Patients present to the healthcare delivery system, oftentimes when self-care will not likely resolve signs or symptoms of illness and sometimes when traditional medicine has failed. Patients present to hospitals and clinics for evaluation and treatment as well as to pharmacies for obtaining medicines like antibiotics. Access challenges can be characterized by 5A’s—accessibility, availability, acceptability, affordability and accommodation. For example, the diagnostic can sometimes be more expensive than just treating presumptively or empirically with antibiotics (that is, without making the diagnosis before treatment).

Patients may have expectations of antibiotic treatment even when the illness is viral and not treatable by such drugs. As end-users of antibiotics, patients also influence rational use of these drugs. Providers may feel compelled to prescribe these drugs, but perhaps less so when alternatives to antibiotic prescribing exist. These approaches range from watchful waiting strategies (delaying the dispensing of an antibiotic till it becomes clear an antibiotic is truly necessary) to having an herbal medicine substitute capable of palliating the symptoms of a viral infection (as Thailand’s Antibiotic Smart Use project has done). When empiric treatment with antibiotics are more expensive than the diagnostic to decide on the use of such treatment, this can also present a quandary for patients and providers. Patients may incur out-of-pocket costs that also preclude their filling of prescribed antibiotics.

The paradox of overuse and underuse of antibiotics is captured in the contrast between treatment of pneumonia and diarrhea. According to UNICEF, more than one out of every four children that die under age 5 will be claimed by pneumonia or diarrhea. Yet of those with pneumonia, fewer than one in three will be treated with antibiotics. Of those with diarrhea, fewer than four in ten will received oral rehydration therapy or continued feeding. Rather many of these children will be treated inappropriately with antibiotics.

Background Literature

A multi-country survey carried out by the WHO revealed that well over half of respondents across the 12 countries erroneously thought that antibiotics could treat viral infections such as colds and influenza. Nearly a third would also stop antibiotics when they felt better, not when the treatment course was completed as prescribed.

Current Efforts

The Swedish strategic program against antibiotic resistance (STRAMA) built a nationwide collaboration that involved professional groups, government, and a One Health perspective. Over a twenty-year period, significant decreases in the use of prescribed antibiotics occurred, and Swedish citizens have among the highest overall knowledge of antibiotics and drug resistance in a European survey. Half of Swedes surveyed can recall being told not to take antibiotics unnecessarily over the past year.

Thailand Antibiotic Smart Use project has fielded several key messages targeting patients: 1) debunking that antibiotics are anti-inflammatory agents; 2) antibiotics are classified under the country’s Drug Act as drugs with potentially serious adverse effects; and 3) three commonly treated conditions—acute diarrhea, uncomplicated wounds and upper respiratory infections—do not require antibiotics. The project also enabled consumers to use a pharyngeal mirror and in pharmacies to prompt them to consider whether a sore throat required antibiotic treatment or not.

Opportunities for Innovation

—How can consumers be empowered to address the 5A’s of access to antibiotics and help ensure rational use?

—How can the expectations of patients to receive an antibiotic be reshaped? How can individual efforts to ensure rational use of antibiotics in the healthcare delivery system become collective action?

—Are there approaches like citizen science (e.g., test kits for substandard or falsified drugs or identifying drug-resistant pathogens in food) that can help mobilize public awareness to tackle AMR in the healthcare delivery system? [Note: This year’s Innovate4AMR competition focuses on the healthcare delivery system, not on food production.]

–What strategies can address consumer concerns over delayed prescribing (watchful waiting) to conserve the use of antibiotics?