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Skip to 0 minutes and 7 seconds Hi, and welcome to this concluding panel discussion. During this course, we have met different aspects of antibiotic resistance, and we will discuss some of these today. With us today, we have Francesco Ciabuschi, Stefan Swartling Peterson, Otto Cars, and Diarmaid Hughes. And first of all, I would like to ask you about the increased level of awareness that we’ve seen during the last years. What do you think? Is it actually doing any good? Or will it just get worse? What do you think, Stefan? Well, I think it’s a nice start if people are aware. But I think awareness is not evenly spread over the world.

Skip to 0 minutes and 43 seconds And with focusing on low-and middle-income countries, as I tend to do, I think things are getting worse. One, we don’t know its real status. The indications are that we actually have weak health systems. We have irrational use of antibiotics, and we have challenges from things like malaria elimination, where the existence of diagnostics actually push up antibiotic use when the malaria test is negative. Great. I am going to stop you there because Otto, I want to ask you, do you agree? Well, I agree. I mean awareness is increasing, but it’s not at the level it should be, not even with politicians. I mean, the issue is still not perceived as a crisis, not perceived as a disease because it’s not diseases.

Skip to 1 minute and 31 seconds This is something that undermines important treatments. It’s a long way to get the crisis awareness. On the other hand, some things are happening. And it has clearly been a much better political momentum, but we’re far from there. Francesco, what do you think? I certainly agree with my colleagues. Anyway, on a more positive note, I would like to say that actually companies, recently, have been starting to come closer to the problem. But, recently, they also signed a document at Davos by stating that they want to engage again. Now, obviously, from a statement to the facts there is still a lot to be seen. But I am positive that things will happen in the coming years. Yes.

Skip to 2 minutes and 16 seconds Ok, Diarmaid, what do you think? Well, in general, I agree with everything they have said. But I’ll be a little bit more positive. I think there’s a lot of research and development in the early stages. The downside is it might be 10 or 20 years before we see the positive benefits. So I think, in summary, it probably will get worse. But, hopefully, it will get better in the longer term. Yeah. Ok, thank you. But it sounds good anyway. So first, I would like to ask you, Otto, do you think it’s acceptable to not give the best available treatment, antibiotic treatment, to patients today to preserve them for the future generations to come? Well, that’s a really broad question.

Skip to 2 minutes and 57 seconds Yes, it is. I’ll try to respond to it quite shortly. But I think if we really believe that the antibiotics is a scarce resource, maybe even a non-renewable resource, we really need to take responsibility to balance the need for this generation and the future generations. So I think, in that respect, the answer is yes. We need to reserve this for the patients that really need it. And having said that, all patients in the world that need it should have it. So it’s an equitable issue as well. But I think we are already doing this. I mean it’s very easy to be an infectious disease doctor if you give the latest treatment to every patient that might have a resistant infection.

Skip to 3 minutes and 38 seconds We don’t do that. We do some kind of analysis. We assess risk factors. And I think that process needs to be strengthened to guide the prescriber in the future to really try to define which patient that really should have the latest drugs and where the risks, the major risk for having a multi-resistant infection, for example. But I think it also falls back really on the lack of diagnostics. Yes. And I think that will improve the situation and make it less difficult. Diagnostics will come, and that will help. But having said that, that will not be..

Skip to 4 minutes and 16 seconds We will always have to guess somehow and I think the responsibility for a prescriber is also to adjust the therapy as soon as the bacterial diagnosis is clear. Yeah. But I would just like to ask you another question. It’s maybe, like in Sweden and Norway, for those kind of countries– because as a mother of small children, and I see I always have a bit of stress of time and money to stay at home. And then you tend to go to the doctor and say I want antibiotics because it gives me 2-3 days. I will be back at work or I can deliver the kids in kindergarten.

