A blog from the Centre for Research Ethics & Bioethics (CRB)

Tag: antibiotic resistance

Antimicrobial resistance: bringing the AMR community together

According to the WHO, antibiotic resistance is one of the biggest threats to global health, food security and development. Most of the disease burden is in the global south, but drug resistant infections can affect anyone, in any part of the world. Bacteria are always evolving, and antibiotic resistance is a natural process that develops through mutations. We can slow down the process by using antibiotics responsibly, but to save lives, we urgently need new antibiotics to fight the resistant bacteria that already today threaten our health.

There is a dilemma here: development of new antibiotics is a high-risk business, with very low return of investment, and big pharma is leaving the antibiotics field for precisely this reason. Responsible use of antibiotics means saving new drugs for the most severe cases. There are several initiatives filling the gap this creates. One example is the Innovative Medicines Initiative AMR Accelerator programme, with 9 projects working together to fill the pipeline with new antibiotics, and developing tools and infrastructures that can support antibiotics development.

Antimicrobial resistance (AMR) to antibiotics and other anti-infectives is a community problem. Managing it requires a community coming together to find solutions and work together to develop research infrastructures. For example, assessing the effectiveness of new antibiotics requires standardised high-quality infection models that can become available to projects, companies and research groups that are developing new antibacterial treatments. Recently, the AMR Accelerator COMBINE project announced a collaboration with some of the big players in the field: CARB-X, CAIRD, iiCON and Pharmacology Discovery Services. This kind of collaboration allows key actors to come together and share both expertise and data. The COMBINE project is developing a standardised protocol for an in vivo pneumonia model. It will become available to the scientific community, along with a bank of reference strains of Gram-negative bacteria that are clinically relevant, complete with a framework to bridge the gap between preclinical data and clinical outcomes based on mathematical modelling approaches.

The benefit of a standardised model is to support harmonisation. Ideally, data on how effective new antibiotic candidates are should be the same, regardless of the lab that performed the experiments. The point of the collaboration is to improve quality of the COMBINE pneumonia model. But who are they and what will they do? CARB-X (Combating Antibiotic-Resistant Bacteria Biopharmaceutical Accelerator) is a global non-profit partnership that supports early-stage antibacterial research and development. They will help validation of the pneumonia model. CAIRD (Center for Anti-Infective Research and Development) is working to advance anti-infective pharmacology. They are providing a benchmark by back-translation of clinical data. iiCON has a mission to accelerate and support the discovery and development of innovative new anti-infectives, diagnostics, and preventative products. They are supporting the mathematical modelling to ensure optimal dose selection. And finally, Pharmacology Discovery Services, a contract research organisation (CRO) working with preclinical antibacterial development, will supply efficacy data.

At the centre of this is the COMBINE project, which has a coordinating role in the AMR Accelerator: a cluster of public-private partnership projects funded by the Innovative Medicines Initiative (IMI). The AMR Accelerator brings together academia, pharma industry, patient organisations, non-profits and small and medium sized companies. The aim is to develop a robust pipeline of antibiotics and standardised tools that can be used by others in this community, to help in the fight against antimicrobial resistance.

In parallel, the effort to slow down antibiotic resistance continues. For example, Uppsala University coordinates the COMBINE project, and in 2016, the University founded the Uppsala Antibiotic Center, a multidisciplinary centre for research, education, innovation and awareness. The centre runs the AMR Studio podcast, showcasing some of the multidisciplinary research on antimicrobial resistance around the world. The University is also coordinating the ENABLE-2 antibacterial drug discovery platform funded by the Swedish Research Council, with an open call to support programmes in the early stages of discovery and development of new antibiotics.

Our own efforts at the Centre for Research Ethics & Bioethics are more focused on how we as individuals can help slow down the development of antibiotic resistance, and how we can assess the impact of how you frame antibiotic treatments when you ask patients about their preferences

Josepine Fernow

Written by…

Josepine Fernow, science communications project manager and coordinator at the Centre for Research Ethics & Bioethics, develops communications strategy for European research projects

Do you want to know more?

EurekAlert! News release: Collaboration to improve the quality of in vivo antibiotics testing, 14 November 2023 https://www.eurekalert.org/news-releases/1007971.

