icm2re logo. icm2:re (I Changed My Mind Reviewing Everything) is an 

ongoing web column  by Brunella Longo

This column deals with some aspects of change management processes experienced almost in any industry impacted by the digital revolution: how to select, create, gather, manage, interpret, share data and information either because of internal and usually incremental scope - such learning, educational and re-engineering processes - or because of external forces, like mergers and acquisitions, restructuring goals, new regulations or disruptive technologies.

The title - I Changed My Mind Reviewing Everything - is a tribute to authors and scientists from different disciplinary fields that have illuminated my understanding of intentional change and decision making processes during the last thirty years, explaining how we think - or how we think about the way we think. The logo is a bit of a divertissement, from the latin divertere that means turn in separate ways.

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Take care of your bacteria

Do scientists and GPs have the right information to fight antibiotics resistance?

How to cite this article?
Longo, Brunella (2015). Take care of your bacteria. Do scientists and GPs have the right information to fight antibiotics resistance? icm2re [I Changed my Mind Reviewing Everything ISSN 2059-688X (Print)], 4.5 (May).

How to cite this article?
Longo, Brunella (2015). Take care of your bacteria. Do scientists and GPs have the right information to fight antibiotics resistance? icm2re [I Changed my Mind Reviewing Everything ISSN 2059-688X (Online)], 4.5 (May).

London, 27 May 2015 - With a new holistic approach, a professor of health system economics at the London School of Hygiene and Tropical Medicine, Richard Smith, writes in the latest issue of the BMJ that the fight against antimicrobial resistance should be reshaped and considered as a social problem, not just as a technological and biological phenomenon (Antimicrobial resistance requires a social solution, BMJ2015; 350:h2682).

He also appreciates the emphasis put by Research Councils UK on the need to develop new rapid diagnostic tools, that is a critical point to address humans and animals infections properly, but insists on the need to open up the debate and look into processes other than the biological mechanisms. This should be the way to engage with other scientists and specialists and contribute to a new interdisciplinary approach, focussing on changing patients behaviours. The idea was validated last year by an ESRC Working Group that has produced a report (Anti-Microbial Resistance: Setting the Social Science Agenda, July 2014). It seems also aligned to the current cross-disciplinary fascination for behavioural economics.

It is, indeed, a fascinating case of dealing with change in a systematic way, very familiar to system engineers and social scientists.

What is all about?

In a small and very easy reading book (The Drugs Don't Work. A Global Threat, 2013), Professor Dame Sally C. Davies, Chief Medical Officer for England, highlights the main points of the current debate about antibiotics resistance. She quotes Al Gore’s invitation to raise individuals’ responsibility in tackling wicked global issues, and pokes at scientists, doctors and healthcare professionals for not treating the antimicrobial resistance seriously.

‘Antimicrobial resistance is like climate change in many ways’ she admits. She assures that in the future ‘the drugs will not work. So in addition to improving our personal hygiene, and stopping demanding antimicrobials from our doctors for the common cold, we all need to raise awareness of the threat of antimicrobial resistance’.

Other systemic solutions identified so far consist in keeping on discovering and inventing new drugs and new combinations of drugs on one side and strengthening the global compliance framework, following the example of other international agreements, on the other.

For sure, competition among big pharmaceutical companies and national health and medical research policies are key factors for the discovering of new drugs. But without global cooperation agreements there is little chance of success against antimicrobial resistance. Davies quotes the UN framework convention on climate change, the WHO framework convention on Tobacco Control and the European Commission’s Common Fisheries Policy as examples of agreements the international and national health policies and legislation rely upon).

What is missing

From my perspective, two aspects are missing in the current debate about how to deal with antibiotics resistance. I try to summarize them here in general terms:

1) the availability of reliable data on a global scale is part of the problem definition

Scientist do not seem very keen on acknowledging this aspect. On the contrary, I believe that this is the key point in order to engage a wider public of data scientists, analysts and statisticians that usually want to deal with aggregate datasets representing complex problems in a simple way.

What do we mean in numerical terms when we talk about antibiotic resistance? People dying of septicemia, the fall of revenues for some medications, the failure of a specific treatment? Or the failure in the diagnosis of specific diseases?

I turned to the European Surveillance of Antimicrobial Consumption Network (ESAC-Net), to discover they provide an amazing quantity of data, namely europe-wide aggregates data on private and hospitals consumption of antibiotics in EU and EEA/EFTA countries (see the website).

The database is an extraordinary example of cooperation of the international community. It has also been made available online with interactive web infographics that make it very trendy. Unfortunately, it aggregates data collected and produced in the primary care and in the hospital sectors either as sales or as reimbursement in very different ways. That should lead the user to very prudent interpretations. Reimbursement data, for instance, do not include consumption of products obtained without prescription and other non-reimbursed courses.