Skip to 4 minutes and 54 seconds But how should we change these norms and these values that we have because I think that’s also one of the problems? Do you agree? Again, it’s difficult. I mean we need to discuss this from different perspective. High-income countries and low-income countries. We will come to that later. But I think it’s really a long process to change understanding, knowledge, and behaviour. And I think one side, a shortcut to that might be to make people aware that we are carrying these bacteria in our normal flora, what we now call the microbiome. And we change that microbiome every time we use an antibiotic. And later on in life, you may get sick from your own bacteria.

Skip to 5 minutes and 37 seconds So it’s not only for the next generation. It’s also for your own sake. And I think that argument has been helpful here in this country. It could be also useful in other places. Is there someone who wants to comment on this? No, certainly, I don’t think it’s acceptable to withhold antibiotics from people who use them. But it becomes a question of what is best. And best is the most appropriate antibiotic which ought to be effective. So with that qualification, yes. Diarmaid? I agree completely. I think it’s important to realise that best is effective. Best isn’t necessarily the latest or the newest. And the patient may not need the very latest antibiotic and especially if we have diagnostics to guide therapy.

Skip to 6 minutes and 23 seconds Good answer. I would like to ask you know, Diarmaid, because, in the course, you talked about the pipeline of antibiotics that is almost running dry. And is the develop of new antibiotics the only way to go? Should we broaden our minds and think otherwise? Or where should we go? Well, the simple answer is yes. Firstly, the pipeline is effectively dry at the moment. But there is a lot of early and middle stage research and development going on. So, hopefully, there will be new antibiotics coming online. But all of the important, large companies, many small companies, and many academics are researching alternatives.

Skip to 7 minutes and 4 seconds So there’s a lot of research going on into antivirulents, into phage therapy, into monoclonal antibodies, et cetera, et cetera. So alternatives are being investigated. Yeah. Yeah. Yes? I think that’s absolutely another way forward. And I think the collaboration between scientists should be strengthened in all these other areas as well, as you mentioned. But I think that the usefulness of those technologies will also be dependent on rapid diagnostics because they are more targeted towards single pathogens. And antibiotics are broad-spectrum so to say. So if we can couple those technologies with diagnostics, that would really be another way forward, to use antibiotics only for where they are really mostly needed.

Skip to 7 minutes and 52 seconds So, you used the word alternative as well. I mean, these are alternatives to direct acting antibiotics. But they’re not alternatives in the sense that you would stop using antibiotics and switch to something else. I think the value may be that we have many different alternatives. And that will have a benefit of possibly reducing the pressure to use antibiotics as often, which will have benefits on resistance selection, and so on. But as Otto says, diagnostics play a big part here. Yes. Francesco, you had a comment? Yes, I would like to add because I really agree with what was just said about the fact that there are no alternatives. Everything has to come forward, to move forward.

Skip to 8 minutes and 35 seconds I would like to point out that though this is true, my belief, we have very different mechanisms and business models around the different alternative treatments or even diagnostics, as Otto was saying. So I would like to point out that these has to be aware also for how financing has to be spread and how incentives has to be created in the different areas. Yes? I have one last caveat. We have research going on into many of these alternatives. What we don’t have is any proven clinical examples. So there is a real danger that some of these will not work in practise, regardless of economic models. But we have to try. Yes, we have to try.

Skip to 9 minutes and 18 seconds It’s interesting that you say so because, in your part of the course, you talked about public-private partnerships. And it’s like one of the models that is always risen up as one of the models. Is this the only way to go? Or should we look at all alternatives regarding the financial part, because it’s a problem with antibiotics because you want someone to put in money for medicine or some treatment that you would like to put on the shelf and only use in emergencies.

Skip to 9 minutes and 50 seconds I’ll try to give some hints because the discussion is ongoing and has been ongoing and certainly will take up a lot of the efforts in the future. There are many suggestions. Currently, I’m involved also in a project which evaluates many different models, mechanisms that should incentivate from behind, push mechanism from the research part, for instance, because if we don’t have more research, more human resources involved in the discovery up front, then we will have a no leads and no compounds to bring forward. So we need to think in a very systemic way. There are mechanisms that could be used in the beginning of the value chain.

