Speaking of Science: Acting now against antimicrobial resistance

In recognition of World Antimicrobial Awareness Week (18–24 November), NHMRC was joined by an expert panel to discuss the importance of AMR and how we’re acting now to protect our present and secure our future.

Panel members including Professor Kirsty Buising (The Royal Melbourne Hospital) Professor Allen Cheng (Monash University), Professor Branwen Morgan (CSIRO) and Professor Mark Blaskovich (The University of Queensland) provided valuable insights into what the burning platform is for AMR, actions required from the health and medical research sector to combat AMR, and further considerations for the associated challenges of AMR.

Recorded on Thursday 20 November 2025 at 11:00 am – 12:00 pm AEDT.

Video transcript

Professor Steve Wesselingh 0:00
Welcome to Speaking of Science and today is a really exciting episode of Speaking of Science about antimicrobial resistance, and you can see on the screen this terrific panel that we've got.

But before we start this morning, I'd like to acknowledge the Traditional Custodians of the lands that we're joining from and elders past and present. I know people are joining from all over Australia, so we're acknowledging all of those lands across Australia. I'd also like to acknowledge any Aboriginal and Torres Strait Islanders that are joining us today online.

I'd just like to, before we start, the sort of formalities indicate there'll be an opportunity to ask questions of our panel at the end. Please use the Zoom chat function to do that. What we're going to do is each panel member will make a short presentation, and then I'll I'll start probably with some really tough questions to get going and and then we'll look at the chat and and start a really good discussion.

I just want to remind people that past webinar recordings are available on our website, and today's will also be recorded and uploaded in the next couple of days and be available. The November Speaking of Science webinar acknowledges Antimicrobial Awareness Week, an international campaign that raises awareness and increases global understanding of antimicrobial resistance, or AMR. Obviously, AMR occurs when bacteria, viruses and fungi and parasites no longer respond to antimicrobial agents. As a result of this resistance, antibiotics and other antimicrobial agents become ineffective, and infections become really difficult to treat, and we have increased risk of disease spread illness and death and so on, but we'll hear all about that, I'm sure, very shortly.

As part of this week, we're being encouraged to act now, protect our present, secure our future. And so this is an international program which underscores the urgent need to take global action to address AMR. As I mentioned, normally we just have a single speaker, but today, we've got a panel of of people who have been intimately involved with AMR for quite a long time, and I'm really looking forward to hearing from them. Each of our panel members will make a presentation, and that will generate some discussion. I'm hoping to have a discussion about what's the burning platform for AMR? What should we the research sector and the health sector be doing? Also compare AMR perhaps to other really important issues that we are facing right now, and why is AMR so important? Why is this front and center?

But before we start, I just want to ask you to join me in welcoming our panel. We've got Professor Kirsty Buising from the Royal Melbourne Hospital. We've got Professor Allen Cheng of Monash University and Monash Medical Center, Professor Branwen Morgan of the CSIRO and Professor Mark Blaskovich of The University of Queensland. Ech are going to start with a short presentation, and we're going to go Allen, Branwen, Mark and Kirsty. Allen, I'd love you to start with your presentation. Thanks very much.

Professor Allen Cheng 3:53
Thanks very much, Steve, and thanks for the opportunity to speak. I'm just getting my slides up. I'd also like to acknowledge the Traditional Owners of the lands on which I'm coming from, which is live on, Burrawang Land down here in Melbourne. I'm just going to, clinicians always started with cases, and I'm going to start with a patient that we saw. I have sort of made it a little bit vague to protect this gentleman's privacy, but we had a patient recently, in his 60s. He had a kidney transplant, and while on holidays overseas, he got a sufficient infection in his leg after a minor injury with pseudomonas, a gram negative bug for various reasons. The resistance pattern is a little bit resistant, but there are treatment options, as you can see on the on the right hand side there. It was treated with an antibiotic, but this bacteria became resistant to this, the infection got worse, and it was changed over to a different antibiotic. You can see that see, of hours on the on the left, which on the right there, which always makes infectious disease physicians hearts sink. It became resistant even to that, and the infection got worse, and unfortunately, this gentleman needed leg amputation to to treat the infection. He did survive, and he he was discharged from hospital, but required nine months in hospital with all the complications of sepsis and rehabilitation for his amputation.

One major consequence of antibiotic resistance is the use of hospital resources that being in hospital bed for for nine months is clearly quite significant. I guess in some ways, this isn't a new problem. So Alexander Fleming in his Nobel Prize acceptance speech in 1945 was reported to have talked about resistance to penicillin back then and he characterised it as an evil that could be averted. I think there are parts of the world, particularly India, where this is really endangering a lot of other medical advances.

If we think of all the times we might need to use antibiotics in surgery and cancer and chemotherapy, organ transplantation and immunosuppression, and all of these, the gains that we've made in that are endangered by antibiotic resistance. It's also an inequity issue in Australia. There's the very well characterised gap in health outcomes between Australians and Aboriginal and Torres Strait Islanders, and that is very true for a lot of antibiotic resistance as well. In terms of the global burden of disease, things actually aren't quite maybe as bad as they might seem.

