Antimicrobial resistance: Healthy Canadians podcast episode 3

Transcript

Transcript

[music]

Megan Beahen: Hi and welcome to Healthy Canadians, your space for nuanced conversations and expert insights about the health topics that matter to us all. We have practical information and resources to help you and your family stay healthy. I am your host, Megan Beahen.

At some points in our lives, most of us have or will use antibiotics. These medications have become so common and widely used that it's hard to imagine a world without them. But what if I told you that there is something that is threatening the effectiveness of these lifesaving medicines? It's called antimicrobial resistance or AMR. You may have heard about it, but it's a bigger and more complex issue than many of us realize. The good news is that there's solutions and things we can do as individuals to help prevent it. More on all that in a minute. But first, a word from, well, us.

Healthy Canadians is brought to you by Health Canada and the Public Health Agency of Canada. We aim to give you information and perspectives about the health topics that matter to all of us living in Canada. What we discuss won’t always reflect the official positions or policies of the Government of Canada, but that's okay. These are conversations, not news releases. Okay, we've got a lot to discuss. Let's talk about antimicrobial resistance. Today, I sat down with Anna-Louise Crago, senior epidemiologist with the Public Health Agency of Canada.

Hello, Anna-Louise, thank you for joining me today.

Anna-Louise Crago: It's a pleasure.

Megan: Today, we're talking about antimicrobial resistance or AMR and you are senior epidemiologist at the Public Health Agency of Canada on the AMR task force. That sounds very impressive.

Anna-Louise: Thank you.

Megan: Can you tell me what exactly it is that you do?

Anna-Louise: Sure. So, I'm part of a division that monitors and tries to work with all the different programs across the Public Health Agency, in fact, that monitor antimicrobial resistance as it emerges and tries to understand what's happening and tries to use that information to help inform action.

Megan: Very cool. You're the right person to talk to them about AMR.

Anna-Louise: Here's hoping!

Megan: So, here's what I know about AMR. Here's the first thing that comes to mind when I think about AMR: it's finish your antibiotics. That must have been like a key message or a campaign a few years ago that stuck in my mind. We're going to come back to that because that's not wrong necessarily, but we're going to unpack that a little bit later. But before we get into the details, let's back it up and talk about what is AMR. So, what are antimicrobials?

Anna-Louise: So, antimicrobials are medicines that are used to prevent or treat an infection in humans, animals or even plants. There are different kinds of antimicrobials used to treat different kinds of germs or microbes. So, antivirals treat viruses, antiparasitic treat parasites, antifungals treat funguses and antibiotics treat bacteria. And today, I'll primarily be talking about bacteria and antibiotic resistance, but I'll be using that umbrella term of antimicrobial resistance or AMR and other people are perhaps more familiar with terms like drug resistance or superbugs and they're (generally speaking) referring to the same issue.

Megan: Okay. Because, yeah, my mind goes right to antibiotics. Until this moment, I actually did not know that AMR was broader than just antibiotics.

Anna-Louise: It is. We tend to focus, in our work, primarily on bacteria, but there are funguses that are of concern like Candida auris is one of them.

Megan: Okay.

Anna-Louise: And antimicrobial resistance is also an issue for antivirals. So, it can be an issue for different lines of treatment in HIV medication, for example.

Megan: Okay, cool. So, why are they resistant? Why are they becoming resistant?

Anna-Louise: Well, let me start by explaining what resistant means. So, antimicrobial resistance happens when a germ develops a way to protect itself from the medication that is trying to kill it or to stop it from growing. And germs can develop resistance (so, let's take bacteria) to one class of antibiotics or to multiple classes of antibiotics. And that's when you start to talk about or hear about multidrug resistant infections. And when you get very far in terms of how many classes it's resistant to, you start often hearing of extensively drug resistant infections or XDR infections. What that means is that infections become a lot harder to treat. They become more costly. It takes more time to treat them. There is more personal suffering involved in treating them, and in some cases, sadly, they become impossible to treat.

Megan: Wow. So, the impact on humans is huge. Or the impact on just being able to fight bacteria infections. Pretty major.

Anna-Louise: Yeah, completely major. So, AMR can emerge naturally. But what is really driving the acceleration and the spread of AMR and the fact that is an issue for us today, is human behaviours that either expose microbes to antimicrobials, or that transmit microbes that have developed these ways of fighting back or resisting antimicrobials.