Skip to 10 minutes and 38 seconds That are mechanisms that will, instead, pull more what already exist and is stuck somewhere forgotten in the pipeline because it’s not maybe deemed to be worth developing or maybe is something that is a second choice compared to the investment currently that a company may be willing to do. So we need to set different mechanisms so that, overall, they will work in pushing forward both discovery of new, and when I say that, I would like to stress that we need new classes. So we need real discovery, real breakthrough innovation. While, certainly, it’s also worth bringing forward what already exist and, therefore, some more downhill type of mechanisms, some more pull factors.

Skip to 11 minutes and 25 seconds Having said that, I want to be brief, but still clear. What is crucial to me is how you combine this mechanisms because, certainly, you don’t solve the problem with one mechanism. There are so many differences also between the countries. We have the more wealthy countries and also, among them, the legislation, reimbursement, the hospitals, they work all in different ways. But also we have all the problems that come from the poorer countries. So there is a need for tailor-making mechanisms and position them in the right setting with the institutional context. And this is difficult. So there it might be also a combination that are not so positive. So we need to think through what works, uphill downhill in this value-chain.

Skip to 12 minutes and 23 seconds And my final point, most importantly, mechanisms that guarantee better access and better stewardship. Otherwise, we are working for just making the problem even bigger in the future. Can I just add to that. I think you mentioned before that, in Davos at the World Economic Forum, there were some 80+ pharmaceutical companies indicating that they now want to come on board again. But there’s not much in the pipeline for them to work with. So I think the real major bottleneck is really to get the larger group of global scientists together. There is a really weak research infrastructure, although positive science is coming. I think it must be much bigger.

Skip to 13 minutes and 10 seconds That’s just the entry point to have something to drive through all this development pipeline. And I may add, also, that there is a clear difference between - I’m still speaking from the business perspective - those companies that declare they are interested in contributing, although they are looking and watching for what type of mechanism may come and help, and those that are not yet involved. And we need to think about those as well. What can trigger new entrants? Because we need really cooperative effort. We need to tackle this problem from all possible sides. That’s interesting because the world is also a different place.

Skip to 13 minutes and 52 seconds And it is actually a question about access and excess because some have a lot and use it [antibiotics] a lot and some don’t even have access to it. And Stefan, I was going to ask you, how can you argue to spend money on antibiotic resistance in a low-income country that struggles with other problems as well because they could have the basic things that sanitation and clean water. I think the argument should be put differently. In many low income countries the total health expenditure per capita is about $50. And at least half of that comes from out-of-pocket, from patients themselves and from their parents. Many of these sick ones are kids.

Skip to 14 minutes and 35 seconds So the question is value for money and quality of care because antibiotics are available everywhere, and they’re being used. The question is, are parents getting value for money? Are patients getting quality of care? The indications are that there are still more people dying from lack of access to antibiotics than there are dying from resistance in low-income countries today. So I think, with a focus on quality of care, we should also achieve what we want to do with rational drug use and antibiotic resistance. Yes, absolutely. I think we need to do that. But also what can be done in those countries, but also everywhere in the world, is to change, what you said in the beginning, change behaviour and social norms.

Skip to 15 minutes and 23 seconds And I think the knowledge and understanding of what antibiotics are used for, should be used for, in low-income countries is very low. So I think we can do a lot of good things by driving knowledge forward and making patients to not demand, to not go and buy the antibodies when there is no need. I think some of those incentive mechanisms, they apply to parents obviously. You want to be sure, and you might not want to drop your kids at kindergarten, like you, Jessica, but you want to go and be a farmer. And you can’t spend the whole day going 5 kilometres to the health centre. So you go to the private sector and buy 50 shillings worth of drugs.