Back in 1990 you can see all of that red particularly across the Indian subcontinent and so South Asia and Africa there. But actually over time, this has improved a little bit, even though there are still some hot spots, and there's still quite a lot of antibiotic resistance, but this does hide that. It does look like a lot of these improvements because of the reduction in infections in young children, but there's been also an increase in older children and adults. Then there are specific bug drug combinations where we worry about particularly Staph aureus, E coli and Klebsiella, which obviously cause a lot of infection.

What is it that we need to do? I guess there's the obvious. Can we understand resistance and how resistance works and the mechanisms a bit better? That leads to new drug targets and drug discovery, those drugs need to develop, and be tested in clinical trials. This includes the best use of drugs that we already have, as well as new drugs we have surveillance looking for. We call it sort of critical bug drug combinations, but also looking for emerging isues, Candida, Auris, as a resistant fungus, was one such thing. One such bug that we're on the close lookout for when there might be incursions into Australia, and surveillance is sort of defined as information fraction so it's not just stamp collecting, it's things that we can actually action.

Then the context of that is really, what are the drivers of resistance? How much do we attribute to cross transmission between patients? How much do we attribute to use in animals or humans and other context. Here is one where we do need to think about - the one health context. We are in a shared environment with animals and and humans. What we do in humans affects animals, and what happens to animals does affect humans as well. But in the end, we need to think about interventions. What are the alternatives to antibiotics? In chickens, I understand, one of the great advances was to vaccinate chickens against some bacteria so that antibiotics were no longer required. Clearly, that's also the case to some degree in humans as well. There's phage therapy as a potential new or revisited treatment. We do need public health responses, how do we prevent infections better? What can patients and the community do to protect their own health? Then the quality use of medicines, which is less a technical problem, and more a social, behavioral problem, almost a cultural problem, about how we get to people to use medicines better. Kirsty is really an expert on that again, I'm sure can speak on that later.

Then what we do in Australia, like with climate change as a problem, what do we do in Australia is only one contributor to the issue. A lot of antibiotic resistance comes in from overseas, so what can we do better in the region and internationally? Then all of this is within economic framework as well, so what sort of incentives do we need to put in place, funding mechanisms to incentivise better behavior, better products and the desired policy settings for that. As one example, we do have this mechanism in Australia to access drugs that are not yet available or not yet approved by the TGA. There are about 5000s of these applications every year, and most of these are for older antibiotics, for things that have gone out of supply in Australia. But we do have about 50 applications each year for new antibiotics for resistant organisms. No one's going to make a lot of money. I'm selling 50 antibiotics a year. But are there other funding models?

An example of that is what's called the Netflix model, where you pay for access to the antibiotic, rather than trying to pay for volume which incentivises more use. In terms of why AMR is important, and obviously it is one of many problems that we face in the world and in health, I would say that it's not really just a need or either or so the antibiotic resistance intersects with so many other health outcomes and diseases, and there is a lot of interest in this and to the extent that it's in the UK's National Risk Register, AMR is listed as a risk among all the other risks that are there. We do need approaches to all these problems that we have in common. I'm going to leave it there, and I'll hand over to Branwen, I think.

Professor Steve Wesselingh 12:27
Yes, thanks Allen, that was terrific and exactly what we needed. Branwen, over to you.

Professor Branwen Morgan 12:33
Thank you. I'm just getting my screen up. I'd like to acknowledge that I'm joined from the lands of the Gadigal people of the Eora.

Burning platform, I don't think there's a single burning platform for antimicrobial resistance, and I think that's the problem. There are many, and together, they're causing a significant impact on loss of life and suffering. If we look just at human health and five of the particularly nasty bacteria that are often antibiotic resistant, the impact is greater than for many other infections. But we don't look at them all together, and the diseases that they cause manifest in different ways, from skin and urinary tract infections to joints and chest infections and more, and they affect different people and different populations and different countries at different levels.

Then we've got to think about what's beyond the human realm. We realise we actually have the theme of burning platforms for antimicrobial resistance. Just think about it. Think about the intensity of the blaze is differing in different places, and the stakeholders responsible for putting out each of these slides and the resources that they have available to them, it's different, and that's why we need to act collectively and in a coordinated manner, and it means not just focusing on people in hospitals and communities who need new and stronger combinations of antimicrobials.

It's also the wheat farmers in Western Australia who see the currently available fungicides getting less effective and crop yields decreasing. It's the increased risk of transmission of drug resistant pathogens to our pets and farm animals. And AMR connects them all, and I think that is really why we need to work together.

We talked about mortality rates, and if we do nothing, of course, more people will die from drug resistant infections. But if no action is taken by 2050 we'll also have a lot of other impacts as well. Increase in health costs, decrease in the global livestock production and also reduction of productivity in Australia's annual GDP. But perhaps AMR isn't our biggest problem. After all, non communicable diseases are the leading causes of death in Australia. But ask yourself, am I at risk of diabetes? Or am I at risk of heart disease? Possibly not. Am I at the sixth answer? Yeah, maybe. But then ask yourself, am I at risk of a drug resistant infection? And there's only one answer, and that answer is yes. We're all at risk, because we live in a world dominated by microbes beneficial and harmful, and it's not to be forgotten that infection is the second leading cause of death in people with cancer.

AMR is a now problem, and antimicrobials, as Alan said, are at the heart of medicine and medical procedures. This means they need to be available and they need to be effective. What can we do to stem the tide of antimicrobial resistance? What are the drivers?