And so on and so forth. Discussions around these datasets can be interminable. Until somebody (usually somebody who is not directly involved in the production or auditing of the same data) makes a dramatic turn in the conversation, pointing to the fact that we do not want to deal with optimisation of sales of antibiotics across Europe… for heaven’s sake! What is the purpose of analysing such data? We are researching the problem of antibiotics resistance!

Whenever we have datasets referring to factual consumptions of a certain category of products at international level, we should rise a flag and constantly remind ourselves that we are using data that count the circulating quantity of various types of the same material, a physical thing (the package identified as ‘antibiotic’ drug at the moment of its usage or presumed usage) across different countries, cultures and settings (in this case: families, extended communities, hospitals) whereas our purpose is to understand an abstract problem or phenomenon (antibiotic resistance) in order to support decision making processes that have an impact on human behaviours, medical research, healthcare policies and investments by pharmaceutical companies around the world.

I am not saying we are not doing the right thing or we should not collect or analyze consumptions data but we should remind ourselves we are inferring, assuming and exchanging thoughts and making decisions on the grounds of a very approximate representation of the problem itself, with enormous risks of misrepresentation and misleading advice reaching different audiences.

In order to deal with the interpretation and the validation of the data and the questions they may stimulate - making paradoxically more difficult for scientists to focus on the problem they want to study - the European Centre for Disease Prevention and Control (ECDC), the European Food Safety Authority (EFSA) and the European Medicines Agency (EMA) seem have really had such a dramatic meeting! They have recently partnered and produced a joint report on the issue, containing warnings and recommendations (Joint Interagency Antimicrobial Consumption and Resistance Analysis, January 2015).

2) Treatment of common infections with antibiotics is based on professional judgement and empirical approach (the ‘best guess’ therapy)

The second aspect I find terrifyingly missing from the current debate is the evidence that there is no consolidated science behind the prescription of antibiotics - and yet the healthcare community tend to believe that all the faulty behaviours causing the insurgence of antimicrobial resistance are in the patients or in their lazy or not so good GPs!

In some countries and communities, doctors initiate antibiotics as soon as possible to prevent the spread of infections that could become very severe with risks of untreatable complications or pose even death risks, whereas in others, like the UK, primary care guidance suggest to delay the initiation of an antibiotic course as a measure to prevent possible misuses. These different orientations of professional conduct have also a huge impact on patients behaviours and choices.

Few years ago, two episodes of severe adverse reactions to two different antibiotics prescribed in the context of a certain treatment made me following the most precautionary advice I found in the publicly available medical literature: I stopped taking any drug whilst doctors and paramedicals suggested to keep taking the medicines or to try a third drug because that was considered a critical success factor in their protocol - based on the continued use of antibiotics for 18 months, that sounded to me... quite a life!

Deciding to confront and to oppose medical advice is a very demanding and in some respect very stressful cognitive activity but sometimes there is no alternative if we are to make effective decisions in the interest of our own health - as long as you have the right skills and competences and confidence in what you are doing.

I had to understand the role of antibiotics in my personal situation. I have a - luckily very low - percentage of - unfortunately very highly - aggressive pathogens ascertained through microbiological and genetic analysis. These can potentially cause a number of disturbances to my health, for which preventative medicine is the critical success factor. Among the successful preventative actions I can quote regular physical exercise, a modest but constant use of a simple bacteriostatic antiseptic, obsessive dental hygiene, occasional ultrasound and laser-therapy treatments.

All these have been very successful and empirical evidences I have acquired over the years have always been confirmed by GPs and specialists as measures to avoid drugs.

But I also have to trust that sometimes antibiotics are the only necessary remedy to fight against an infection and make the percentage of my aggressive parasites to behave without causing me trouble.

Luckily enough I have a very good knowledge of databases and authoritative sources in various technical and scientific fields, plus a basic knowledge of chemistry terminology, and a good enough confidence in statistical notions. So instead of simply giving up the antibiotics treatment I had been prescribed I wanted to review my immediate decision to suspend the treatment so that I could reconsider it and possibly renegotiating it with the doctors and paramedicals involved.

I started identifying the exact drugs names and compounds I was given from the information leaflets of the prescribed drugs. Then I searched public and commercial sources, including PubMed, besides USA, European and UK health authorities and medical associations to see first what was the recommended use for such specific products and secondly in which way the guidance should be translated in the specific context of my ascertain genetic risk to develop a certain type of illnesses. I selected and accessed documents intentionally prepared and published for a general audience as well as articles containing reviews of clinical practices.

