Dear All (Wonkish alert! Not technical but lengthy … so settle in and enjoy the ride!):
Regular readers will know of my fascination with language: e.g., this 20 Feb 2020 newsletter entitled “Language Matters: CRE vs. CPE; SDD vs. I; And MDR, XDR, PDR, UDR vs. DTR.” How about that for acronymics taken to Olympian levels (😃)!
Continuing with the theme of the language AMR, I heard a fascinating talk by Eva Krockow during the recent Uppsala Antibiotic Days symposium. Sparked by her comments, we have this 4-part newsletter:
- AMR is a really bad acronym … and other choices aren’t that much better
- Metaphor is a powerful tool
- ChatGPT got creative with this!
- Closing comments
… and, we’re off!
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Part 1: AMR is a really bad acronym … and other choices aren’t that much better
Here are links that you’ll need. If you are pressed for time, the first paper in the list is the key:
- [KEY PAPER] Krockow, E.M., Cheng, K.O., Maltby, J. et al. (2023). “Existing terminology related to antimicrobial resistance fails to evoke risk perceptions and be remembered.” Commun Med 3, 149 (2023). https://doi.org/10.1038/s43856-023-00379-6.
- It was a lecture grounded in data from this paper that prompted this newsletter!
- [GOOD BACKGROUND] Krockow EM (2020). “Nomen Est omen: why we need to rename ‘antimicrobial resistance.” JAC-Antimicrob Resist. 2(3): dlaa067. https://doi.org/10.1093/jacamr/dlaa067.
- Nomen est omen = “the name is a sign.” This paper reviews the transformation of names in other spaces (e.g., GRID became HIV/AIDS) and provides an introduction to the psycholinguistic properties of names.
- [FOR A DEEPER DIVE] Mendelson, M., M. Balasegaram, T. Jinks, et al. (2017). “Antibiotic resistance has a language problem.” Nature 545(7652): 23-25., https://doi.org/10.1038/545023a.
- The authors argue that “AMR” is confusing, that “DRI” (Drug-Resistant Infection) would be better, that “stewardship” is ambiguous, and that “war on AMR” fails to recognize our symbiotic relationship to our microbiome,
- Sorry, but this one is behind a paywall!
- [FOR A DEEPER DIVE] Anonymous (2019). “Reframing Resistance. How to communicate about antimicrobial resistance effectively.” https://wellcome.org/reports/reframing-antimicrobial-resistance-antibiotic-resistance
- Based on message testing with 12,000 people in Germany, India, Japan, Kenya, the UK, the USA, and Thailand, this fascinating report from Wellcome emphasizes the power of words grounded in the here and now about how AMR is universal issue that undermines modern medicine
- [FOR A DEEPER DIVE] Karvanen, M. and O. Cars (2024). “The language of antimicrobial and antibiotic resistance is blocking global collective action.” Infect Dis (Lond) 56(6): 487-495. https://www.tandfonline.com/doi/full/10.1080/23744235.2024.2332455.
- This recent paper suggests the use of “ABR” (antibiotic resistance) and is a good resource for recent papers on the idea(s) of the language of AMR..
- There are other papers on these themes .. see below my signature (and below the ChatGPT conversations) for the ones I spotted while writing this newsletter.
If you survey the papers above, the thing that emerges is that everyone agrees that “AMR” is reasonably accepted with technical audiences but is not a great way to convey the complex idea(s) of antimicrobial resistance to lay audiences. Alternatives have been proposed but none have been tested for their ability to punch through the noise of day-to-day life.
Starting from the premise that creating behavior change would be easier with memorable, evocative terms, Krockow and colleagues surveyed phrases already in circulation, hoping that perhaps one of these would be sufficiently clear as to be good-to-go. They found six terms in (reasonably) common use: AMR, Antibiotic Resistance, Antimicrobial Resistance, Bacterial Resistance, Drug-Resistant Infections, and Superbugs. A bit of context on these terms is provided in this table:
Combining those six terms with 34 other terms for key health risks and disease names taken from WHO’s 2009 Global Health Risks report (e.g., “cancer”) , the research team tested the terms for risk association (i.e., is the term scary?) and memorability with 237 US and 924 UK participants.