So, to paraphrase Swift, it's us. We're the problem. It's us.

Megan: Should we change the AMR tagline to that?

Anna-Louise: Potentially [laughs].

Megan: That said, and this is key: antibiotics, of course, save lives. And there are times where it is absolutely essential that we have them and that we're able to use them or that children are able to use them. So, the issue is reducing antibiotic use when it is not necessary and ensuring that when we do use them, we're using the right dose for the right duration in the right kind of antibiotics, and also trying to stop the spread of infections that have developed some of these resistance mechanisms.

Megan: Okay.

Anna-Louise: And if we zero in on some of how that happens, it might explain a bit better why that's key. So, if we take bacteria as our bug and antibiotics as our drug and look at those together. The first thing to know is our bodies are filled with bacteria, billions of them. And some of those bacteria can become harmful if they develop into an infection and others if those bacteria are friendly, if you will, what are called commensal bacteria. As these bacteria reproduce, they sometimes can change. What's called the mutation, and sometimes that has no effect on the bacteria's ability to survive. Sometimes it actually harms its ability to survive. Sometimes it gives us an advantage, an advantage like, for example, the ability to fight off antibiotics, trying to kill it. So, some antibiotics can develop these nifty little pumps that will try and pump out antibiotics that enter the cell.

Others will try and develop enzymes that act like little scissors snipping up the antibiotics as they come near them. And this can happen in both the friendly and the harmful bacteria. And when those bacteria are passed on to somebody else, if they are harmful and they have developed this resistance mechanism, that person might also develop an infection that's difficult to treat. The other thing to know is that in some cases when you expose someone to antibiotics or these bacteria to antibiotics, those processes can be accelerated. And so that's why you're trying to remove the unnecessary use and make sure you're carefully targeting when you do use antibiotics.

Megan: What I'm hearing is there are solutions [laughs], and there are things we can do to prevent. Like, me and you, there are things we can do to prevent, and we'll get into that a little bit later. But if you could just explain a bit about why would someone misuse or take antibiotics they don't need? Are people out there just casually taking antibiotics because they think they need them, like can you give me an example of why that happens?

Anna-Louise: I mean, we know from a study that was done in 2020, that study estimated that close to a quarter of all antibiotic prescriptions (this was a Canadian study) were for infections that very rarely ever needed antibiotics or never needed antibiotics.

Megan: Whoa.

Anna-Louise: When it came to children, it rose to a full quarter of those prescriptions were for infections that never needed antibiotics, like the common cold. That same study also found a lot of inappropriate prescribing. So, again, the wrong class of drugs, the wrong duration, or just prescribing a drug that's not necessary for ear infections, sinus infections, many common infections. The other classic thing is, again, the prescription of antibiotics to treat a virus when antibiotics do not treat viruses. So, we know there is an issue at that level. We also know that AMR can be – the spread of AMR can be facilitated in certain contexts, like hospitals, long-term care. But to turn to the positive about what you see is infection control and prevention measures in hospitals have had a really important effect. So, for example, when we look at – I can think of one infection in particular that we track as a key one - which is called MRSA or ‘mersa’ bloodstream infections. So, methicillin-resistant Staphylococcus aureus.

Megan: It’s a mouthful.

Anna-Louise: It's hard to spell. But what we see is that those can be acquired in the community or in health care settings. And there's been a real decline in the acquisition of them in health care settings. And so that showcases a little bit the importance of doing some of this infection control and prevention work. We also know that certain things can help reduce unnecessary prescriptions. So, point of care testing, for example, for strep, can help prescribers identify whether or not somebody has a bacterial or a viral infection. The other thing is a lot of prescribers talk about feeling a great deal of pressure to give a prescription. And, you know, the reality is many of us face a lot of time constraints or it can be work or money constraints or difficulty accessing medical professionals. And you sort of feel like, “oh, if I if I need a prescription, I better get it right now.” But there's two things to keep in mind.

The first is that we did public opinion research at the Public Health Agency of Canada, and it was a very high percentage. I believe it was about 87% of people reporting that they made their health decisions based on the guidance that they got from a health care professional. And that was across all sociodemographic groups that there was this large majority that had that opinion. So, when prescribers feel a lot of pressure, it's helpful perhaps to realize that when they're explaining the risks and benefits of an antibiotic, when they're talking about AMR, and when they're giving a recommendation that can have a real effect on the person who is listening to it. The other thing that has been developed over the years are things like “pocket prescriptions”, or taking a “wait and see” approach.

