Table 2.

A summary of suggested research strands on “prevention of antibiotic resistance”

Research area	Know-do gaps
Epidemiology and Surveillance	Explain differences in antibiotic usage and resistance across Europe in longitudinal cross-country studies. Address the global divide between excessive use in well-to-do regions and inadequate access in poor regions. Global surveillance and estimates lack valid data from LMICs. Quantitative assessments need to be supplemented with qualitative and social research. Assess changes in resistance following decreased drug consumption.
One Health – an interdisciplinary and intersectoral issue	Bridging is needed between biomedical, environmental, animal and social sciences. Implementation research should address unused knowledge to be put into practice. Closer collaboration and better documentation of antibiotic use across sectors are called for. Address the economic forces behind infectious diseases and antibiotic resistance. Better understanding and documentation of the irreversible consequences from not taking actions are needed. ABR needs to become a high-profile social issue, like cancer, tobacco control and HIV/AIDS.
Understanding what drives AMR	Analyse the population impact of different drivers of antibiotic resistance. Assessing the direct effects of antibiotic use on resistance need clinical studies on bacterial culture and colonization. Assess relations between antibiotics prescribed in primary care and infections that require secondary care treatment. Clarify the effects of antibiotic dose, duration and adherence on resistance. For interpretation of intervention studies we need randomized studies with proper control groups.
Antimicrobial stewardship	Strengthen the evidence base for programmes in hospital settings through systematic reviews and meta-analyses. Mixed evaluation models are needed supplementing quantitative methods with qualitative approaches. Behavioural science is lacking in the development and evaluation of antimicrobial stewardship programmes. Account should be taken of the cultural and social norms around prescription and clinical practice. Stewardship programmes outside hospital settings, e.g as community or public campaigns have not been assessed. In view of the importance of context, information on stewardship programmes is generally lacking from LMICs. Provide solid and generalizable data on cost and cost-effectiveness of hospital stewardship programmes.
Antibiotic resistance – a policy and health systems issue	Strengthen the evidence base for the effectiveness of the numerous policies across the human and animal sectors. Stimulate the development of new antibiotics and evaluation of alternatives. New business models are called for where public stakeholders involve private partners. Prevention of ABR should be more visible in Agenda 2030 and more closely related to its SDGs. Research comparable and in analogy with that regarding other global health threats should be encouraged. Preserving antibiotic effectiveness ensuring universal access, is an ethical obligation warranting in-depth research. Analogies with other global concerns can help us understand scope and consequences of no-action.
Health Care Practices and Guidelines	Knowledge is lacking about major variations in prescription rates between primary care practices. Cyclic administration of antibiotics has been advocated for intensive care but is still subject to limited efficacy. We lack complete evidence that combination therapy reduces ABR. Research on ABR prevention needs to move beyond the laboratory to the community.
Preventive Strategies	We need to better understand how organizational structures and processes impact on preventive strategies and policy. Address the tension between societal concerns and individual patients. Advertisements in medical journals are an interesting venue for research on ABR communication.
What do people know?	How do people perceive of ABR in comparison with other global threats? How do people in different ages and cultures cope with antibiotic resistance? How do people look upon the responsibilities for change for the individual versus society? KAP surveys on ABR need improvement through stronger theoretical frameworks.
What do prescribers know?	Communication research on the dialogue between the patient and the doctor should be stimulated. Synthesis of qualitative and quantitative studies may enable more in-depth explanations of knowledge and beliefs. Interventions are called for to improve prescribing behavior and rebuild patient-physician trust. Qualitative research could address how social norms and standards of care can influence prescribing behaviour.
Alternatives to antibiotics	Establish the probiotic strains and doses that provide the best results and safety in immunocompromised patients. Assess efficacy and potential side effects of probiotics as a means of reducing the emergence of resistance. Assess evidence favouring the effectiveness of probiotics through larger, randomized and double-blind studies. Undertake proper safety studies including documentation of dosing and types of microbes.