Well, the UK Government produced the Systems Map. Yep, it's a lot and in our team, we talk about decision paralysis, where to act when there are so many options, there's really four outcomes to work towards, reduce the burden of disease, conserve and steward the effectiveness of existing outcomes, slow down the emergency spread of AMR and also stimulate the development of new antimicrobial vaccines, diagnostics and novel therapy. But even then, it's hard to know which will have the greatest impact.

One of the things that we did was devise a prioritisation framework based on impact, a midterm horizon, and alignment with other government strategies and priorities, and that allowed us to come up with a shortlist. One way to do this when you've gone through that process, is to think about what is the impact you want to have, and then to write the headline that you want to see in the next five to 10 years, so that's what we did. Vaccines not having an infection means there's no need for antibiotics. So one of the modeling studies looking at a vaccine for group A Strep showed that it could reduce the need for 72 million doses of antibiotics annually, and increase hospital costs related to AMR by up to 3.6 billion per year. Vaccination is clearly a great strategy, and it aligns with the current Australian investments in vaccine manufacturing, antibiotic contaminated waste and waste products from aged care homes, on the theme of circular economy, again, very, very topical and related to risk guidelines that inform water treatment to remove antimicrobial contaminants and break the transmission cycle, co design frameworks to demonstrate appropriate use of antimicrobials In the animal industry.

There's more to do. These are just some of our headlines that we took and then worked backwards, but then you have to start working forwards again. So how do you do that? I's about thinking about what's available to us. Where is the funding for these different types of research? Who's doing what? We've used the global AMR and D hub to look at the different investments in the different sectors and you can modify this and then work through the dynamic dashboard looking at both investment and projects. The Australian Government contributes data into the AMR and D hub. There are some funds that are missing, for example, from our RDC, but it is very useful to get a picture of where we sit.

We've also produced a free dynamic report with the lens to look at how Australian researchers and innovators are contributing to AMR solutions and technology. This allows anyone to jump in and have a look and interrogate those links between patents, papers and people.

So what now? Well, in some ways it's easy to say what we shouldn't be doing than what we should be doing. We should obviously not try to do everything and not duplicate what others are doing. I think we have a huge opportunity to connect to global opportunities and funding so things like carb X, the work that the European Union is doing in the Horizon Scheme, which is a follow on from the joint programming initiative in AMR, and also there are new innovative initiatives coming through. The three biggest philanthropic organisations in the world have combined on the Gradi Innovation Initiative and the other things we should be doing is using that data to make evidence informed decisions, so the funding data, the outcome data, and to help evaluate where we in Australia have the strength and scale to contribute to global efforts, as well as solve some local and regional challenges. I think it goes without saying that advocating for tackling this problem and educating it's something we should all be doing, and we should all be invested in minimising the impact of AMR. That's actually one of the topics that we will be discussing next year at a Global AMR Summit in Sydney that we're co hosting with the Fleming Initiative out of the UK. It's three days. It draws on the FIP declaration that we signed up to last year at the United Nations center assembly meeting. It's designed to be distinct and different from other events. It's not a scientific and technical meeting to bridge sectors, but also public private investors as well. We have just this week, opened up a few more spots that is limited capacity, and we do expect to be sold out by Christmas, but you can register your interest.

I'd just like to acknowledge the sponsors that really believed in our vision for this, and particularly the universities that have come on board to support the meeting. So thank you. I'll leave it there.

Professor Steve Wesselingh 20:36
Thanks, Branwen, and a good plug for the meeting. Well done, excellent. We now move on to Mark.

Branwen, can you stop your slides and we'll move on to on to Mark. Thank you very much.

Professor Branwen Morgan 20:55
It should be stopped, but I think I had to get somebody to force it to stop before there we go.

Professor Mark Blaskovich 21:06
Alright, so I'm going to take a slightly different attack approach, and in terms of the burning platform, I'll look at it from an antibiotic perspective, development of new antibiotics.

The problem of antimicrobial resistance is nothing new, from the very first antibiotic introduced through the deduction of every other class of antibiotics, antimicrobial resistance to that class of antibiotics generally shows up within a few years of its clinical use, and for current drugs coming before they're even clinically approved. One of the real problems driving the crisis of antimicrobial resistance is that the discovery of new antibiotics is just not keeping pace with the development of resistance anymore, and so we're running out of antibiotics that are effective. This is reflected in the, this is the US FDA approval of antibiotics, which has peaked in the 1980s, 1990s, and has been on the decline ever since. We really only get one or two antibiotics approved every year now, which isn't enough to keep up with the pace of rising resistance.

If you compare antibiotics with other therapeutic classes of drugs, so in terms of the development pipeline, the number of anti oncology drugs that are in the three stages of clinical development leading up to approval, they're around 1500 to 2000 currently in those those three stages of trials. Given that antimicrobial resistant infections are predicted to kill more people than cancer by 2050 you'd think, you'd hope to have a similar number of drugs available for antibiotics, but in reality, we've got about 50 to 60 that are currently in the pipeline, so there's just a woeful under investment in the development of new antibiotics.

Antibiotics are like any other drug. It takes a lot of time and a lot of money. If I discovered a wonderful new compound in my lab today, it's at least 10 to 15 years before it'll get approved. If everything goes well, and that's going to cost. If everything went smoothly for this one drug, probably about 500 million, but more likely $1 to $2 billion so it's a really expensive endeavor that requires a lot of investment.