Their results are shown below. At below left, we have the terms ranked by scariness. At below right, we have the terms ranked by memorability. Ugh! “AMR” is really rock bottom (red arrows) whereas “Cancer,” “Ebola,” and “AIDS” are very strong. “Drug-resistant infections” did well on ‘sounds scary’ but it was “antibiotic resistance” that did the best on both scales (green arrows).
Well, how about that! Absolutely NONE of the terms did very well and “AMR” was definitely dead last.
As the authors conclude: “Our findings support the previous literature on the inappropriateness of current terminology for public health communication about AMR” and “no existing AMR-related health term is likely to be sufficient for drawing the warranted attention to AMR’s global public health issue.”
And, that’s just for communication in English! What about other languages? In a sidebar conversation, Eva pointed out to me this paper and its supplemental data:
- Mokoena, T. T. W., N. Schellack and A. J. Brink (2021). “Driving antibiotic stewardship awareness through the minibus-taxi community across the Tshwane District, South Africa-a baseline evaluation.” JAC Antimicrob Resist 3(3), https://doi.org/10.1093/jacamr/dlab106.
- Supplemental data: dlab106_Supplementary_Data (a Word .docx file)
Beyond the witty title (look closely), the impact of the diversity of languages is well illustrated by this excerpt from the supplemental data:
You don’t have to be a linguist to realize that translation is going to be a big deal! Some of those phrases are really long!
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Part 2. Metaphor is a powerful tool
If those terms are so inadequate, are there other options? In her lecture at Uppsala Antibiotic Days, Eva turned to a 2011 PLoS One paper by Thibodeau and Boroditsky. Entitled “Metaphors we think with: the role of metaphor in reasoning,” this paper shows that even brief use of metaphor can strongly influence thinking and behavior. She noted, for example, that likening COVID-19 to smoke conveyed a message of “better ventilation is a good idea!”
So, to that end, she mused about the possibility of finding metaphors to convey the ideas of antibiotic resistance (ok, I will try to stop using AMR!).
Two metaphors that we already have are “Antibiotics are the Fire Extinguishers of Medicine” and “Diagnostics are the Smoke Detectors of Medicine.” I’ve found these to be very useful for English-language speakers, but will these translate to all settings? Unknown … and needs to be examined!
We don’t (yet) have any new answers but excitingly Eva and Marc Mendelson (the lead author of paper #3 cited above) are now starting a project called the ALARM Study: Advancing health Literacy about Antimicrobial Resistance through use of Metaphor. Great idea!
Eva and Marc are keen to involve stakeholders in their research. In fact, they’ll be conducting a so-called Delphi study, which will involve an expert stakeholder panel rating existing metaphor ideas and contributing their own suggestions. If you’d like to get involved or learn more about the project, please check out the project site (https://le.ac.uk/psychology-vision-sciences/research/health-and-wellbeing/alarm) or email Eva directly at emk12@le.ac.uk.
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Part 3. ChatGPT got creative with this!
OK, so I’ll admit I got very excited about this lecture and idea of metaphor. Seeking a bit of inspiration, I turned to ChatGPT and asked it for help! The full transcript is below my signature but here’s the summary:
- Explain antimicrobial resistance using a metaphor
- Medieval kingdom under siege
- Garden infested with weeds
- City overrun by crime
- Computer under attack by viruses and malware
- Give me some alternative metaphors to describe antibiotics
- The repair crew for your city
- A team of pest exterminators
- Snowplows
- And it was interesting that for all 3 of these, ChatGPT extended its text to talk about failure of (say) the repair crew as a metaphor for antibiotic resistance
- Give me some alternative metaphors for diagnostics
- The compass of medicine
- The roadmaps of medicine
- The detectives of medicine
Fascinating! Snowplows and kingdoms under siege didn’t do much for me but I rather liked the idea of diagnostics as a compass or map … I can see this as telling you which to go to become well. In that metaphor, you then choose a particular road (antibiotic) for your journey. Is antibiotic resistance then a washed-out road? Hmmm. Getting pretty complicated here!