Megan: I bet know what that is.

Anna-Louise: Do you?

Megan: Well, I was just thinking as you we’re talking, a context could be when you're traveling and you're given a prescription for antibiotics. Sometimes when you're traveling, you see a travel doctor and they give you a prescription to take if you need it kind of thing. Is it a take it if you need to approach, the pocket prescription?

Anna-Louise: It’s a take it if you need it approach. But that, I would say, is much more conservative.

Megan: Okay.

Anna-Louise: So, what it is, is for many infections where you historically would go to see a prescriber and or health care professional and say, I have this infection, whereas in the old days you might automatically get an antibiotic. Often for certain common infections, what happens now is you're given a prescription and you're given some clear advice. So, you're told not to fill the prescription right away, but to watch for certain signs and symptoms. So, if this gets worse or if you start to see this happening after X amount of time, then take the prescription. However, if after X amount of time things are getting better, then you don't need to take it. And so that can also relieve a bit of the anxiety of like, ‘Oh, I need that prescription right now. And since I got it, I should take it.’

Megan: Okay.

Anna-Louise: …Because I don't have time to come back.

Megan: It's a good thing.

Anna-Louise: It's a good thing.

Megan: It's a good thing. Okay. Because when you started talking about it almost sounds like you're giving the power into a consumer – a patient's hands. Right, and they have to decide. But they can do that in consultation with a health care professional, maybe.

Anna-Louise: Oh, yeah. And often a lot of prescribers looked at that really clear forms that have an explanation of when to take one and when not to and what the duration should be, etc.

Megan: Okay. So, it actually could be a very empowering thing.

Anna-Louise: Yeah, absolutely.

Megan: Cool. So, you touched a lot about on like the scope of the problem and, sorry, the scope also of the use of antimicrobials. So, someone might use it. You know, I think about using antibiotics when I was a kid and I had strep throat all the time. That's the first thing that comes to mind for me. But people are using it. They have different chronic conditions. It's obviously being used in hospitals for various reasons. So, they're really important. We don't want to we don't want to lose them. They're very important. But, the failure when they don't work, can be a big, big problem, have a really big impact. Is that right?

Anna-Louise: Absolutely. So, we estimate that about 15 Canadians die every day directly from AMR.

Megan: Wow.

Anna-Louise: And a lot of people don't recognize or see themselves in that or think, how could that be happening around me? But that's because you have to realize drug resistance is happening across a whole range of different infections. So, when you think about it that way, sometimes people think, “Oh, well, I know that my uncle had this infection and then all of a sudden the antibiotic stopped working” or “I know somebody who had this and then it just was no longer treatable”. Well, that is one of the ways that AMR can manifest. On a global scale, it's one of the leading causes of mortality globally. So, the estimates for 2019 were that close to 5 million people die of deaths associated with AMR. And of those, about 1.3 million die directly from AMR, meaning that had the medicine worked, their deaths could have been avoided.

Megan: Whoa.

Anna-Louise: Yeah, and on a very concrete level, what it means for us and Canada is a lot of the antibiotics that used to work to treat infections don't work anymore. So, estimates are that about 26% of infections in Canada no longer respond to what is called first line treatment. So, the medication that is generally used to treat it and that by 2050 we might be at 40% that don't respond to first line treatment. So, that's what it can mean concretely for all of us. The thing to understand, fundamentally, is a lot of times people think AMR is a problem over there. It's a problem that happens to other people. It's a problem in the future. It's a problem that actually affects all of us right now. And it's true, certain groups are disproportionately affected and have a disproportionate burden. So, people who have long hospitalizations, people who have certain medical conditions, elderly people, infants, very young children, they're also depending on the infection. Certain communities who are disproportionately affected, it could be people who travel abroad who have spent a great deal of time living abroad. It could be certain First Nations, Inuit and Métis communities, certain northern communities.

