Guest blog by Adam Castaño‡, Sujal Parikh‡ and Eunice Yu, medical students at the University of Michigan Medical School, Ann Arbor, Michigan, USA (‡ These authors contributed equally to this post). Contact Adam Castano on firstname.lastname@example.org.
Nowhere in the world is free from the spread of drug-resistant bacteria, parasites and viruses. The World Health Organization (WHO) Global Alliance for Patient Safety has recognized the dual problems posed by the increasing incidence of drug-resistant bacteria and the decline in antibiotic innovation. For the past two years, a working group of policy makers, scientists, epidemiologists, and economists have assembled at several international meetings to outline an international strategy to address antimicrobial resistance (1). Policy recommendations, to be launched in 2010, will establish new roles for governments, public health departments, industry, and physicians as primary stakeholders in AMR prevention and alleviation. Physicians prescribe antimicrobials, contribute to the spread of pathogens (particularly hospital-acquired infections), educate patients about appropriate use of antimicrobials, perform research, and set research agendas. Medical students are being trained in an era where the toll of antimicrobial resistant infections is evident on a daily basis. As future physicians, they have the potential to help to address this problem. Here, we describe new leadership roles for medical students within their medical schools, hospitals, communities, states, and countries to alleviate the problem of AMR.
The role of medical students in medical schools
Medical schools, in particular the preclinical years, offer time for extracurricular activities that could be devoted to student forums dedicated to educating peers and discussing antimicrobial resistance with faculty members from a wide variety of disciplines. Medical students can form a student group, such as a chapter within their medical school of Antibiotic Defense , an organization of doctors, scientists, and professionals dedicated to conserving the availability and efficacy of antibiotics. Initial meetings dedicated to discussing fact sheets and publications from experts and opinion leaders would build the knowledge base needed to understand core issues in the field. Initiatives at the World Health Organization (2), ReAct: Action Antibiotic Resistance,(3) the Alliance for the Prudent Use of Antimicrobials,(4) and the Global Health Education Consortium (GHEC) contain useful information. Antibiotic Defense, in conjunction with GHEC, has published an open-access online module that medical students can utilize to educate themselves about the global nature of antimicrobial resistance (5).
Once students have attained a baseline understanding of the field at the local, community, national and international level, they can help educate fellow students in health professional schools in their region. GHEC accepts modules written by medical students designed to educate peers about issues pertaining to global health. Medical students can also work with faculty in their medical school to identify and fix gaps in their curriculum. Medical students should be informed of relevant international, national, and local policies affecting antimicrobial resistance, in addition to epidemiology, pathophysiology, and treatment. It should be emphasized to medical students that they play a role in containing AMR (figure).
The role of medical students in hospitals
Medical students in hospitals – as healthcare providers and as inadvertent contributors to the spread of pathogens – play an important role in the containment of AMR. Hospital-specific resistance trends and drug sensitivities for specific organisms can be learned from antimicrobial stewardship committee lectures and in-house publications. Familiarity with such resources can inform accurate antimicrobial choices. Equally important are drug resistance and sensitivity data for individual patients with culture-positive infections. Medical students can find this data by calling the microbiology lab or contacting outside hospitals for transferred patients. This up-to-date culture information can influence medical decision-making and ensure rational antimicrobial use. Finally, medical students can contribute to patient safety guidelines and quality improvement efforts in addition to role-modeling infection control techniques for their patients, residents, and attendings (senior physicians).
The role of medical students in the community
In addition to promoting change in their schools and hospitals, medical students can play a key role as educators and advocates in their local communities. The first step to fulfilling these functions is learning local patterns of AMR using resources outlined above. Students can then educate their community by writing opinion pieces and informational articles that discuss the growing problem of antimicrobial resistance and highlight its local manifestations. Articles specifically outlining steps for community members to limit the spread of resistance will be most applicable to community audiences. For example, methods highlighted for a community should relate to its unique circumstances in addition to reiterating known containment methods, such as not sharing antibiotics or thoroughly cleaning shared items like gym equipment (6).[v] Students can also determine the extent to which local public health and sanitation regulations limit the spread of antimicrobial resistance and lobby policymakers to change those statutes to protect public health.