Ancillotti M, Nihlén Fahlquist J, Eriksson S, Individual moral responsibility for antibiotic resistance, Bioethics, 2022;36(1):3-9. https://doi.org/10.1111/bioe.12958

Smith IP, Ancillotti M, de Bekker-Grob EW, Veldwijk J. Does It Matter How You Ask? Assessing the Impact of Failure or Effectiveness Framing on Preferences for Antibiotic Treatments in a Discrete Choice Experiment. Patient Prefer Adherence. 2022;16:2921-2936. https://doi.org/10.2147/PPA.S365624

A shorter version of this post in Swedish

Approaching future issues

Attitudes, norms and values ​​that can influence antibiotic resistance

Human use of antibiotics creates an evolutionary pressure that drives the development of antibiotic-resistant bacteria. If antibiotics lose their effectiveness, simple infections can become life-threatening and it becomes more difficult to treat infections in hospitals in connection with surgical interventions or other treatments. We should therefore reduce the use of antibiotics and use them more wisely.

Greece is at the top among European countries when it comes to antibiotics consumption. Nevertheless, studies have shown that Greeks are aware of the connection between the overuse of antibiotics and antibiotic resistance. It is not as surprising as it may sound. Other research shows that information alone is not enough to change people’s behaviour.

Since ignorance about the problem cannot explain the overuse of antibiotics in Greece, other factors should be investigated. In an article in BMC Public Health, Dimitrios Papadimou, Erik Malmqvist and Mirko Ancillotti present an interview study (focus groups) in which other possible explanations were examined, such as attitudes, norms and values ​​among Greeks.

The Greek participants saw overconsumption of antibiotics as an entrenched habit in Greece. It is easy to get access to antibiotics, they are often used without a doctor’s prescription, sometimes even as a precaution. In addition, doctors frequently prescribe antibiotics as a reliable remedy, participants said. Although critical of this Greek pattern of antibiotic consumption, participants considered it morally questionable to restrict individual access to potentially beneficial antibiotic treatments in the name of the greater good. Nor did they want to place the responsibility for handling antibiotic resistance on the individual. The whole of society must take responsibility, it was argued, perhaps above all government actors, healthcare staff and food producers. Finally, participants expressed doubts about the possibility of effectively managing antibiotic resistance in Greece.

There certainly seem to be more factors than limited awareness of the problem behind the overuse of antibiotics in Greece (and in other countries). If you would like more details and discussion, read the study here: Socio-cultural determinants of antibiotic resistance: a qualitative study of Greeks’ attitudes, perceptions and values

Hopefully, the study motivates future quantitative investigations of attitudes, norms and values, with more participants. Changing the use of antibiotics is probably like changing the course of a huge ship. Simply being aware of the necessary change is not enough.

Pär Segerdahl

Written by…

Pär Segerdahl, Associate Professor at the Centre for Research Ethics & Bioethics and editor of the Ethics Blog.

Papadimou, D., Malmqvist, E. & Ancillotti, M. Socio-cultural determinants of antibiotic resistance: a qualitative study of Greeks’ attitudes, perceptions and values. BMC Public Health 22, 1439 (2022). https://doi.org/10.1186/s12889-022-13855-w

This post in Swedish

Approaching future issues

Can consumers help counteract antimicrobial resistance?

Antimicrobial resistance (AMR) occurs when microorganisms (bacteria and viruses, etc.) survive treatments with antimicrobial drugs, such as antibiotics. However, the problem is not only caused by unwise use of such drugs on humans. Such drugs are also used on a large scale in animals in food production, which is a significant cause of AMR.

In an article in the journal Frontiers in Sustainable Food Systems, Mirko Ancillotti and three co-authors discuss the possibility that food consumers can contribute to counteracting AMR. This is a specific possibility that they argue is often overlooked when addressing the general public.

A difficulty that arises when AMR needs to be handled by several actors, such as authorities, food producers, consumers and retailers, is that the actors transfer the responsibility to the others. Consumers can claim that they would buy antibiotic-smart goods if they were offered in stores, while retailers can claim that they would sell such goods if consumers demanded them. Both parties can also blame how, for example, the market or legislation governs them. Another problem is that if one actor, for example the authorities, takes great responsibility, other actors feel less or no responsibility.

The authors of the article propose that one way out of the difficulty could be to influence consumers to take individual responsibility for AMR. Mirko Ancillotti has previously found evidence that people care about antibiotic resistance. Perhaps a combination of social pressure and empowerment could engage consumers to individually act more wisely from an AMR perspective?

The authors make comparisons with the climate movement and suggest digital innovations in stores and online, which can inform, exert pressure and support AMR-smarter food choices. One example could be apps that help consumers see their purchasing pattern, suggest product alternatives, and inform about what is gained from an AMR perspective by choosing the alternative.