I learned that the antibiotics I was given should be prescribed only in case of ascertained resistance to simpler broad spectrum antibiotics - that was not my case. There was no evidence that any adjunctive antimicrobial treatment could provide more effectiveness to the treatment with laser therapy I was receiving. Above all, I reckoned that my genetic risk to develop a pathology could not have been halted experimenting the use of different antibiotics for a period of 18 months. All in all I guessed that is safer to take two courses of antibiotics per year, in a combination that I am sure I am not allergic to, as a way to keep the aggressive bacteria at bay in a preventative approach to the problem (or when there is evidence of a bursting infection), than taking amoxicillin / clavulanic acid preparations for 18 months, for which after only two days my liver had turned me upside down!

So all in all, in the art of prescribing the right antibiotic at the right time the ultimate authoritative guidance for prescriptions must include not only scientific, social and epidemiological advice but also the patient personal conditions and context. It is often only the patient that has the complete view and understanding of a framework in which a treatment can or cannot be effective. GPs who prioritise their own judgement over an overarching political direction to limit the prescription of antibiotics do in my opinion the right thing.

The existence of confirmation bias among scientists doctors and healthcare professionals in respect of our antibiotics consumptions and self-prescription needs is an educational problem of the same relevance of the patients’ ignorance about types of infections, hygiene, antiseptics and bacteriostats.

The words of Professor Davies could not be clearer in expressing the pre-existing belief - and possibly also a certain patronising attitude - very frequent among healthcare professionals: ‘Another study in the UK found that nearly 6% of households had antimicrobial drugs in their medicine cabinets, unused from a previous prescription. Half of these households had kept them in case of future illness. This is doubly worrying, as it indicates that people may not be completing their prescription and that they plan to self-medicate with a likely incomplete course of medication - both of which increase the risk of colonization and infection with drug-resistant organisms.’

I am sorry but this type of reasoning is obviously very wrong and I am sure that every scientist including Professor Davies would surely acknowledge it. People may have interrupted - very wisely! - the wrong treatments and may have, in turn, spare intact packages of antibiotics in their cabinets, kindly sent to them from a mother in another Country (mine has done it for several years), because they know that they could be exposed to the risk of serious complications and even death in case their genetic aggressive pathogens decided to have a burst party and the next available appointment to see their English GP is in two weeks time!

The essential is unknown until it is defined

Like climate change and antibiotics resistance, cybercrime is a global problem. In researching and working on the latest, I have come to conclusions similar to Smith’s ones few years ago: if we want to tackle and extirpate cybercrime we have to look at the wider processes and behaviours that take place in digital environments, not just at viruses, botnet and malware forensics. The same is for antibiotics resistance. Language is therefore the first thing to think about: confronting the way in which diverse specialist audiences contribute to the language used to discuss the problem is a fundamentally descriptive and very slow step but it is also an enormously useful tool to speed up the discovery of new knowledge.

I have also moved forward from such a starting point in that: I came to the belief that the only perspective and practical scenario that makes sense within an interdisciplinary framework to deal with the cybercrime menaces is the victims’ one.

This is actually a crucial aspect of any dilemma considered as a global social problem: in fact, we do not really know who the victims are, how they have coped, how they have succeeded and failed. Sometimes they themselves may not know they have become victims for long, for instance in the case of identity theft or autoimmune diseases.

Until we hold on a simple and realistic representation of the problem from the victims’ point of view, we keep on projecting on them our own interests, understanding and bias.

There is no proven method to stop such flourishing of narratives nor to get a representation of the issue in financial terms either. So that we tend to perceive the whole issue as a long term excruciating problem but non as a priority: it stays in the background of the political and business agendas, and it does not mean it cannot be dealt with in some way by battalions of researchers and specialists. But the day by day routines and important activities or emergencies of ordinary people have another rhythm.

Media, advertisers, public relation experts, non governmental organizations and charities have discovered that global dilemmas and wicked issues can have a great impact in terms of engagement with a return in terms of attention towards associated brands and behaviours.

Even negative publicity is not so negative after all if it can engage people and motivate them to learn more about issues at stake or bring more support to the party that has greater access or better use of communication processes (see the current case of FIFA corruption scandal).

Is all communication good communication?

Perhaps it is, if it can increase the general awareness on global issues. Unfortunately higher levels of media exposure, especially in emotional terms, of a still immature, poorly defined and controversial subject cause exponential increase of noise, confusion and instrumental partnerships for commercial reasons.

But it is unlikely that science, general knowledge and public policies make a progress in dealing with problems such cybercrime or antimicrobial resistance until we genuinely agree on what are the best requirements for a solution.

Once again, the wickiest global issues of our times are urgent calls for data engineers.