Unfortunately, the economic market for antibiotics is basically screwed. The best new antibiotic approved today, you can charge maybe $1,000 per day for, say the standard 10 days of treatment. You get $10,000 reimbursement, and you compare that to the newest oncology drug, so car-T therapy, which the insurers are willing to pay almost half a million dollars for treatment for a single patient. There's just this huge disparity in the amount of reimbursement available. The most successful two antibiotics over the past decade, Teflaro and Avycaz, in their first two years of sales, they made 50 million, 80 million, respectively. Yu compare that to other indications, so Lyrica for epilepsy, Januvia for diabetes, made over a billion dollars in their first two years. If you're an investor, a pharmaceutical company looking where to put your money, you're not going to put into antibiotics where you're very unlikely to make any profit. You're going to put it into the the other therapeutic indications and this is the main reason why almost every major pharma company has exited from antibiotic research, they just can't see a profitable path towards development of new antibiotics.

Now the onus is on small biotech companies to develop new antibiotics. But unfortunately, the track record for antibiotic focused biotech companies is not good. This is basically a list of antibiotic focused companies, a lot of them had success in actually getting antibiotic approval, but all of them have either gone bankrupt or being taken over by other companies. Poster child for this is a company called Occasion and they had a new antibiotic approved in June 2018. Normally for a biotech company, your stock goes up, you start to make money, but they actually went bankrupt a year later. So post approval, their R&D expenses for 2018 were $103 million and they made less than a million dollars in revenue for their new approved antibiotic with partly because they were only able to charge $3,000 per patient.

Financially, it's really hard to justify investing in new antibiotics. So what can we be doing? Particularly within Australia and globally, one of the big issues is that we're lacking a coordinated approach, both for policy, funding and enabling action, just within the government. In Australia, antimicrobial resistance crosses multiple government agencies, so even within a department. Department of Health, you've got some control over hospitals. You've got the Therapeutic Goods Administration, you've got reimbursement policy, you've got the new Australian Center for Disease Control. You've got funding through NHMRC and MRFF. None of these work together in a coordinated fashion, and there's no one point person you can go to. Department of Industry, Science and Resources is involved in funding and other areas of research. Department of Agriculture, Fisheries and Forestry, AMR and the environment and agriculture. Department of Defense has a lot of interest, particularly the DST, DMTC with the Saber Alliance and HSA and then Department of Education, because they provide funding for universities. Within all these agencies and entities, there's no real single key point of contact that you can go to. Even if you do identify a champion within government, is quite likely they can move on in a couple of years to another position.

There's this constant personnel turnover. In terms of how do we enable funding? This slide kind of dates me when I put it up, because a lot of people don't know that. Push me, pull me from Dr Doolittle. But there's push funding, in terms of funding to encourage research into antimicrobial resistance. Within Australia, it's traditional entities of NHMRC, ARC MRFF, internationally, Carb-X has probably had the most impact in trying to incentivise earlier stage drug discovery research. I's a fund about 800 million US has gone into the fund so far, predominantly devoted to small biotech companies to take drugs from discovery through to the end of phase one.

On the other hand, pull incentives are trying to provide a market incentive for you to get the antibiotic approved. Already, as Allen's already mentioned, the Netflix subscription model, and both Carb-X and Netflix are something which I really think Australia could help adopt, and in terms of one piece of the solution. The antimicrobial resistance network, it's a multi stakeholder expert group, bringing together, particularly antibiotic developers, companies, as well as other institutions and entities involved in combating AMR. So 33 organisations, over 200 members, and it does a number of activities such as generating reports and particularly advocating for policy. They've been pretty instrumental in advocating for Australia to adapt this Netflix subscription model. They also give Australia presence on the global stage. They remember the WHO Taskforce and net micro resistance, and importantly, they've got pretty close association with Carb-X.

Carb-X has officially joined as a partner organisation, and ideally Carb-X has funded three projects within Australia, so contributed over probably 15 million research funding into Australia. It'd be really good if the Australian government was able to contribute to Carb-X to make sure that AMR Net has continued to be funded, and ideally fund a Carb-X accelerator within AMR Net, which has been proposed to help further advance antibiotic discovery and development and diagnostic development within Australia.

Finally, why is AMR important? I think the others have illustrated that. Well, I'll just highlight a quote from the WHO Director General from this year that AMR is outpacing advances in modern medicine, threatening the health of families worldwide. It's not tomorrow's problem. It's a crisis that we must address today, and I'll finish with that.

Professor Steve Wesselingh 29:14
Thanks very much. Another terrific presentation, and Kirsty for the final presentation, over to you.

Professor Kirsty Buising 29:23
Thank you very much. I'll just share my slides, hoping that's working okay for you.

That's set it up really beautifully, because I think from Allen, we've heard about the clinical nature of the problem and the global spread of the issue, from Branwen we heard about the complexity of the responses across many different sectors, and from Mark, we heard about the drug discovery, sort of highly technical but extraordinarily important component of the response.