For certain infections, it's two-spirit, gay, bisexual, men who have sex with men community or people who inject drugs. And it can also be factors like for some resistant infections, having recently taken an antibiotic increases your risk or having travelled to receive care abroad can increase your risk. But fundamentally, we are all at risk. And fundamentally, it's an issue that resistant bacteria are things that we are detecting in every province, in every territory right now in Canada. And perhaps more importantly, we all have really concrete ways that we can be part of the solution.

Megan: I keep teasing the solution and the prevention part, but we're not going to go there yet. But just to say that there's something for everybody there, right? Like, we all need to think about prevention and can learn more about AMR. First, I want to talk about the history. So, it's fascinating; the development of antimicrobials and the evolution of our understanding of them. Could you talk a little bit about that?

Anna-Louise: Absolutely. And I think the first thing is to understand what medicine was like and what the world was like prior to antibiotics. So, the mass production of antibiotics started in the early ‘40s. Prior to that, an infection from childbirth, from unclean water, contaminated food, from something as small as a scrape or a scratch could be deadly. And in fact, those infections did kill millions of people every year. Things like tuberculosis and pneumonia loomed large as killers of otherwise healthy young adults, and some of that is as captured in film and fiction. I think for those who know them well, Le Moulin Rouge, what that represented to people. Thousands and thousands of children died every year from what are now very treatable infections. In 1920 in Canada, one out of every five children did not live to see their fifth birthday.

Megan: Whoa.

Anna-Louise: Yeah. So that gives you a bit of a picture of what a world without antibiotics can be like. A world where even minor surgery or something like childbirth can be very dangerous.

Megan: Very risky.

Anna-Louise: Yeah. The way the story is usually told is that then in 1928, Alexander Fleming, a scientist, has a very happy accident. And he goes on vacation and he comes back and he finds mould in his lab growing on a petri dish of staph bacteria. And lo and behold, the mould is pushing back the growth of the staph bacteria. And he realizes he's fallen onto something that could be a potential really, really important medication. And he names it penicillin. And usually that is where the happy story ends.

Megan: That's what I heard.

Anna-Louise: But it's the larger story, is a lot more complex and a lot more interesting in terms of getting insight into what we're up against today, which is he tries to get colleagues to help him refine it, to turn it into medicine. And people are not that interested. It sits on a shelf for a while. And meanwhile, in Germany in 1934, there's a scientist named Gerhard Domagk, and he invents, or discovers, and refines (for use) the first class of antibiotics called sulfa drugs. And in fact, one of the first patients to be successfully treated is his six-year-old daughter, who has a very severe strep infection from an unsterilized needle. The sulfa drugs go on to be used for gonorrhea, for meningitis, for pneumonia, for burns, which were a real common occurrence during the war. However, within the first couple of years, those drugs stopped working as well as they did.

Megan: Wow.

Anna-Louise: Resistance starts to emerge.

Megan: So, we knew right away.

Anna-Louise: It's starting. In the meanwhile, other chemists pick up where Alexander Fleming left off. They refine penicillin, but they can't make enough to distribute it to large groups of people. So, they connect with the Department of Agriculture in the United States and the civil service scientists working there and they say basically help us out.

And there's a woman who was employed there as a lab assistant named Mary Hunt, who got the idea to go out and buy a whole bunch of moldy melons at the market and test and see what their concentration of penicillin was like. And sure enough, she figured out that they had six times the concentration of what Fleming had found. And this opened a door into understanding what are the factors that can increase the concentrations, and what are the factors. We need to have mass production and mass production starts to roll out in 1941, and it's a revolution in medicine.

So, antibiotics start to be used to treat all kinds of infections. They start to be used to enable different surgeries. They are key for childbirth. They are key for certain kinds of safe abortions. They are key for eventually, for chemotherapy. They also start to be used for animal health and to protect food security. But again, within one to two years, they start noticing that for some infections, penicillin is not working as well anymore. And in fact, by 1960, 80% of the staph infections in hospitals in Europe are not responding to penicillin anymore.

Thankfully, someone discovers methicillin. But you get the picture, which is that it's not a simple happy ending. What it is, is the beginning of this incredible race to keep up with resistance, with new discoveries and new antibiotics to protect these incredibly precious gains we've made and trying so hard to keep pace with them. And you see a golden age in antibiotic discovery and development, and then it slows down to a trickle. And that's where we are now as AMR is outpacing us and expanding and accelerating. So, that's the challenge we’re facing.

