Fighting Superbugs: Can Social Science Win the Battle Against Antibiotic Resistance?
"Discover how behavioral insights are key to changing prescribing habits and slowing the rise of antimicrobial resistance."
The rise of antibiotic-resistant bacteria poses a significant threat to global health. While new drugs are part of the solution, changing human behavior—specifically how antibiotics are prescribed and used—is crucial. This means reducing unnecessary antibiotic use and preventing infections in the first place.
Current strategies to improve antibiotic prescribing, known as antimicrobial stewardship programs (ASPs), often fall short. While there's plenty of evidence that ASPs can be effective, many don't adequately consider the social and behavioral factors that influence prescribing decisions. This is where the social and behavioral sciences can make a real difference.
By understanding the 'why' behind prescribing behaviors, we can design more effective and sustainable interventions. This article explores how insights from these fields can be applied to improve ASPs, focusing on defining the problem, using theory-driven design, ensuring practical implementation, and maximizing learning from past efforts.
A Growing Global Burden
The CDC reports that more than 2.8 million antimicrobial-resistant infections occur each year in the United States. The World Health Organization reports that between 2018 and 2023, antibiotic resistance rose in over 40% of the pathogen-antibiotic combinations it monitored. Research published in The Lancet draws on 520 million individual records or isolates and 19,513 study-location-years to assess the global burden of bacterial antimicrobial resistance.
Stewardship and Testing
Antibiotic stewardship seeks to measure and improve how antibiotics are prescribed by clinicians and used by patients. Its central challenge is that the antimicrobial effect that saves lives also exerts selective pressure on replicating bacteria, contributing to the emergence of drug resistance. Antimicrobial susceptibility testing remains an important part of treatment decisions, but a review of common testing methods emphasizes that each method has distinct advantages and disadvantages.
From Penicillin to Stewardship
Recognition of antibiotic resistance began shortly after penicillin entered widespread use in the 1940s. The term “stewardship” was first used in relation to antibiotic use in a 1996 article in New Horizons. Modern accounts describe antimicrobial resistance as an evolutionary arms race that has challenged infectious-disease treatment since the discovery of the first modern antimicrobials.
Why 'What' and 'Whose' Matter: Getting Specific About the Problem
Many interventions aimed at changing healthcare professionals' behavior are designed without a clear understanding of what drives those behaviors in the first place. Instead of relying on assumptions or 'best guesses,' the social and behavioral sciences emphasize the importance of a thorough 'behavioral diagnosis.'
- Who: Is it surgeons, general practitioners, or nurses whose behavior needs to change?
- What: Are you targeting the decision to prescribe, the choice of antibiotic, the duration of treatment, or something else?
- Where: Is the focus the hospital, primary care clinic, or long-term care facility?
- When: Does the issue arise during initial assessment, during treatment, or at discharge?
- Whom: Which type of patients does this behavior affect?
Stewardship Shows Measurable Effects
Recent reviews identify new antimicrobial drugs, alternative therapies, surveillance, and diagnostics as important elements in responding to antibiotic resistance. The CDC defines stewardship as ensuring that antibiotics are prescribed and used when they provide a clear health benefit. A 2023 study reported that antimicrobial stewardship programs were associated with a 19% reduction in total antibiotic consumption and a 27% reduction in use of restricted antimicrobial drugs.
Why Stewardship Can Fall Short
Inappropriate antibiotic use contributes to the emergence of antimicrobial resistance because antibiotic exposure creates pressure that favors resistant organisms. One review describes the failure to curb resistance rates as a multifactorial problem involving many members of the healthcare team and the acute-care setting. The resulting threat extends across an increasing range of infections caused by bacteria, parasites, viruses, and other pathogens.
Access, Alternatives, and Equity
In low- and middle-income countries, delayed or absent access to antibiotics remains a major danger; one review states that it still kills more people than antibiotic-resistant bacteria. Comparative strategies therefore include not only stewardship but also alternatives such as dressings without active antimicrobial ingredients, hydrogels, and DACC-coated dressings. Resistant infections can nevertheless be associated with a much higher risk of death, and survivors may experience lasting consequences.
Key Takeaways for Effective Antimicrobial Stewardship
The social and behavioral sciences offer valuable tools and frameworks for designing and implementing effective ASPs. By understanding the factors that influence prescribing behaviors, we can move beyond simple education and create interventions that address the complex realities of healthcare settings.
Stewardship Requires Expertise
Antimicrobial stewardship programs are presented as critical tools for improving antibiotic use and patient outcomes while combating antimicrobial resistance. Pharmacists play a central role in these programs by helping optimize antimicrobial use and improve outcomes. Their expertise also supports efforts to stop or delay the emergence of resistance.
Rising Demand for Antibiotics
One projection estimates that global antibiotic consumption will increase by 52.3%, rising from an estimated 49.3 billion defined daily doses in 2023 to 75.1 billion. This outlook makes stewardship and the development of alternatives increasingly important areas for future action. The projection is a forecast rather than a guaranteed outcome, so its scale depends on future patterns of antibiotic use.
A Problem Beyond Prescribing
Antibiotic resistance is unlikely to be solved by prescribing changes alone. The challenge involves interacting pressures across healthcare systems, access to treatment, professional practice, and everyday medicine use. A durable response will therefore require coordination across these settings, although the precise balance of interventions will vary by context.
Patients Behind the Statistics
Patient stories show that drug-resistant infections can become life-threatening and difficult to treat. The Infectious Diseases Society of America describes an experimental antibiotic saving a man's leg and life after an aggressive drug-resistant infection. Case studies profiled by The Pew Charitable Trust illustrate how healthcare facilities are using antibiotic stewardship programs in practice.
Here are some key recommendations:
<ul><li>Clearly define the problem in behavioral terms.</li><li>Conduct a 'behavioral diagnosis' to understand the factors influencing prescribing.</li><li>Match intervention strategies to the specific behavioral diagnosis.</li><li>Consider the broader social and environmental context.</li><li>Draw on evidence from the broader behavior change literature.</li><li>Assess implementation and sustainability.</li><li>Describe and report interventions comprehensively.</li></ul>