Date Published: June 11, 2019
Publisher: Public Library of Science
Author(s): Susan Rogers Van Katwyk, Jeremy M. Grimshaw, Miriam Nkangu, Ranjana Nagi, Marc Mendelson, Monica Taljaard, Steven J. Hoffman, David Banach
Abstract: BackgroundGrowing political attention to antimicrobial resistance (AMR) offers a rare opportunity for achieving meaningful action. Many governments have developed national AMR action plans, but most have not yet implemented policy interventions to reduce antimicrobial overuse. A systematic evidence map can support governments in making evidence-informed decisions about implementing programs to reduce AMR, by identifying, describing, and assessing the full range of evaluated government policy options to reduce antimicrobial use in humans.Methods and findingsSeven databases were searched from inception to January 28, 2019, (MEDLINE, CINAHL, EMBASE, PAIS Index, Cochrane Central Register of Controlled Trials, Web of Science, and PubMed). We identified studies that (1) clearly described a government policy intervention aimed at reducing human antimicrobial use, and (2) applied a quantitative design to measure the impact. We found 69 unique evaluations of government policy interventions carried out across 4 of the 6 WHO regions. These evaluations included randomized controlled trials (n = 4), non-randomized controlled trials (n = 3), controlled before-and-after designs (n = 7), interrupted time series designs (n = 25), uncontrolled before-and-after designs (n = 18), descriptive designs (n = 10), and cohort designs (n = 2). From these we identified 17 unique policy options for governments to reduce the human use of antimicrobials. Many studies evaluated public awareness campaigns (n = 17) and antimicrobial guidelines (n = 13); however, others offered different policy options such as professional regulation, restricted reimbursement, pay for performance, and prescription requirements. Identifying these policies can inform the development of future policies and evaluations in different contexts and health systems. Limitations of our study include the possible omission of unpublished initiatives, and that policies not evaluated with respect to antimicrobial use have not been captured in this review.ConclusionsTo our knowledge this is the first study to provide policy makers with synthesized evidence on specific government policy interventions addressing AMR. In the future, governments should ensure that AMR policy interventions are evaluated using rigorous study designs and that study results are published.Protocol registrationPROSPERO CRD42017067514.
Partial Text: Antimicrobial resistance (AMR) is currently high on the global political agenda. This attention has opened a rare policy window for achieving meaningful action on AMR [1–7]. Although the potential for AMR has been recognized since the earliest days of antibiotics , the misuse and overuse of antimicrobials has persisted over decades, contributing to the development of resistance . AMR is now expected to have severe consequences for human health, social well-being, and economic development. AMR has already rendered some infections untreatable using existing antimicrobials [10,11], and global projections suggest that AMR could derail the Sustainable Development Goals, driving an estimated 24 million people into extreme poverty and exacerbating global economic inequality , and potentially resulting in tens of millions of deaths .
A protocol describing the full methods of this project was published in advance  and registered in PROSPERO (CRD42017067514). Deviations from the protocol are noted below, and the paper has been reported in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines . In brief, we produced an evidence map that identifies government policy interventions aiming to reduce antimicrobial use in humans. To be included in the evidence map, studies had to (1) clearly describe a government policy intervention aiming to reduce human antimicrobial use and (2) apply a quantitative design to measure the impact.
From 13,635 abstracts, we identified 69 evaluations of government policy interventions to reduce human antimicrobial use. Fig 1 shows the full summary of screening and inclusion. Of the 69 included studies, 67 focused on antibiotics and 2 on antimalarials; no studies aimed to reduce the use of other antimicrobial agents. The majority of policies targeted healthcare workers (n = 44) or healthcare workers and the community (n = 13), while the remaining 12 policies exclusively targeted a community audience. We found evaluations in 4 of the 6 WHO regions—the Americas (n = 24), Western Pacific (n = 22), Europe (n = 21), and Africa (n = 2)—but did not identify any evaluations from the South East Asian region or the Eastern Mediterranean region. Of the 69 included studies, 67 were published in English and 2 were published in Spanish.