Read the article with its constructive proposal to engage consumers against antimicrobial resistance: The Status Quo Problem and the Role of Consumers Against Antimicrobial Resistance.

Pär Segerdahl

Written by…

Pär Segerdahl, Associate Professor at the Centre for Research Ethics & Bioethics and editor of the Ethics Blog.

Ancillotti, Mirko; Nilsson, Elin; Nordvall, Anna-Carin; Oljans, Emma. The Status Quo Problem and the Role of Consumers Against Antimicrobial Resistance. Frontiers in Sustainable Food Systems, 2022.

This post in Swedish

Approaching future issues

Our individual responsibility for antibiotic resistance

Antibiotic resistance is a global threat to public health, as the chances of treating infections decrease when antibiotics lose their effect on bacterial growth. But who is responsible for antibiotic resistance and what is the responsibility?

We may believe that the problem is too big and complex for us as individuals. Antibiotic resistance is a problem for governments and international organizations, we think. Nevertheless, it is not least our individual use of antibiotics that drives the development. For example, we may take antibiotics when it is not really necessary, or perhaps we do not follow the doctor’s prescription but discontinue the antibiotic treatment prematurely and throw leftover pills in the dustbin. Then we go on a journey and spread bacteria that are resistant to the antibiotic that we did not use properly. Or we ignore getting vaccinated because we think that there are antibiotics if we get sick. Well, maybe not for long!

If we have an individual moral responsibility to act with awareness of environmental problems, then it is not unreasonable to think that we also have a responsibility to act with awareness of the antibiotic problem. Mirko Ancillotti (who recently defended his dissertation at CRB) examines this possibility in an article in Bioethics. Do we have an individual moral responsibility for antibiotic resistance and how should the responsibility be understood?

Mirko Ancillotti immediately points out that not all people have the same opportunities to improve their antibiotic behaviour. Apart from the fact that many people lack information about antibiotic resistance, not everyone finds it as easy to change their antibiotic use. Some have less access than others to correctly prescribed treatments, for example, if they live far from a hospital but can easily buy antibiotics without a prescription. In addition, not everyone has the same financial means to stay at home if they are ill.

Another thing that makes it difficult to talk about individual responsibility for antibiotic resistance, is that you can hardly determine how much the pills you threw in the dustbin actually contributed to the problem. We know that people die due to antibiotic resistant bacteria, but it is difficult to determine the consequences of your particular antibiotic behaviour.

For these reasons, Mirko Ancillotti proposes a virtue ethical concept of responsibility. He suggests that we as individuals cultivate personal qualities and habits, which support responsible antibiotic use as a virtue. If I understand him, this means cultivating certain norms about antibiotics use, which we try to meet, such as following the doctor’s prescription, not using antibiotics unless necessary, not persuading the doctor to prescribe antibiotics, and making sure that we are vaccinated. However, since the conditions for acting with this normative sensitivity vary with human circumstances, there is in many cases a need to improve the conditions and institutional support for responsible antibiotic use.

A comparison: We have learned that we should preferably not travel by air, that it is irresponsible and perhaps even shameful to fly if it is not necessary. To be able to meet this new norm, new societal conditions are needed in the form of better international train connections and simpler ticketing systems. In the same way, new normative sensitivities regarding antibiotics can be developed, simultaneously with improving the opportunities for meeting the norms, Mirko Ancillotti suggests.

If you want to read more about Mirko Ancillotti’s virtue ethical concept of an individual responsibility for antibiotic resistance, read the article in Bioethics: Individual moral responsibility for antibiotic resistance.

Pär Segerdahl

Written by…

Pär Segerdahl, Associate Professor at the Centre for Research Ethics & Bioethics and editor of the Ethics Blog.

Ancillotti, M., Nihlén Fahlquist, J., & Eriksson, S. (2021). Individual moral responsibility for antibiotic resistance. Bioethics, 1– 7. https://doi.org/10.1111/bioe.12958

This post in Swedish

We like real-life ethics

Two new dissertations!

Two of our doctoral students at CRB recently successfully defended their dissertations. Both dissertations reflect a trend in bioethics from purely theoretical studies to also include empirical studies of people’s perceptions of bioethical issues.

Åsa Grauman’s dissertation explores the public’s view of risk information about cardiovascular disease. The risk of cardiovascular disease depends on many factors, both lifestyle and heredity influence the risk. Many find it difficult to understand such risk information and many underestimate their risk, while others worry unnecessarily. For risk information to make sense to people, it must be designed so that recipients can benefit from it in practice. That requires knowing more about their perspective on risk, how health information affects them, and what they think is important and unimportant when it comes to risk information about cardiovascular disease. One of Åsa Grauman’s conclusions from her studies of these issues is that people often estimate their risk on the basis of self-assessed health and family history. As this can lead to the risk being underestimated, she argues that health examinations are important which can nuance individuals’ risk assessments and draw their attention to risk factors that they themselves can influence.