Megan: That is fascinating. And I read and you can tell me this is true or not, that when Fleming won the Nobel Prize for penicillin, he kind of low key said: “I don't know if this is going to work forever.”

Anna-Louise: You know, that's a really interesting point, and I have no idea if it's true or not.

Megan: Okay, well, let’s go with it.

Anna-Louise: But I will counter you with another Nobel story, which is: this guy got the Nobel Prize, but he was arrested by the Nazis for going to claim it. And he, having made this great discovery, it was very quickly, in most cases, replaced by penicillin. And he realized early on that drug resistance was going to be a big issue. And so even though that new drugs were being developed for tuberculosis, his main fear and his main purpose in his later years was finding substitute antibiotics because he felt and he was very prescient in this regard, that without antibiotics, that that we would run into resistance for tuberculosis and without different lines of treatment for tuberculosis, it would become the horrible travesty that it had been before.

Megan: Wow. Okay. So, that is sort of the global race is to understand it more and then either find a new treatment, find a new antimicrobial, or something else like, is that what we're working on?

Anna-Louise: Yeah. And these are all – absolutely, we need to develop new antimicrobials and there are unique challenges to that. But we also need to conserve the antimicrobials we have, and we also need to try and prevent transmission of bacteria that have resistance. So, it's a bunch of different fronts at once.

Megan: Right. So, one of the complexities with antimicrobial resistance I know is farming and animals. Could you speak to me a little bit about that?

Anna-Louise: Yeah, it is complex. So, antimicrobials (and antibiotics in particular) are essential to keeping animals healthy and by extension, to protecting our food security. However, agricultural practices can lead to AMR in animals that can spread to humans through food and through the food chain. Animals can transmit AMR to humans, and humans can transmit AMR to animals. And furthermore, some of the medicines that we use in the human health sector are also used in the veterinary and animal health sector. And this includes what we call the AIMs – sorry, the MIAs – the medically important antimicrobials. So, 82%, by volume, of all medically important antimicrobials sold in Canada in 2020, went to food producing animals or horses. Now, to be clear, there are more animals than humans in Canada. They, generally speaking, are heavier than humans. So, when you weight standardize it, they're consuming about one and a half times what humans are. Nonetheless, the amount of MIAs, medically important antimicrobials, sold for food producing animals is three times the average of what is sold in European countries.

Megan: Wow.

Anna-Louise: So, you can see why the agricultural sector becomes a very key partner in addressing AMR. It can't just be limited to the human health sector.

Megan: We're all connected.

Anna-Louise: We're all connected.

Megan: Can you speak a little bit about the one health approach?

Anna-Louise: Yeah. So, what the one health approach refers to is the notion that AMR emerges and spreads among humans, animals, crops and the environment that we share and that there's all kinds of interconnections back and forth amongst those. So, if you think of AMR spreading among humans, we often tend to think of like hospital acquisition, but it also spreads in the community. So, if you think of, for example, resistant gonorrhea, which is a sexually transmitted infection, well, that spreads through sexual contact in the community or some infections that spread through contaminated food and water, spread in the community.

Furthermore, we can spread AMR to transmit it to animals, and we can spread it in the environment. For example, when we flush antibiotics down the toilet or throw them in the garbage, and the antibiotics end up in the environment and can favour the emergence of AMR. As for animals, certain agricultural practices can also favour the spread of AMR in the environment, as well as potentially to humans through food, or also people who work closely with livestock are at higher risk of carrying AMR or even in some cases of AMR infections.

Megan: Oh wow.

Anna-Louise: In terms of the environment, it's a bit – there are risks to humans that are well known in terms of AMR, but they are less understood and less quantified than other areas of AMR. So, there's a lot of work to do to better understand what is happening with AMR in the environment and how it is affecting humans. But we know to give an example, that AMR can be found in fresh water. It is even found, sometimes, AMR bacteria or genes can sometimes be found in not well-cleaned, not potable water. Water that's supposed to be potable, but isn't. So, there’s much more left to understand about how all of those pieces interact. But certainly, the environmental piece underscores that AMR does not have simple borders.

Megan: Wow. Okay. Well, to keep it positive, obviously it's important. We've already talked about national, international collaboration. It seems like there's a lot of collaboration probably happening, you know, across industries, specialties to really understand from an interconnected one health perspective as well, right?

