Interventions against antimicrobial resistance [AMR] : a review of the literature and exploration of modelling cost-effectiveness

Most of the studies reviewed were: from the developed world (principally the United States), with few community-level interventions; concerned with controlling disease transmission as opposed to preventing disease emergence; and did not measure the cost impact of AMR to the health service, patients, or society. Specifically, the studies covered two main types of interventions aimed at controlling AMR: (1) antimicrobial reduction measures that affect the emergence of AMR, such as combination therapies, vaccinations, antimicrobial restriction, prescriber education, feedback, and the use of guidelines; and (2) alternative approaches that affect transmission of AMR, such as surveillance, decontamination, handwashing, and response to epidemics (multiple control policies). Also reviewed were about 35 studies examining strategies to reduce AMR in developing countries, many of which focused on prescription patterns for antimicrobials. The main modeling methods covered in the literature review include: decision-analytic models, Markov "chain" models, Monte Carlo (stochastic) simulation, mathematical models, statistical models, and macroeconomic models. Overall, there appears to be no definitive evidence (cost and/or effectiveness) suggesting that one specific control measure (or combination) is particularly more successful than another in containing the spread of AMR. In addition, many interventions that impinge on levels of antimicrobial usage, and thus ultimately on levels of resistance, are not currently subject to such formal evaluation. A suggested minimum data set and proposals for future research are detailed in conclusion.