If you want more conclusions and see the studies behind them, read Åsa Grauman’s dissertation: The publics’ perspective on cardiovascular risk information: Implications for practice.

Mirko Ancillotti’s dissertation explores the Swedish public’s view of antibiotic resistance and our responsibility to reduce its prevalence. The rise of antibiotic-resistant bacteria is one of the major global threats to public health. The increase is related to our often careless overuse of antibiotics in society. The problem needs to be addressed both nationally and internationally, both collectively and individually. Mirko Ancillotti focuses on our individual responsibility for antibiotic resistance. He examines how such a responsibility can be supported through more effective health communication and improved institutional conditions that can help people to use antibiotics more judiciously. Such support requires knowledge of the public’s beliefs, values ​​and preferences regarding antibiotics, which may affect their willingness and ability to take responsibility for their own use of antibiotics. One of the studies in the dissertation indicates that people are prepared to make significant sacrifices to reduce their contribution to antibiotic resistance.

If you want to know more about the Swedish public’s view of antibiotic resistance and the possibility of supporting judicious behaviour, read Mirko Ancillotti’s dissertation: Antibiotic Resistance: A Multimethod Investigation of Individual Responsibility and Behaviour.

Pär Segerdahl

Written by…

Pär Segerdahl, Associate Professor at the Centre for Research Ethics & Bioethics and editor of the Ethics Blog.

Åsa Grauman. 2021. The publics’ perspective on cardiovascular risk information: Implications for practice. Uppsala: Acta Universitatis Upsaliensis.

Mirko Ancillotti. 2021. Antibiotic Resistance: A Multimethod Investigation of Individual Responsibility and Behaviour. Uppsala: Acta Universitatis Upsaliensis.

This post in Swedish

Ethics needs empirical input

People care about antibiotic resistance

The rise of antibiotic-resistant bacteria is a global threat to public health. In Europe alone, antibiotic resistance (AR) causes around 33,000 deaths each year and burdens healthcare costs by around € 1.5 billion. What then causes AR? Mainly our misuse and overuse of antibiotics. Therefore, in order to reduce AR, we must reduce the use of antibiotics.

Several factors drive the prescribing of antibiotics. Patients can contribute to increased prescriptions by expecting antibiotics when they visit the physician. Physicians, in turn, can contribute by assuming that their patients expect antibiotics.

In an article in the International Journal of Antimicrobial Agents, Mirko Ancillotti from CRB presents what might be the first study of its kind on the public’s attitude to AR when choosing between antibiotic treatments. In a so-called Discrete Choice Experiment, participants from the Swedish public were asked to choose between two treatments. The choice situation was repeated several times while five attributes of the treatments varied: (1) the treatment’s contribution to AR, (2) cost, (3) risk of side effects, (4) risk of failed treatment effect, and (5) treatment duration. In this way, one got an idea of ​​which attributes drive the use of antibiotics. One also got an idea of ​​how much people care about AR when choosing antibiotics, relative to other attributes of the treatments.

It turned out that all five attributes influenced the participants’ choice of treatment. It also turned out that for the majority, AR was the most important attribute. People thus care about AR and are willing to pay more to get a treatment that causes less antibiotic resistance. (Note that participants were informed that antibiotic resistance is a collective threat rather than a problem for the individual.)

Because people care about antibiotic resistance when given the opportunity to consider it, Mirko Ancillotti suggests that a path to reducing antibiotic use may be better information in healthcare and other contexts, emphasizing our individual responsibility for the collective threat. People who understand their responsibility for AR may be less pushy when they see a physician. This can also influence physicians to change their assumptions about patients’ expectations regarding antibiotics.

Pär Segerdahl

Written by…

Pär Segerdahl, Associate Professor at the Centre for Research Ethics & Bioethics and editor of the Ethics Blog.

M. Ancillotti, S. Eriksson, D.I. Andersson, T. Godskesen, J. Nihlén Fahlquist, J. Veldwijk, Preferences regarding antibiotic treatment and the role of antibiotic resistance: A discrete choice experiment, International Journal of Antimicrobial Agents, Volume 56, Issue 6, 2020. doi.org/10.1016/j.ijantimicag.2020.106198

This post in Swedish

Exploring preferences