As students engage in these processes, they will undoubtedly encounter topics where no reliable information is available. In these cases, joining a team that researches the biological, clinical, epidemiological, social, or economic aspects of antimicrobial resistance can generate the knowledge required to engage the activities outlined throughout this article.
The role of medical students in their state and country
Medical students can also influence discourse and policy at the provincial, state and national level. For example, In the United States, state health departments and the National Institutes of Health (NIH) offer opportunities for medical students to work to address the problem of AMR. Internships at state health departments could be arranged in order to learn epidemiology and public health initiatives involved in AMR surveillance and containment. At the national level, the NIH offers prestigious year-long fellowships in basic, clinical, and translational research. Such a program can be pursued to study the latest issues and solutions in AMR (7). Medical students interested in the politics and policies related to AMR can pursue similar internships in the office of a United States Congressperson. In addition, the collective voice of medical students can be harnessed through organizations such as the American Medical Student Association (AMSA) or American Medical Association (AMA) in support of efforts to strengthen research and development in this sector. Similar efforts can be pursued in other countries by working with state and provincial health departments, national medical organizations, and the International Federation of Medical Student Associations. The World Health Organization offers additional opportunities for medical student contributions both at its Switzerland headquarters and at regional offices in the United States, Denmark, the Philippines, India, the Congo, and Egypt.
A fundamental shift is needed in our attitudes to antimicrobials. What if antimicrobial effectiveness – not just antimicrobials themselves – was viewed as a global public good, much like clean water and forests? Antimicrobial effectiveness is a depletable resource, accessible to all but limited in quantity. Every time someone uses an antimicrobial, the effectiveness of that drug is slightly “used up” or “lost.”[vii] This continual depletion of antimicrobial effectiveness diminishes our ability to combat life-threatening infections and practice modern medicine. The spread of resistance by antimicrobial overuse is therefore similar to the problems we face with regard to other resources, such as carbon emission, overfishing, and the exhaustion of oil reserves. If we view antimicrobials as a global public good, a powerful agent whose effectiveness belongs not to an individual person or institution, but to society as a whole, then innovative efforts and policies become applicable. These realities must of course be balanced with the benefit of antibiotic use to the individual patient.
Competing interests statement: The authors are members of Antibiotic Defense, an organization founded by medical students at the University of Michigan that aims to preserve antibiotic effectiveness.
Figure : The role of medical students in limiting the spread of antimicrobial resistance
 World Health Organization, Third Global Patient Safety Challenge, Tackling Antimicrobial Resistance (2008). Available: http://www.who.int/patientsafety/events/09/12-130309_amr_minutes.pdf. Accessed : 28 October 2009.
 Cure With Care: Understanding Antibiotic Resistance. ReAct: Action on Antibiotic Resistance: Available: http://soapimg.icecube.snowfall.se/stopresistance/cure%20with%20care.pdf. Accessed: 28 October 2009.
 Alliance for the Prudent Use of Antibiotics. Research and Surveillance Initiatives: Available: http://www.tufts.edu/med/apua/Research/research.html . Accessed 28 October 2009.
 Castaño A, Kober M, Jain A, Prensner JR, Haack S, Parikh S (2008) “Antibiotic Resistance: Challenges and Solutions.” Global Health Education Consortium. Available: www.globalhealthedu.org. Accessed: 28 October 2009.
 Centers for Disease Control, Interagency Task Force on Antimicrobial Resistance and a Public Health Action Plan to Combat Antimicrobial Resistance. National Center for Preparedness, Detection, and Control of Infectious Diseases/Division of Healthcare Quality Promotion (2006) Available: http://www.cdc.gov/drugresistance/actionplan/index.htm. Accessed 28 October 2009.
 Howard Hughes Medical Institute, Research Scholars Program. National Institutes of Health. Available: http://www.hhmi.org/cloister/. Accessed 28 October 2009.
 Laxminarayan, R and Brown GM (2000) Economics of Antibiotic Resistance: A Theory of Optimal Use. Resources for the Future. Discussion Paper 00-36. Available: http://www.rff.org/rff/Documents/RFF-DP-00-36.pdf. Accessed 28 October 2009.