I'm going to bring to you just my lens on an example of and how we're choosing to contribute to the response to antimicrobial resistance through the World Health Organization Collaborating Center for AMR that's located at the Doherty Institute. I guess our approach to this, our role, is to support our international partners, including the WHO to strengthen prevention, surveillance and response to AMR and the core capacities that we think are really important are ensuring laboratory diagnosis, pathogen genomics and surveillance have become really, really important, and I'll elaborate on that a little bit further, and then the core capabilities of infection prevention and control antimicrobial stewardship, making sure that we're using the drugs that we have in the best way possible and and Clinical Infectious Diseases, so delivering the appropriate care when people do have infections, and our approach stretches across thinking about strategy and governance, as well as capacity building, developing workforce, policy and advocacy, monitoring and evaluation and supporting partnerships.

To give you some examples of the types of work that we do, we are very fortunate to be supported by DFAT and through a project called Combat AMR, where we provide quite targeted technical support to many countries in our region. That may be around multidisciplinary, regular meetings to provide mentoring for clinical support, infection control, developing surveillance, guidelines, referral pathways for genomic sequencing, and bridging across animal health as well as human health with what we do through this project. Branwen mentioned the Fleming Fund, which has been an extraordinary contributor to progressing work in the space of AMR and at the Doherty Institute, we are a host institution for Fleming fellows, which means that we focus on developing in country leaders who can understand the nuances of the issues within their own country. We've supported now more than 100 fellows across five countries, and they've spread from human health and animal health, initially, now moving across into food and food laboratory and environmental health as well, and more recently, some policy and professional fellows who have expertise in policy development.

Just two weeks ago, I was at the Western Pacific Regional Office, regional forum for WHO and one of the days that I participated in was a workshop on pandemic preparedness and surveillance for all pathogens of pandemic potential, which includes AMR pathogens. I think this is an interesting framework to be placing AMR within and I thought it was worth sharing with you that WHO's regional vision is to really focus on genomic surveillance, fashion to suit countries needs to help us be better prepared for and respond to outbreaks of AMR pathogens. They really wanted to focus on strengthening in country core competencies to manage health emergencies, driving innovation, but a focus on equity and improving connections between countries in the region, so that we collectively develop our actions and responses.

This goal by 2029 that 100% of countries have timely access to sequencing for pathogens of pandemic potential. We're pretty much there in our region, which is very exciting to hear. The goal is that 70% of countries have in country capability to perform genomic sequencing, and we're four countries away from being able to achieve that goal, which is fabulous to hear when we've got four more years to get there. I'm going to finish on this graphic, which comes from WHO head office in Geneva, and is the way that they've envisaged the response to antimicrobial resistance in human health.

I acknowledge that it is human health in particular here, but I find it quite helpful and what they've done here is divided the four main activities around prevention of infection, access to quality health services, ability to make a clear diagnosis, and then ability to provide treatment down the middle and then on the left and right, they've separated them into system challenges and individual patient or consumer challenges. As you work through that, you can see that it helps you to define what some of the core interventions might need to be as they focus on different components. it highlights for me that we need to be thinking about health services and health systems as well as public health activities. Things like water and sanitation and hygiene are really critical to this. Immunisation, for example, when we talk about people challenges, it's not just provision of education or information, but it's also behaviors.

I wanted to highlight that that is balanced on both sides. It's information provision and behaviors that are happening at the patient and consumer level in the broader public as well as provision of information and behaviors that are happening at the healthcare provider level, because there's a lot that needs to be done there to improve our ability to respond appropriately to antimicrobial resistance.

I would strongly recommend accessing this people centered approach to addressing AMR and that's just reflecting on this graphic to think about how it highlights for us where our capacity building activities and importantly, our research activities may need to focus in coming years.

That's all from me, Steve. I'm happy to hand back to you for further comment. Thank you.

Professor Steve Wesselingh 35:59
Thanks, Kirsty, and thanks everyone. I mean, they were a great selection of presentations right across the broad areas of AMR and covering everything we hoped you would so really good.

I just say to everyone online, if you have questions, please put them in the chat now and we'll start a bit of a discussion. I'm going to start the discussion on the drivers of resistance and and I guess I'm just interested in people's thoughts. I mean looking sort of slightly superficially, but it strikes me that one of the biggest drivers of of resistance is actually inequality, and the fact that when you look at those maps that a number of you showed the worst resistance is in the poorest countries.

Actually countries like Australia, although it's threatening, are much better off than a lot of poor countries in Africa and Asia. Are the biggest drivers of resistance people? And are they people in poorer countries, and would our best response be thinking globally, or are there important things we have to do in Australia in terms of people and animals and One Health? I think the answer probably is we need to do both. But I'm just interested in people's thoughts, where the biggest threats are, and our response to those biggest threats. I might perhaps, because I know what Kirsty's answer is going to be, actually, I'm going to go to Branwen to comment on that.

Professor Branwen Morgan 37:41
Thanks, Steve, wow, biggest threat? Well, I think you know, my second slide that compared the 5 gram negative resistance infection against the other type of infection sort of highlighted some of the pathogens that we should be looking at. It's really regionally disparate, right? I mean, even in Australia, we can take an area, and we did this study around Wollongong and the Illawarra Shoalhaven, and showed that 10 to 20 kilometres apart, you can have your resistance level double between suburbs. In terms of the driving factors in antimicrobial use, which links to resistance, there was a paper in 2016 by Allison Bones and colleagues, that showed the two biggest drivers are, of course, antimicrobial misuse, both in humans and animals. Misuse, not just being overuse, it's also under use or sub optimal use, and that's linked to access as well. Those are the two biggest drivers.

