop resistance to antibiotics over time, allowing for the emergence of "superbugs" that are no longer readily killed by available antibiotics.

After several years of working with the World Health Organization (WHO) to promote the safe and optimal use of antibiotics worldwide, the Stanford Antimicrobial Safety and Sustainability program (SASS) has been designated a WHO Collaborating Centre for Antimicrobial Resistance and Stewardship -- the first designation of its kind.

Leading this effort are Stanford physician-scientists Stanley Deresinski, MD, and Marisa Holubar, MD. I reached out to them to learn more.

What makes antimicrobial resistance a global public health emergency? 

Deresinski: Antibiotics are unlike other classes of drugs in that their very use guarantees their eventual obsolescence. As antibiotics lose their effectiveness, the treatment of infections becomes increasingly difficult and, in some cases, totally ineffective. As a consequence, there is concern that we are heading toward a post-antibiotic era -- effectively reverting to a time before the availability of these "wonder drugs." Without antibiotics, even a minor surgery could become life-threatening if ordinary antibiotics can't control infection.

Recent predictions forecast that antimicrobial resistant infections could cause 10 million deaths globally each year by 2050. This demands immediate and coordinated action to avert disaster. 

What does it mean to be a World Health Organization Collaborating Centre, and what will be Stanford's role specifically?

Holubar:  WHO Collaborating Centre designations recognize at least two years of productive collaboration between the institution and WHO, and continued excellence in the field. Specifically, we will provide technical support and guidance to the WHO to strengthen the capacity of nations to implement antimicrobial stewardship programs in clinical care. We will also continue to develop and refine educational curricula and programs designed to enhance the competency of antimicrobial prescribers. 

What led to your collaboration with the WHO?

Deresinski: After starting SASS in 2012, we developed a massive open online course, "Antimicrobial Stewardship: Improving Clinical Outcomes by Optimization of Antibiotic Practices," in which more than 30,000 students have enrolled. At the time our colleagues at WHO in Copenhagen were looking for such freely available educational material and contacted us. We have been working with them ever since. Most recently, we developed a course for WHO's educational website entitled "Antimicrobial Stewardship: A Competency Based Approach" which has enrolled over 21,000 since its release in January 2018. Other activities have included developing and implementing antimicrobial stewardship curriculum and participating in WHO missions in places such as Turkey, Armenia, Jordan and Uzbekistan.

What are the next steps?

Holubar: Optimizing the use of antimicrobials in resource-limited settings is complex and activities must be tailored to available resources. The complexity is illustrated by the fact that antibiotic overuse exists side-by-side with lack of access in some lower income countries. There is no "one-size-fits-all" solution.

For example, American stewardship programs typically are led by infectious disease physicians and pharmacists -- but health care workers with this kind of training are uncommon in some countries.  But that doesn't mean that stewardship can't be done.  We are interested in developing resources, including educational materials, to help member states get started with their available resources and formally assess their progress.

What are the most important steps that clinicians worldwide can take to begin reducing antimicrobial resistance?

Deresinski: To never consider antibiotic prescribing as routine, to always think carefully about its use and take into account the balance between possible benefit and harm -- not only to the individual patient but to subsequent patients because of the effect of antibiotics on the bacterial ecology -- the microbiome -- and emergence of resistance.

Is there anything non-clinicians can do to help?

Deresinski: Patients can learn the difference in symptoms between common viral infections, for which antibiotics provide no benefit, and more serious problems that may be due to bacterial infection. They should understand that antibiotics, although necessary in some circumstances, can also have harmful effects. 

Holubar: Patients are a critical partner in the fight against antimicrobial resistance and must educate themselves about the best ways to use antibiotics. In the outpatient settings, patient's real or perceived desire for antibiotics promotes the misuse of antibiotics. In addition, patients can avoid infections with hand washing and getting vaccinated. More information for families is available here:

What is the best possible outcome? In other words, what hope is there in stewardship?

Holubar: Stewardship is just one aspect of the fight against antimicrobial resistance. We also need new ways to prevent and fight infections, including new antibiotics. Using our current antibiotics wisely will help slow the emergence of resistance giving us time for new technologies to be developed and introduced in clinical practice. 

Deresinski: Dealing with this problem will be a constant ongoing struggle from which we can never retreat.

Photo of methicillin-resistant staphylococcus aureus and a white blood cell by NIAID

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