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Part 4. Closing comments
Well, that was a sobering diversion! AMR is not a good phrase for lay audiences, but to some extent we are stuck with it in the technical literature. I don’t think, for example, that I am going to rename AMR.Solutions!
But, I do think we should look hard for better communication vehicles and I am excited for the project that Eva and Marc are undertaking! And if this interests you, then please reach out to help them per the details above.
And with that, we come to a close in our consideration of the:
#SmokeDetectorsOfMedicine
Metaphorically yours, –jr
John H. Rex, MD | Chief Medical Officer, F2G Ltd. | Operating Partner, Advent Life Sciences. Follow me on Twitter: @JohnRex_NewAbx. See past newsletters and subscribe for the future: https://amr.solutions/blog/. All opinions are my own.
Metaphors for antimicrobial resistance
[Me] Explain antimicrobial resistance using a metaphor.
[ChatGPT] Imagine a medieval kingdom under siege. The kingdom represents the human body, and the invaders are harmful bacteria. The kingdom’s defenses are the antibiotics. Initially, these antibiotics are like highly skilled knights who can defeat the invaders with ease.
However, over time, the invaders start to adapt. They learn the knights’ fighting techniques and develop armor and tactics to counter them. This adaptation is akin to bacteria developing resistance to antibiotics. The once effective knights (antibiotics) now find it harder to win battles, as the invaders (bacteria) have become stronger and more resilient.
Eventually, if the invaders continue to evolve and the kingdom doesn’t develop new strategies (like new antibiotics or treatments), the defenses will fail, leading to the kingdom being overrun. Similarly, without effective antibiotics, bacterial infections become much harder to treat, posing a significant threat to health.
[Me] Can you give me another for antimicrobial resistance?
[ChatGPT] Sure, think of a garden infested with weeds. The gardener uses a special herbicide to kill the weeds, which represents antibiotics fighting bacteria. Initially, the herbicide works well, and the weeds are kept under control.
However, some of the weeds start to develop a resistance to the herbicide. They mutate and become tougher, able to survive despite the gardener’s efforts. Over time, these resistant weeds spread, and the herbicide becomes less effective. The gardener has to use more herbicide or switch to a stronger one, but the weeds keep adapting.
If the gardener can’t find new ways to combat these resistant weeds, they will overrun the garden, just as drug-resistant bacteria can overrun the human body if new treatments aren’t developed.
[Me] Love it! Can you think of another?
[ChatGPT] Imagine a city with a powerful security system designed to catch and stop thieves, representing antibiotics targeting bacteria. In the beginning, the security system works perfectly, catching almost every thief that tries to break in.
However, over time, some thieves learn to bypass the security measures. They become more cunning, finding ways to sneak past cameras, disable alarms, and avoid detection. These smarter thieves are like bacteria developing resistance to antibiotics.
As more thieves learn these tricks, the security system becomes less effective. The city has to upgrade its security, but the thieves keep adapting to the new measures. Eventually, if the security system can’t keep up with the increasingly clever thieves, the city will be overrun by crime, much like how infections can become uncontrollable when bacteria become resistant to antibiotics.
[Me] Those are great! Can you think of a 4th metaphor for antibiotic resistance?
[ChatGPT] Sure! Picture a computer system that is constantly under threat from viruses and malware. The system has a robust antivirus software (antibiotics) that initially detects and eliminates these threats efficiently.
However, the malware creators are always looking for ways to outsmart the antivirus software. They develop new, more sophisticated versions of their malware that can evade detection. This process is similar to bacteria developing resistance to antibiotics.