Anna-Louise: Absolutely. And one of the really exciting things that has recently come out is the Pan-Canadian Action Plan on AMR. And it really seeks to sort of formalize the Canadian Government's commitment to AMR, but also to galvanize Canadians, to become informed and engaged, and as individuals, as communities, and as part of all of these different sectors to address AMR. And it's also an ongoing collaboration between the provinces and the territories. There are five pillars to the Canadian action plan.

Megan: Let’s hear them.

Anna-Louise: So, the first is research and innovation. So, that gets at what we talked about earlier. The second is what's called surveillance. But really what that means is understanding and detecting when AMR is emerging or spreading, and a number of what are called key pathogens. So, what are the germs we're most worried about in that we're focused on looking at? And right now, it's about ten of them, give or take, it’s in the process of being changed and updated. But it gives you an idea of how much you have to keep your eye on so many different moving parts at once. And it's trying to gather that information to try and inform, better inform, how to take action and how to protect Canadians health.

The third is what's called stewardship. And what that really means is: how do we conserve and protect the antibiotics we have? What measures can, you know, can be taken or what can be done to try and conserve the antibiotics we have? The fourth one is infection control and prevention, which is absolutely key in hospitals to reduce emergence and spread. And the fifth one is leadership. So, I invite anyone listening to go look it up on the Canada.gc.ca website. It's really accessibly written and it's really interesting in explaining, laying out: what are the problems, and what are potential solutions, and how can everyone get on board to try and reach them? So, it's dealing with a very serious issue, but I find it to be a very optimistic document. And the other one that you can look at (if you're interested in globally) what's being done, is the World Health Organization, WHO’s AMR action plan.

Megan: I feel like after this conversation, people might want to go read those documents if they're looking on Canada.ca, do we just go to Canada.ca and maybe just type in antimicrobial resistance action plan?

Anna-Louise: I mean, that is what I do. I'm sure we can drop some links.

Megan: You could probably just drop that in Google even.

Anna-Louise: Yeah, you could. You could.

Megan: We’ll put it in the show notes. How about that?

Anna-Louise: Yeah, yeah.

Megan: And then they can just click on it.

Anna-Louise: The other thing is a lot… So, there are what are called what's called CARSS, which is the Canadian Antimicrobial Resistance Surveillance System. So, it looks at all these programs across the agency that are doing surveillance of different pathogens or in different environments, like are we seeing more AMR of this type in hospitals or not, for example? So, that's working with some of the amazing programs and within fact, like CNIS, for example, does the hospital-based surveillance and we in the CARSS report try and bring together at a high level that's pretty accessible, some of the findings from each of those programs.

Megan: Tell the story a little bit.

Anna-Louise: Yeah, tell the story by bringing those pieces together so everybody can see all the different parts of the story in one place.

Megan: That's very cool. Okay. We've come to the prevention portion of this conversation, the part everybody's been waiting for. What can we do ourselves to help prevent AMR, slow the pace of AMR? And maybe, let's just start with the key message I started with, which was: finish your antibiotics.

Anna-Louise: So, the message to finish your full course of antibiotics was one that the World Health Organization, for example, had up until 2017. And then, that message changed to: follow the guidance and advice of your health care professional. That is really important, and it's really important to ask your health care professional questions and get guidance. One of the reasons the WHO moved away from that message, to follow the guidance, and adhere to the guidance as a message, is because in so many areas of medical and scientific work, evidence is changing.

Megan: Right.

Anna-Louise: We're trying to keep abreast with all the changes and give the best possible information you can in the moment, and that is what the WHO was trying to do in that moment. One of the areas where evidence is changing, that's really interesting, is the duration of prescriptions for many common infections. So, traditionally, for many infections, you would go and you would automatically get an antibiotic and it would be for a quite long duration, often like two weeks. But there is emerging evidence that for some, not all, for some pretty common infections, that shorter one to seven-day prescriptions can be just as effective without some of the same risks of side effects, and that in some circumstances, the longer duration prescriptions can actually favour the emergence of AMR. Now, how do you know if that's the infection you have. Talked to your medical prescriber.

Megan: You have to ask your health care professional.