I think the next one down was looking at the environment. When you have poor sanitation and you have that transmission of drug resistant bugs through open source tips and in the air, as we saw in one of the slides, is really a hot spot in terms of and that's also where manufacturing is antimicrobial for a lot of manufacturing occurs as well. It really comes down to where we want to put our money? Do we want to focus at home? Do we want to demonstrate evidence and efficacy and return on investment of new technologies and innovation? Or do we want to invest more in the regional perspective as the whole geopolitical landscape changes and the Fleming Fund, which now no longer exists as different countries seeks to divert their overseas development.

Professor Steve Wesselingh 38:37
Thanks, Branwen. Kirsty, did you want to comment on that?

Professor Kirsty Buising 39:18
Yeah, thanks, Steve.

I guess when you look at those graphs about AMR, I'm always cautious, because the sampling and testing is heavily biased. We all know that in countries where people are needing to pay a lot of money to have a test done, that they're only having that test done oftentimes when they're at the extremes, when they failed several courses of empiric antibiotics. We may be getting biased views that we need to be cautious about. But nevertheless, my answer to this would be that it's locally dependent. I think in a country where you don't have clean water in your hospital, that's the priority. Whereas, if you're in another country where perhaps that need is being met, but you've got rampant over use of over the counter anti microbials in the community for conditions that aren't even infections, that might be your priority.

I'm very keen that we try to build capacity locally, and that those local champions can customise the responses within their own countries to suit their key drivers. But my last response to your question is, yes, I do think the response to AMR needs to be a global one. Although Australia is an island, we're not isolated and what happens internationally affects us.

Professor Steve Wesselingh 40:49
I'll go to Allen next to just comment on that.

Professor Allen Cheng 40:51
Oh, look, I probably don't have much to add. But just reflecting on what Kirsty was saying, it's almost like we have a Maslow's Hierarchy of Needs, the sort of sanitation and basic health needs initially and I guess I might add to that sort of basic levels of education. But then sort of moving up the level to more complex or high level needs that need to be in place. I think a framework to think about that from immunisation lenses, you know the maturity level. This country is starting out with this. Have basic needs, certain levels of maturity, and then as the system evolves and improves, then you can do other things as well.

Professor Steve Wesselingh 41:38
Mark, I'm actually going to give you a different question, and that is one of the ones on the chat. What do you think are the most optimistic areas in AMR research at the moment? If you were NHMRC, where would you throw your money?

Professor Mark Blaskovich 41:54
In terms of what could have a short term, immediate impact from a therapeutic or preventative area, I think, as Branwen mentioned, introducing vaccines for additional bacteria would have greatly reduced the need for the use of antibiotics. I think the Meningococcal vaccine has strongly demonstrated that. Looking at the decline that Allen presented, that would be the reason why there has been such a decline in strep Meningococcal diseases from a treatment, from preventing the unnecessary use of antibiotic in humans, the best short term impact would be development of a rapid diagnostic. At that point of care, a physician would be able to say, yes, you do have bacterial infection rather than a viral infection, and ideally also identify what type of bacteria was, resistance profile was, so you could, right from day one, give the appropriate antibiotic treatment without this empirical therapy of a broad spectrum antibiotic that may not be needed for infection that you have, or you may not even have a bacterial infection. Thanks.

Professor Steve Wesselingh 43:04
Thanks very much. Thanks. We've got Wee-Ming's question here.

Thanks for highlighting so much in such an impactful way. Could you comment on the QUM aspects of antibiotic use as some of these behavioural adjustments can make huge gains without a major adjustment. Is there one QUM adjustment that you would like to see and why? I don't know who wants to go there.

Professor Allen Cheng 43:33
I'll take that a bit if you'd like Steve, but I will let Kirsty probably comment on this is sort of a world expert in this.

But so I worked for a short time in Denmark, and Denmark is sort of famous for, or Northern Europe in general, is sort of famous for not using a whole lot of antibiotics in primary care without obvious lack of differences in outcomes. We've got an idea of what the culture is like. That sort of gives you that result, and two anecdotes that sort of spring to mind, that the very first patient I saw in Denmark, yet he was in hospital, it's a bit unwell, but not desperately unwell. He had sinusitis. ]I said, well, we don't normally give antibiotics for sinusitis, but you've been in hospital for a while, you're not getting better. We haven't found any other reason, I think it is time for antibiotics. He said to me, can we give it just another another day or so, just to see if I'll get better and turn the corner, I really don't want to take these antibiotics. I thought, well, that's probably the first time that's anyone's ever said that to me.

Then the other one anecdote was the Danish physicians were having a discussion about what antibiotic we should put someone on? I said, it was pneumococcal pneumonia, I said, I'll probably change him to amoxicillin when we can, and it's well absorbed. It's only three times a day and they looked at me in horror, and said is that's a broad spectrum antibiotic, you know, why don't use penicillin? I went, oh, yeah. Probably made me really rethink, sort of, the context that I work in and I guess it's that overarching culture that sort of gives you some of those results. To answer, I really can't answer Wee-Ming's question, it's not really one thing, but it's a whole lot of things. But you know it's the context, and it's about public education and changing the culture in medicine and doctors as well. But yeah, interested in Kirsty's opinion on this?