Skip to 16 minutes and 4 seconds So the question is how can we increase access to effective antibiotics in the right dose at the right time, et cetera. And that, I think, will take interventions both on the so-called supply side, public as well as private, and on the demand side, knowledgeable consumers. But I was wondering, in some places you would need clean water, for example. And starting by that, should you rather use money on that in these parts of the world where this is the bigger problem because, of course, children would also die from that, and you will also spread resistant bacteria from lack of sewage. So how should you argue when you say we are all responsible because it’s a global problem.

Skip to 16 minutes and 49 seconds I think we’re not in a position to make - we’re only to a limited extent - to make those decisions with public funds that we put in because parents make decisions for their children. And they spend their money accordingly. And having a sick kid is a very compelling situation.

Skip to 17 minutes and 10 seconds If I can come in here. I don’t think these things are necessarily in opposition to each other, sanitation versus antibiotics. If the aim, as Stefan is saying, is parents want their children not to die of bacterial infections or viral infections. If you look at the history of the Western world, in the early part of the 20th century, there was a huge drop in mortality, which is largely associated with improved sanitation, clean water, not with the introduction of antibiotics. Antibiotics are very helpful, very useful to individuals. But for society as a whole, the biggest improvement can probably come from improvements in sanitation. And I think this is an issue for those countries.

Skip to 17 minutes and 51 seconds And maybe world organisations should be helping them because not only will it benefit their people, but it will benefit global antibiotic usage and resistance and effectiveness, again, by reducing the pressure to use as much antibiotics as we use. Prevention is key. And of course, a lot of hospital outbreaks where children die are caused by lack of sanitation, like lack of basic hygienic principles and lack of alcoholic handrub or soap. So I mean those basics things is really important. But I think we haven’t started making one of those huge public campaigns. If I look back at my life in Sweden, I’ve grown up listening to people - I don’t know if it has been all the time. Has it?

Skip to 18 minutes and 43 seconds Saying that you should take my antibiotics properly. And all of that massive investment in public education has yet to happen around the world. Yes, of course. But maybe we should raise awareness about that as well then.

Skip to 18 minutes and 59 seconds I was wondering, in your opinion. What would be the most important action point right now? Let’s start with you, Otto. What do you think? I was hoping to get later on. Ok, we can… No, I can start for sure. It’s because it’s a really difficult question again. Yes, I know. We can’t only do one thing. I know. But I think though that… I’ve been at numerous meetings over many years. And I think what comes up all the time and has come up all the time. If we just had the point of care diagnostics, if we just had a diagnostics, we would be much better off to pinpoint the patients that really need the drugs.

Skip to 19 minutes and 36 seconds And I think that development line has been standing still for too long. It’s coming along now. But I think that should be a real focus. That would help a lot, especially in low-income settings where there is lack of laboratory facilities and so forth. So diagnostics and, of course, new treatments is key. And I think they need to be upfront. And then we have to do all the other things in parallel. Stefan… I think we must avoid making things worse. I think there’s an obvious risk that we, in high-income countries, will lock up the antibiotics from people in low-income countries and make access worse.

Skip to 20 minutes and 15 seconds So the fact that there is excess and irrational use must not really punish access for the most vulnerable in the world. So I think it’s pimum non nocere, first is not to harm. And so let’s not make things worse for poor people as we attempt to address this. Francesco, do you have a major point? I think that, to add on, what I would like to underline is the fact that, right now, we need to implement the mechanisms so that we can support basic research and the SMIs involved in the first stages of development and bringing back more pharmas, big pharmas investment. We need to implement mechanisms.

Skip to 20 minutes and 55 seconds We need to be out there and test new ways of collaborating, sharing risks, and cost so that we’ll have some new antibiotics.