As the malware evolves, the antivirus software struggles to keep up. The malware starts infiltrating the system more frequently, causing disruptions and damage. If the antivirus software isn’t updated or new protective measures aren’t developed, the computer system will become increasingly vulnerable to these persistent threats. This mirrors how bacteria can become resistant to antibiotics, making infections harder to treat.
The fire extinguishers of medicine
[Me] It’s been said that antibiotics are like fire extinguishers. Can you think of another metaphor to describe antibiotics?
[ChatGPT] Certainly! Think of antibiotics as a specialized repair crew for a city’s infrastructure. The city (your body) occasionally experiences damage from natural disasters like storms or earthquakes, which represent bacterial infections.
When a disaster strikes, the repair crew (antibiotics) is dispatched to fix the damage and restore the city to its normal functioning state. They are highly effective and efficient at their job, quickly repairing roads, buildings, and utilities.
However, if these natural disasters become more frequent or severe (more resistant bacteria), the repair crew has to work harder and longer. If the repair crew encounters damage they’ve never seen before and for which they don’t have the right tools or knowledge (antibiotic resistance), they struggle to make repairs. Over time, without new tools or methods, the city’s infrastructure may deteriorate beyond what the current repair crew can handle, leading to widespread disruption and decay. This is similar to how infections become difficult to treat as bacteria develop resistance to antibiotics.
[Me] Great! Can you think of a 2nd metaphor to describe antibiotics?
[ChatGPT] Certainly! Imagine antibiotics as a team of expert exterminators in a large house, where the house represents the human body and pests represent bacterial infections.
When the house gets infested with pests, the exterminators are called in to eliminate them. Initially, they have the perfect tools and methods to get rid of the pests effectively.
However, some of the pests start to adapt and become resistant to the extermination methods. They find new hiding spots, develop immunity to the chemicals used, and multiply despite the exterminators’ efforts. This adaptation is akin to bacteria developing resistance to antibiotics.
As the pests become more resilient, the exterminators have to use stronger chemicals or find new techniques, but the pests keep evolving. If the exterminators can’t keep up with the increasingly resistant pests, the infestation will grow, making it much harder to control. Similarly, bacteria that become resistant to antibiotics make infections more challenging to treat.
[Me] Ok! Do you have one more?
[ChatGPT] Of course! Think of antibiotics as a fleet of snowplows tasked with clearing the roads in a city during a heavy snowfall, where the snow represents bacterial infections.
When a snowstorm hits, the snowplows are deployed to clear the streets, ensuring that traffic can move freely and safely. Initially, the snowplows are very effective, quickly removing the snow and keeping the roads clear.
However, over time, the snowstorms start to change. They become more intense and produce a type of snow that is harder for the plows to handle. This change in the snow represents bacteria becoming resistant to antibiotics.
As the snowstorms continue to evolve, the snowplows struggle to keep the roads clear. They may need to work longer hours or use new techniques and equipment. If the snowplows can’t adapt to the increasingly difficult conditions, the roads will become impassable, causing significant disruption. Similarly, as bacteria become resistant to antibiotics, treating infections becomes much more challenging.
Diagnostics are the smoke detectors of Medicine
[Me] It had been said that diagnostic tests are the smoke detectors of medicine. Can you think of another metaphor to describe diagnostics tests?
[ChatGPT] Diagnostic tests can also be thought of as the “compass” of medicine, guiding healthcare professionals toward the right diagnosis and treatment direction.
[Me] That’s great! Can you think of another metaphor for diagnostic testing?
[ChatGPT] Diagnostic tests can also be considered the “roadmaps” of medicine, helping doctors navigate through symptoms and signs to reach the accurate diagnosis and optimal treatment plan.
[Me] Ok! Can you think of a 3rd metaphor for diagnostic testing?
[ChatGPT] Certainly! Diagnostic tests could be likened to “detectives” in medicine, uncovering clues and piecing together evidence to solve the mystery of a patient’s condition.