Professor Kirsty Buising 45:36
Alan, you went to the same place that I would have gone to as well.

I would be commenting on primary care as well, but importantly, not to be critical of our primary care colleagues. They are doing an enormous amount to try and reduce antimicrobial use. I really want to acknowledge all the efforts that are being driven by general practitioners in Australia. But I think it does mean that we need to be doing education of the public as well as education of the healthcare providers, so that people are less likely to be expecting that if their cough has gone on for two weeks they must need an antibiotic, when we know that's what happens with bronchitis, and it doesn't necessarily need an antibiotic.

If I was answering Wee-Ming's question, I would probably look to primary care too, because that's where the greater volume is and probably the most impact for those who aren't pharmacist. QUM I should explain is quality use of medicine, so it's just about improving the way that we use our antibiotics. If we were talking about hospital medicine, then probably durations of therapy would be something to look at, and in particular, calling out surgical prophylaxis prolonged durations as an opportunity for improvement there. But yeah, I thought very similarly to what Allen was thinking.

Professor Steve Wesselingh 46:52
Thanks. Branwen, did you put your hand up or something to answer that question?

Professor Branwen Morgan 46:59
Oh, before it was Steve. It was about the point of care diagnostic and you're asking where do you put money? I think the really interesting case study here is we do have a point of care diagnostic that distinguishes between viral and bacterial infections. It was developed in Australia. It's FDA approved. It's got good evidence behind it, but we're struggling to get it into practice. Why? Because what do you do with that point of care diagnostic? Do you walk in as a patient like you would if you picked up a pregnancy test at the pharmacy? Does the GP have a whole stock of them in the office? Then do they pay for those in advance? Who reimburses you? Sit down, you do the test. It takes 10-15 minutes. Then what happens? Does the doctor write it into that medical practice system, and how is that linked to the prescription, to show the value or evidence and having that point of care diagnostic to reduce inappropriate prescribing. If we don't have our systems linked up, if we don't have our evidence chains linked up, we can't show the economics, and we can't show the benefits.

Professor Steve Wesselingh 48:00
Thanks for that. Actually, I think that goes to, and it's another question here, but linked to the first question, and that is how much do Australians know about AMR and how much do they care?

As Allen said, do we have Australian patients going to doctors and saying, don't treat me with antibiotics? I do think, actually, the microbiome work has changed that a little bit. I think people are now worried about their micro, they're taking yogurt and probiotics, and now they worry that antibiotics are going to stuff all that up. Just interested in, should we be doing more in terms of public education and how do you deliver this to the public? Apublic that we now know doesn't actually read newspapers very often, but reads lots of news on other areas and the role of influencers as well.

Mark, you look like you want to say something. Go for it.

Professor Mark Blaskovich 48:55
Yeah, I do. I mean, I do a fair amount of public lectures, and there's certainly a percentage of the population that's across the issue, but there's also a significant proportion that that just don't understand it.

When they're talking about antibiotic resistance, they think it's your body's becoming resistant to the antibiotics, not the bacteria. Somehow we have to be able to tell the story better. The Wellcome Trust has done some studies on the terminology and antimicro resistance doesn't cut through. They had suggested drug resistant infections, but then a more recent study says that that's not very effective.

The messaging is really important and I think the other thing just in terms of trying to get the public not to use antibiotics so much. There's this general perception that that antibiotics are harmless, right? So you can take one just in case. If people hang on to their antibiotics that they're prescribed and will take it if they're not feeling well at some other point. You don't do that with any cancer drugs. You don't take an anti cancer drug just in case you have cancer and so somehow we need to get across that antibiotics are not harmless. They both have acute toxic effects. They can cause kidney damage. They can cause damage to hearing loss, as well as that more nebulous long term effects of you're contributing to the development of resistant bacteria that eventually may kill someone else. Thanks.

Professor Steve Wesselingh 50:21
Thanks very much, Mark.

The next question is actually about where's the best place to look, where's the best place to do surveillance?

I think Kirsty did say primary care, but is our primary care system set up to do surveillance? It does mean that when you go to the GP, the GP actually has to take a swab and send it off for culture. Maybe we'll go to Kirsty. Branwen's already answered on the chat, so I'm not going to go to you Branwen, I'm going to go to Kirsty and say is our surveillance good? How could we improve it? Is primary care the target?

Professor Kirsty Buising 51:08
I think this is a difficult question to answer, Steve, because there is a risk in too much testing and there's an important component to all of this, which is diagnostic stewardship and not over testing, because test results can actually drive inappropriate antibiotic use.

A person without urinary symptoms who has a urine scent might well be colonised by bacteria in the urine, but they don't need treatment, and it's very hard to explain that to a patient when they can see an organism on the report. So over testing is a risk, and we need to think carefully about what surveillance is most useful. That being said, I do think that the aura report, which is the antimicrobial usage and resistance in Australia that the Commission for Safety and Quality in Healthcare, help to produce is an excellent report, and it does cover primary care and hospitals separately, and gives us a nice perspective on what's likely to be going on. Of course, we can improve, but I think that's been a major step forward, and we ought to be very proud of that.

Professor Steve Wesselingh 52:21
Thanks, Kirsty.