Skip to 21 minutes and 5 seconds I will agree with all of this and add on one extra thing, which is I think we have to realise this is a never ending game. We have to have a continuous pipeline of investment because we cannot risk the issue that came up a couple of decades ago where people simply left again, problems arose, now we’re trying to pick up the pieces. So investment, sustainable economic models, research, new therapies, alternatives, everything. But it has to be ongoing. And I think we also have to be aware that the bacteria have been around here from ages. I mean, we have been here a few seconds of the bacteria’s lifetime.

Skip to 21 minutes and 49 seconds And we should probably be a bit aware of what we do to them and how we react to them to save our future. I think this was really interesting. And I would like to follow up with the final question. Diarmaid, where do you think we are in like 50 years from now? Well, if we don’t develop sustainable models to continue research and development, I think we will be in very big trouble. So it’s pessimistic, but.. ..I hope we make the right choices. Otto, what do you think? I think it was the Nobel Laureate Niels Bohr who said, “Predictions are always difficult, especially about the future.” So I think it’s difficult to say.

Skip to 22 minutes and 35 seconds I think climate change may have a significant change in infectious disease epidemiology. We don’t know what that is heading, what that will entail for this problem. But I think, as was said, we can never solve the problem. We can only get back to balance. And I really think that we will have some more balance between innovation, availability to drugs, and balance to rational use. And also new technologies like nanotechnology, microbiome engineering, genetics will probably help a lot. Stefan? Right now, we focus on individual deceases or, as in this case, a class of drugs.

Skip to 23 minutes and 18 seconds In 50 years from now, I want to see us focusing on people, being healthy, staying healthy - prevention as we discussed - but also addressing them with the problems in an integrative manner when they are sick. As it is now, you may present, as a kid, with acute febrile illness. And you’ll be told, good luck. You don’t have malaria. Congratulations. Have antibiotics instead, or vice versa. We need to integrate diagnostics into clinical algorithms and solve the problems, whether they are caused by one disease and treated by one class of drugs or other. Otherwise, we’ll be in a mess. Ok. Francesco, what do you think in 50 years?

Skip to 24 minutes and 1 second Well, with a positive tone, I think that, in 50 years, we will certainly have some new antibiotics, maybe some other problems will arise. But we will be able to tackle some of these issues. But most importantly, I wish that we will have world wide control over the antibiotic use and distribution. That’s a good point and a very optimistic point. Thank you. And with that, I would like to thank you all for being here today and sharing your opinions and your interests, Diarmaid, Otto, Stefan and Francesco. And finally, I would like to ask you who participated in this course, where do you think we are in 50 years from now?

Skip to 24 minutes and 44 seconds Please join us on the discussion forums and the social media and discuss with us. Thank you so much.

Panel discussion

Watch our experts Otto Cars, Stefan Swartling Peterson, Diarmaid Hughes and Francesco Ciabuschi share their views in this panel discussion led by Jessica Lönn-Stensrud.

The following questions are discussed (timestamps in parentheses):

  • Given the increasing level of awareness in recent years, are things getting better or still getting worse? (00:23)

  • Is it acceptable to not give the best available antibiotic therapy to patients today in order to preserve them for future generations? (02:41)

  • Many consider themselves to neither have the time nor the money to wait out the body’s own immune system to heal a minor infection, such as ear infections or tonsillitis. What norms and values do we need to change in order to reduce further spread of resistance? (04:27)

  • The pipeline of new antibiotics is almost running dry, but how much more can we really get out of the existing antibiotics? Is it time to move on to alternative drugs? (06:23)

  • Are public-private partnerships the only way to spur development of badly needed new antibiotics or are there other ways to promote innovation financially? (09:18)

  • How can one argue to spend money on antibiotic resistance in a low-income country with limited resources, where you have basic problems, such as lack of sanitation, clean water and education? (13:52)

  • What are the most important action points right now? (19:00)

  • Where will we be in 50 years? (21:58)

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This video is from the free online course:

Antibiotic Resistance: the Silent Tsunami

Uppsala University