Table 1.

List of Potential Antimicrobial Stewardship Activities That Can be Supported by Pharmaceutical Industry, Using as a Case Study Merck & Co., Inc. (Kenilworth, NJ, USA), a Large, Multinational Company Marketing Antimicrobials and Vaccines for Human and Veterinary Use

Type of Activity	Example
AMS awareness and education
AMS research methodology training	Independent educational grant for development of an annual conference focused on research methodology training and best-practice sharing for AMS clinicians, which was convened by the Society for Healthcare Epidemiology of America AMS each year from 2016 to 2018.
Online AMS resources	Independent grant for the Center for Infectious Disease Research and Policy’s Antimicrobial Stewardship Project, a multifunctional, online AMS resource providing comprehensive, high-quality information and interactive discussion. This content-rich website is designed to engage a diverse, international audience and includes a broad range of AMS-related topics, such as clinical practice, infection control/prevention, diagnostics, policy/legislation, research, public health, and veterinary medicine [9].
Patient engagement	Independent grant for George Washington University in collaboration with the Urgent Care Association of America to develop and implement an educational campaign to improve AMR and AMS health literacy and maintain or improve patient satisfaction in the urgent care clinic setting [10].
Patient advocacy	Financial support to the Peggy Lillis Foundation [11]. Additionally, health literacy expertise was utilized to redesign an educational brochure on Clostridioides difficile infection for the Foundation [12].
Veterinary educational campaigns	Program (“Time to Vaccinate”) that advises farmers how to keep ruminant herds healthy and productive by increasing immunity against various pathogens through vaccination and improved housing, hygiene, and nutrition; fewer outbreaks of livestock infectious diseases help reduce the need for antimicrobial use in agriculture.
Raise awareness in the private sector	Signatory to the Global Chief Medical Officer’s Network pledge on AMR, which states that each signatory company commits to promoting AMS among their employees, including employee education and tracking and reporting the company’s AMS initiatives [13].
Promotional practices	(1) Training on AMS principles for sales representatives and all other relevant field staff (in both human and animal health), in order to encourage responsible use of antimicrobials. (2) Pilot program in which field sales representatives’ performance incentives are not based on antimicrobial sales volume.(3) Regular assessment of all promotional materials to ensure they encourage responsible use of antimicrobial agents; this assessment utilizes a stewardship framework referred to as the “Star of Stewardship” [14].
AMR surveillance and AMS research
Global surveillance programs	SMART global surveillance program, in which isolates from various bacterial infection types are collected and tested at a central laboratory for susceptibility to the company’s antibacterial agents, as well as to other, widely used agents.
Local surveillance programs	Generation of local susceptibility data, including technical assistance with the evaluation of local epidemiology and antibiogram development.
Animal health surveillance	Commercial surveillance partnership with Kansas State University for monitoring multidrug-resistant bacteria across the live animal, beef, and dairy production chain.
Investigator-initiated AMS research	Investigator-initiated research studies around the world, with specific areas of interest related to AMS, which are defined and released every year [15].
Funding not-for-profit vaccine research	Joint-venture partnership with the Wellcome Trust to fund and support Hilleman Laboratories, a not-for-profit organization aiming to create new vaccines and improved vaccine technology for diseases predominantly affecting low-income countries [16].
AMS implementation
Reduce environmental impact from production of antibiotics	Commitment of $100 million to a water-infrastructure improvement initiative to install active pharmaceutical ingredient-treatment technology at all antibiotic manufacturing facilities.
Facilitate patient-centered AMS program implementation in acute care hospitals	(1) Support a collaborative project with the U.S. CDC and the Duke Antimicrobial Stewardship Outreach Network to develop practical and meaningful safety outcome measures for hospital AMS programs and to provide a publicly available guide to help hospitals collect and report such outcomes [17]. (2) Support the Antibiotic Stewardship in Acute Care Playbook, published by the National Quality Forum; this is a manual providing practical guidance for acute care facilities on how to implement the U.S. CDC’s core elements of hospital AMS programs [18]. (3) Serve as a knowledge, resource, and/or logistics partner to hospitals outside the United States to assist with antibiogram and clinical pathway development, education of providers, and monitoring outcomes [19]. (4) Establish AMS Centers of Excellence via partnerships with various organizations, whereby the partner organization serves as a central hub within their region to provide training for and assistance with hospital AMS program implementation [6, 7].
Support for development and implementation of national AMR and AMS action plans	(1) Independent grant to the Center for Disease Dynamics, Economics, and Policy’s Global Antibiotic Resistance Partnership to develop actionable, country-level AMR plans for low- and middle-income countries [20]. (2) Independent grant to the Pan-American Health Organization and Florida International University to develop regional AMS guidelines for Latin America and the Caribbean, resulting in a subsequent guideline publication [21].
Decision support tools	(1) Commercially available technology, through a subsidiary, designed to help health systems address the unique challenges of infectious diseases, with the goals of helping hospitals accelerate patient access to appropriate interventions, efficiently track prescribing and patient outcomes, and communicate within the hospital workflow [22]. (2) “Poultry Convenience” program provides veterinarians and farmers with technical support and expertise to help protect poultry against major respiratory and immune diseases, including a component on achieving optimal animal vaccination and welfare standards. (3) A web- and mobile phone app-based management system that helps individual farms reduce the impact of the porcine reproductive and respiratory syndrome disease complex through appropriate control and prevention strategies, with a focus on optimizing vaccination. (4) “BeSecure” program improves internal and external biosecurity, thus reducing pathogen entry into and circulation within farms.
Improved diagnostics	(1) Collaboration with OpGen to create diagnostic tests that can rapidly detect resistant infections and build a genomic knowledge base of antibiotic-resistant pathogens for predicting antibiotic susceptibility [23]. (2) Collaborations with antimicrobial susceptibility testing device manufacturers to expedite the inclusion of novel antibacterial agents on susceptibility testing panels. (3) Animal health division markets a stethoscope system that assists in a more accurate diagnosis of bovine respiratory disease, thus helping determine which animals require antibacterial treatment.
AMS advocacy
Initiatives to advance policy supportive of AMS	Advocacy with infectious disease societies, patient groups, industry, and other partners to advance reimbursement reform proposals that enable appropriate patient access to novel antibiotics, including the DISARM Act in the United States and the Novel Antibiotic Subscription Model in the United Kingdom.
Initiatives to improve manufacturing practices	(1) Work to broaden adoption of the “Common Antibiotic Manufacturing Framework” across the industry [24]. (2) Work with third parties across the manufacturing and supply chain to ensure good practices for eliminating antibiotic discharge.

Abbreviations: AMR, antimicrobial resistance; AMS, antimicrobial stewardship; CDC, Centers for Disease Control and Prevention; SMART, Study for Monitoring Antimicrobial Resistance Trends.