There was a question further up the list that I over missed, but that was about phages. Maybe mark or Allen could comment on. There's actually quite a lot of good phage research going on in Australia, yet I think there's a bit of resistance in using phages in clinical medicine. But just interested in your thoughts about phage research and where it's going and its potential.

Professor Mark Blaskovich 52:50
I'm happy to speak to that. Phage therapy is being used for decades, right? It's used extensively in Eastern Europe in the 20s, 30s, 40s, when they didn't have access to antibiotics, and has continued in a number of the Eastern European countries. As you mentioned, Australia is one of the world leaders in developing phages as a treatment therapy.

The biggest problem is that there still are not placebo controlled or controlled clinical trials that actually demonstrate it has really significant ethnic disease. It's a lot of one off, anecdotal evidence that this helped to save a patient's life. In terms of future of phage therapy, I think it's got potential to be specialised cases of infections in terms of replacing antibiotics as a general, broad therapeutic approach because of specificity of the phages, the potential for development of resistance against phages. I'm not sure it will ever be the mainstream replacement for something as broad spectrum as an antibiotic. I think it'll work well in parallel or in companionship with antibiotics.

Professor Allen Cheng 54:02
From a clinical perspective, I think there's a number of patients where we're reaching for the phages, when we haven't got much else to to reach for and those are sort of part of trials and research. I think part of the issue that Mark sort of alludes to, is that we have for antibiotics, we have a lab. We have testing to say we can use this antibody, we can't use that antibiotic. That whole infrastructure would need to be set up for phages as well as to show that it actually does work. I think there's a little way to go there in terms of what is the place of phages in therapy? What you know? How do we know which patients it'll work and or not work in? Then you know, what is the benefit and potential risk, I suppose, in in using them. I think there's still a lot of work to be done there.

Professor Steve Wesselingh 54:57
Thanks, Allen. I'd really like to thank the panel for answering all the questions on the chat which is terrific.

There was a really good question about workforce, and there's been about three different things come up on the chat about workforce. Thanks for answering those questions and sending all that information. That's terrific. We're getting close to the end so what I'm going to do is ask each of you to think about what is the one thing that you would like to see done, and that can actually include what you'd like to see NHMRC do, by the way, if you'd like us to do something.

But yeah, I'm just going to ask you what's the one thing that can be a global thing, can be a local thing, can be a funding thing, whatever. But I just want to ask you to choose one thing that you'd like to do.

Actually, before we go to that, I just like to congratulate the panel on their presentations. I thought they were fantastic. I really liked the burning platform. I thought that was terrific and also the pull push necdote from way back. Most people would have never seen that Mark, so that was really good as well. But I'm going to go to Branwen, Kirsty, Mark and Allen. That's across my screen for your final pitch. This is your sort of big pitch. Go Branwen.

Professor Branwen Morgan 56:23
I would focus on implementation and follow on funding for the projects that have demonstrated impact. I'm thinking of things like STI diagnostics and remote and rural communities. When that funding runs out, there is no money to pay those community nurses, no money to support these diverse diagnostics and the treatment of infections in those patients. Can we think a little less about the shiny, sexy, new toys that we want to develop and more about implementation funding, what works with a community based impact focus? Thank you.

Professor Steve Wesselingh 56:54
Fantastic. Thanks. Kirsty.

Professor Kirsty Buising 56:56
I'd like to see more investment in behavioural interventions, Steve. So understanding the drivers for the requests for antimicrobials, particularly in situations where they're not necessarily needed, and to narrow down to a better understanding of the person centred drivers for the behaviours that are perpetuating this problem.

Professor Steve Wesselingh 57:16
Fantastic. Thank you, Mark.

Professor Mark Blaskovich 57:18
I'll take a step back and really it's funding. We need more funding to do everything that we want to try doing, and there needs to be more government investment. I think that the recent announcement of additional CIRO cuts, and particularly in health, is particularly disappointing. But yeah, we just need more investment into research.

Professor Steve Wesselingh 57:38
Yeah, I can't disagree with that. Allen.

Professor Allen Cheng 57:41
The problem with going last is everyone else has finished my points. But I guess two things I would say would be thinking more broadly than even. AMR, how do we do public education in this sort of era of disinformation and mistrust of science? I think it is an important problem to understand. I think the other one, as a key area, is vaccines for key infections. If we had a vaccine against Staph aureus, we would beat a whole lot less than antibiotics, at least in that area.

Professor Steve Wesselingh 58:13
Thank you very much. I'd love to keep going, but we really have to finish. Actually, I'm over time, and I'm not supposed to be over time.

I really want to thank you for your time and effort coming on today and also developing your presentations, and then all the stuff in the chat as well. It really has been terrific, and I think we've learned a lot, and there's been a lot of very positive chats about how good the presentations have been.

Thank you very much. I do want to emphasise that this has been recorded, so if anyone has a desire to watch it again or to send it to somewhere else, please do that. If you have any more questions, please continue to either put them in the chat or talk to the media team. We can actually send the questions to Branwen, Kirsty, Mark and Allen, and I'm sure they'll answer them for us and and really, again, want to thank everyone for coming online.

We have lots of people online, lots of great questions, lots of positive comments. Fantastic panel on what has been an incredibly important issue and will continue to be an important issue and one that I think the research community, the clinical community and the public health community, and then finally, the public needs to solve together. So thank you very, very much.

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