As World Antimicrobial Awareness Week 2022 winds down, I’ll touch on a statement that I’ve seen a lot over the past week. “We need to reduce misuse and overuse of antibiotics” or “Misuse and overuse of antibiotics are driving antimicrobial resistance (AMR).” Those are great sound bites but largely miss the mark.

Yes, misuse and overuse are problems, but that’s only part of the story.  Focusing on misuse and overuse alone can lead to overly simplistic and ineffective approaches to combating AMR.

Anytime an antimicrobial is used in people, animals or plants, there’s some degree of selection pressure and risk of further dissemination of AMR.  It doesn’t matter if we consider it to be overuse, misuse or appropriate use. It’s what happens to the bacteria that are exposed to the drug that matters.

  • Misuse is important because there’s risk of selection for AMR with less clinical benefit.
  • The same applies for overuse: we create extra AMR risk without extra benefits.
  • But ANY use still potentially cause problems.

So, we have a problem with antimicrobial USE. Period. Misuse and overuse are part of that, but not the whole story.

Misuse and overuse are also sometimes subjective. We can say that antimicrobials shouldn’t be “misused,” but if we can’t clearly explain to prescribers and users what that means, we don’t achieve anything.

We absolutely need to reduce misuse and overuse. They contribute to resistance risk while providing little to no significant benefits.  For an issue like AMR, where there’s always risk, cost-benefit considerations are key.

But just as important is the need to IMPROVE use of ALL sorts. That often includes reducing use, but not always. It can involve changing things such as drug selection and duration or timing of treatment, to maximize the benefits and minimize the risks.

So, how to do we address antimicrobial “use” overall?

  • Pay attention to misuse and overuse, and try to eliminate those.
  • Better understand and communicate what constitutes “appropriate” use.
  • Develop robust surveillance systems so we can understand how antimicrobials are used, so we can know what’s actually happening and where we can intervene.

What’s as important, though, is reducing the need for any use at all by preventing infections before they start.

Antimicrobial resistance is an outcome of antimicrobial use, and antimicrobial use is an outcome of animal (and human) health issues. If we improve animal management systems, we improve animal health and we reduce the need for antimicrobials. That can include things like better raising of farm animals, vaccination, use of antimicrobial alternatives and improved access to veterinary care.  Improving public health and human healthcare likewise improves human health, and reduces the need for antimicrobials in people.

Healthy animals need fewer antibiotics.  The same is true for healthy people.

Improving health makes sense but gets less attention. There’s nothing sexy about it. It’s usually low-tech, and often involves improving use of routine measures such as maintaining water quality, sanitation, hygiene, ventilation and preventive medicine like vaccination. We’re not likely going to “tech” our way out of AMR. We’re going to improve things by using myriad basic health strategies to reduce our need for antimicrobials and preserve the efficacy of the ones we have.