Anna-Louise: Yeah, and don't be afraid to ask the questions. Don’t be afraid to say, I want to know, what is the latest evidence or guidelines around duration for this kind of infection? Should I take a prescription right away? Is this an infection where it's appropriate to have a pocket prescription? These are all great questions. Do I keep on taking the antibiotic if I start to feel better or not? And go to your health care provider to answers to all of these questions, and if you are taking an antibiotic and you don't get better, it's also helpful to go to a medical provider and share that information with them. So, those are questions we shouldn't be afraid to ask.

Megan: We should feel empowered to talk to our health care professional about that.

Anna-Louise: Yeah, and to ask for things, like ask and see, is this a good moment for a pocket prescription, would this be advisable right now, and can you explain to me why or why not?

Megan: I think some people might listen to this episode and maybe be a little bit nervous now about taking antibiotics, or nervous about going to a health care professional because they don't want to be overprescribed. Could you speak to a listener like that?

Anna-Louise: I think that's a valid concern that could be the starting point for a really good discussion with a health care provider, because so much has to do with your individual situation. I think it's a really good starting point to talk about. What are the risks and what are the benefits to me of taking antibiotics, and should I be concerned about AMR with this infection or with this situation? So, I think it's a great starting point to have a conversation.

Megan: About being more mindful, maybe.

Anna-Louise: Maybe, or also perhaps it's a way to get information on specifically how to take the antibiotic and which one to take, and I think it's a helpful place to start, and I would also say one of the issues that concerns us is unprescribed antibiotic use. And I think it's very understandable, again, that there's so many constraints so many people face in getting to see a health care professional.

Megan: Right.

Anna-Louise: But if you're taking unprescribed antibiotics because you ordered them on the internet or you're taking old ones or you borrowed them from a friend, there's always a risk that you are taking the wrong kind of antibiotic, that maybe you have a viral infection, don't need them, or a bacterial infection that could clear on its own for which you might not be prescribed them. You might be taking the wrong dose, and there are non-negligible side effects to many antibiotics that are concerning. There's some evidence that certain kinds of antibiotics can alter your gut microbiome for two months. I think we do have to take antibiotics seriously, but more importantly, a medical professional can make sure you get the right medicine you need, if you need a medicine, or give you the advice you need to get better, and that's really important.

Megan: So, don't take antibiotics unless they’re prescribed to you.

Anna-Louise: Yeah, and unless you know you have all the information you need on how to take them.

Megan: Do you have any other practical tips you'd like to share?

Anna-Louise: I think on a practical level, it's really important to not dump your old antibiotics down the toilet and the garbage. You can bring them back to a pharmacy.

Megan: Okay.

Anna-Louise: I think if you're a prescriber, I know a lot of health care professionals are dealing with so much, it's really hard to keep on top of the latest information and evidence on every single possible health issue, but there are really interesting models and projects out there, and examples of how, as a prescriber, to address overprescribing or inappropriate prescribing of antibiotics. I think as individuals, we can have these conversations. I think some of the communities that are disproportionately affected by AMR can benefit from getting information and thinking about, on a community level, how do we want to address AMR in our community and how can we learn also from how other communities have addressed outbreaks of drug-resistant infections in their midst? There's a lot of experience and expertise that if we share, we can learn from, and that's encouraging to me.

Megan: That is great practical information. Thank you.

Anna-Louise: You're welcome.

Megan: I feel very lucky to have talked to you today, Anna-Louise. Thank you so much for sharing all your information. Before we close, as a senior epidemiologist working on the AMR task force at the Public Health Agency of Canada, what's your favourite part of your job?

Anna-Louise: [laughs] It's a great question. I really feel very lucky to work with some really wonderful people who are really committed to bringing a whole variety of skillsets and backgrounds to take on this massively complex problem with a great deal of optimism and tenacity. And, you know, I am relatively new to the job but there have been people who have really left a mark on the AMR world, not just in Canada, but globally, and I feel really lucky to follow in their footsteps as best I can.

Megan: AMR collaboration at the end of the day.

Anna-Louise: [laughs]

Megan: That's awesome. Thank you so much for joining us. We will have all the resources linked in our show notes.

Anna-Louise: It's a pleasure.

Megan: Thanks for tuning in to Healthy Canadians. If you're watching on YouTube, don't forget to click the ‘Like’ button below and subscribe to stay up to date on future episodes. Find us wherever you get your podcasts, and leave us a review if you like what you heard. For more information on the health topics that matter to you, visit canada.ca/health.

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