Further resources
While researching this newsletter, I also found these fascinating articles:
- Haenssgen MJ, Charoenboon N, Zanello G, et al. Antibiotic knowledge, attitudes and practices: new insights from cross-sectional rural health behaviour surveys in low-income and middle-income South-East Asia. BMJ Open. 2019 Aug 20;9(8):e028224. https://doi.org/10.1136/bmjopen-2018-028224. PMID: 31434769; PMCID: PMC6707701.
- Charoenboon, N., Haenssgen, M.J., Warapikuptanun, P. et al. Translating antimicrobial resistance: a case study of context and consequences of antibiotic-related communication in three northern Thai villages. Palgrave Commun 5, 23 (2019). https://doi.org/10.1057/s41599-019-0226-9.
- Djerf-Pierre, M., & Lindgren, M. (2021). Making sense of “superbugs” on YouTube: A storytelling approach. Public Understanding of Science, 30(5), 535-551. https://doi.org/10.1177/0963662521989251.
- [NEW] Environmental AMR issues, anyone? ICARS has call open through 1 Aug 2024 for “projects in the public health sphere that aim to mitigate the evolution and transmission of resistance in the natural or built environment.” Grants are available of up to $800k for up to 4 years. Go here for details; for questions and submissions, write to RFP_EDAR@icars-global.org. Applicants should also refer to “Mitigating antimicrobial resistance (AMR) using implementation research: a development funder’s approach” from JAC 2023 (https://doi.org/10.1093/jacamr/dlad031).
- CARB-X has open calls that span four areas: (i) Therapeutics for Gram-Negatives, (ii) Prevention for Invasive Disease, (iii) Diagnostics for Neonatal Sepsis, and (iv) Proof-Of-Concept for Diagnosing Lower-Respiratory-Tract Infections. See this 6 Mar 2024 newsletter for a discussion of the call and go here for the CARB-X webpage on the call. There are multiple opportunities to submit — see the CARB-X webpage for details.
- BARDA’s long-running BAA (Broad Agency Announcement) for medical countermeasures (MCMs) for chemical, biological, radiological, and nuclear (CBRN) threats, pandemic influenza, and emerging infectious diseases is now BAA-23-100-SOL-00004 and offers support for both antibacterial and antifungal agents (as well as antivirals, antitoxins, diagnostics, and more). Note especially these Areas of Interest: Area 3.1 (MDR Bacteria and Biothreat Pathogens), Area 3.2 (MDR Fungal Infections), and Area 7.2 (Antibiotic Resistance Diagnostics for Priority Bacterial Pathogens). Although prior BAAs used a rolling cycle of 4 deadlines/year, the updated BAA released 26 Sep 2023 has a 5-year application period that ends 25 Sep 2028 and is open to applicants regardless of location: BARDA seeks the best science from anywhere in the world! See also this newsletter for further comments on the BAA and its areas of interest.
- HERA Invest was launched August 2023 with €100 million to support innovative EU-based SMEs in the early and late phases of clinical trials. Part of the InvestEU program supporting sustainable investment, innovation, and job creation in Europe, HERA Invest is open for application to companies developing medical countermeasures that address one of the following cross-border health threats: (i) Pathogens with pandemic or epidemic potential, (ii) Chemical, biological, radiological and nuclear (CBRN) threats originating from accidental or deliberate release, and (iii) Antimicrobial resistance (AMR). Non-dilutive venture loans covering up to 50% of investment costs are available. A closing date is not posted insofar as I can see — applications are accepted on a rolling basis; go here for more details.
- The AMR Action Fund is open on an ongoing basis to proposals for funding of Phase 2 / Phase 3 antibacterial therapeutics. Per its charter, the fund prioritizes investment in treatments that address a pathogen prioritized by the WHO, the CDC and/or other public health entities that: (i) are novel (e.g., absence of known cross-resistance, novel targets, new chemical classes, or new mechanisms of action); and/or (ii) have significant differentiated clinical utility (e.g., differentiated innovation that provides clinical value versus standard of care to prescribers and patients, such as safety/tolerability, oral formulation, different spectrum of activity); and (iii) reduce patient mortality. It is also expected that such agents would have the potential to strongly address the likely requirements for delinked Pull incentives such as the UK (NHS England) subscription pilot and the PASTEUR Act in the US. Submit queries to contact@amractionfund.com.
- INCATE (Incubator for Antibacterial Therapies in Europe) is an early-stage funding vehicle supporting innovation vs. drug-resistant bacterial infections. The fund provides advice, community, and non-dilutive funding (€10k in Stage I and up to €250k in Stage II) to support early-stage ventures in creating the evidence and building the team needed to get next-level funding. Details and contacts on their website (https://www.incate.net/).
- These things aren’t sources of funds but would help you develop funding applications
- AiCuris’ AiCubator offers incubator support to very early stage projects. Read more about it here.
- The Global AMR R&D Hub’s dynamic dashboard (link) summarizes the global clinical development pipeline, incentives for AMR R&D, and investors/investments in AMR R&D.
- Diagnostic developers would find valuable guidance in this 6-part series on in vitro diagnostic (IVD) development. Sponsored by CARB-X, C-CAMP, and FIND, it pulls together real-life insights into a succinct set of tutorials.
- In addition to the lists provided by the Global AMR R&D Hub, you might also be interested in my most current lists of R&D incentives (link) and priority pathogens (link).
John’s Top Recurring Meetings
Virtual meetings are easy to attend, but regular attendance at annual in-person events is the key to building your network and gaining deeper insight. My personal favorites for such in-person meetings are below. Of particular value for developers are the AMR Conference and the ASM-ESCMID conference. Hope to see you there!
- 17-20 Sep 2024 (Porto, Portugal): ASM/ESCMID Joint Conference on Drug Development to Meet the Challenge of Antimicrobial Resistance. Go here to register!
- 16-20 Oct 2024 (Los Angeles, USA): IDWeek 2024, the annual meeting of the Infectious Diseases Society of America. Save the date! More details to come!
- 25-26 February 2025 (Basel, Switzerland): The 9th AMR Conference 2025. Go here to register!
- 11-15 April 2025 (Vienna, Austria): ESCMID Global 2025, the annual meeting of the European Society for Clinical Microbiology and Infectious Diseases. Go here for details.
Upcoming meetings of interest to the AMR community:
- 13-17 June 2024 (Atlanta, Georgia): ASM Microbe, the annual meeting of the American Society for Microbiology. You can’t register yet, but you can go here for general details.
- 27 June 2024 (virtual, 5p-630p CEST): GARDP REVIVE Webinar “Progressing an antibacterial drug discovery project – an SME perspective”. Click here for details.
- 17-20 Sep 2024 (Porto, Portugal): ASM/ESCMID Joint Conference on Drug Development to Meet the Challenge of Antimicrobial Resistance. See Recurring Meetings list, above.
- 16-20 Oct 2024 (Los Angeles, USA): IDWeek 2024, the annual meeting of the Infectious Diseases Society of America. See Recurring Meetings list, above.
- 19-27 Oct 2024 (Annecy, France, residential in-person program): ICARe (Interdisciplinary Course on Antibiotics and Resistance). Now in its 8th year, Patrice Courvalin directs the program with the support of an all-star scientific committee and faculty. The resulting soup-to-nuts training covers all aspects of antimicrobials, is very intense, and routinely gets rave reviews! Seating is limited, so mark your calendars now if you are interested. Applications open in March 2024 — go here for more details.
- 4-5 Dec 2024 (in person, Washington, DC): “Fungal Dx 2024: Fungal Diagnostics in Clinical Practice” is a 2-day in-person workshop organized by ISHAM‘s Fungal Diagnostics Working Group. The program and registration links are available at https://fungaldx.com/; the agenda is comprehensive and features an all-star global list of speakers.
- 11-15 April 2025 (Vienna, Austria): ESCMID Global 2025, the annual meeting of the European Society for Clinical Microbiology and Infectious Diseases. See Recurring Meetings list, above.