1. Think globally

2. Act locally

3. Make it personal

While campaigns focusing on the approaching ‘antibiotic apocalypse’ work to capture public attention, qualitative interview data show that these messages are often too sensationalized, which may backfire on their credibility. ⁷ Both clinicians and patients view AMR as a geographically and temporally distant phenomenon with a less personal impact on them. ^{Reference Van Hecke, Butler, Wang and Tonkin-Crine8} Rather than the more nebulous societal consequences of AMR, antimicrobial awareness campaigns should shift focus to the personal impact of AMR, including the very tangible and current risk of side effects, personal risk of AMR affecting future treatment options, and the perturbations to the microbiome.

4. Make the invisible visible

What does AMR look like? The concept of AMR is abstract to many. The exceedingly large projections of the impact of AMR do not tell the personal story of the devastation caused by drug-resistant infections on individual lives. Sharing patient stories can help ‘put a face’ to AMR, making the problem more relatable and inspiring efforts for change. ^9,10 Campaigns like ‘Go Blue for AMR’ include wearing light blue and illuminating local buildings and landmarks in light blue, which can further the visibility of what some have called the ‘silent pandemic.’ ¹¹

5. Think beyond the hospital walls and beyond the prescriber

Antimicrobial stewardship was initiated in the hospital setting; however, 80% of antibiotics are used in the community. ^{Reference Suda, Hicks, Roberts, Hunkler and Danziger12} Of those antibiotics, 20%–50% are used inappropriately. Primary care providers cite patient pressure for prescribing antibiotics for viral illnesses. ^{Reference Sanchez, Roberts, Albert, Johnson and Hicks13} Engaging physicians, veterinarians, and other healthcare professionals and policy makers in AMR awareness is essential to promoting One Health coalitions. ⁴ This need is highlighted by the WAAW 2022 theme, ‘Preventing antimicrobial resistance together.’ ⁵ Professional education and training for students and practitioners in human and animal health should also be established, as should the inclusion of antimicrobial use and resistance in school curricula and media to promote a better understanding of AMR. ⁴

Several recent ASHE publications have stressed the importance of broadening the horizon of antimicrobial stewardship awareness beyond prescribers and patients as well as outside the hospital walls. Gullen et al ^{Reference Gulleen, Krantz and Zier14} found that while ambulatory cancer center staff largely knew the term “antimicrobial stewardship,” there were opportunities to improve knowledge about appropriate antibiotic use, particularly among nurses and other clinic staff. Catanzaro et al ^{Reference Catanzaro15} highlighted the importance of involving nurses in antimicrobial stewardship using educational modules. Similarly, Manning et al ^{Reference Lou Manning, Pogorzelska-Maziarz, Jack and Wheeler16} demonstrated how patient simulations can improve nursing-student awareness of their role in antimicrobial stewardship. Hughes et al ^{Reference Hughes, Evans and Fitzpatrick17} identified several opportunities for improvement in dental antimicrobial stewardship, including improved awareness of and access to evidence-based guidelines, as well as harnessing social comparison to improve prescribing behavior.

6. Reframe what the “safe side” is

Antibiotics are often prescribed “just in case” and to “be on the safe side.” In a cross-sectional study using interviews of 90 dentists, 91.2% stated that they prescribed on a ‘just in case’ basis. ^{Reference Hughes, Evans and Fitzpatrick17} In a retrospective cohort study, 205 patients (80.7%) received empiric antibiotic therapy indicated for presumed urinary tract infection despite meeting criteria for asymptomatic bacteriuria. ^{Reference Bixby, Raux, Bhalla, McCoy and Hirsch18} However, given the known harms of antibiotic therapy, there is an opportunity to reframe messaging regarding “erring on the side of caution” to now mean thoroughly evaluating and monitoring the patient while considering other noninfectious causes before prescribing an antibiotic.

7. Meet the public where they are: use creative social media strategies

Social media has facilitated the rapid spread of health-related misinformation, ^{Reference Lanier, Diaz, Saleh, Lehmann and Medford19} but at the same time, it provides an instant connection between infectious diseases experts and the public. Social media platforms present not only an opportunity, but a responsibility to share accurate, clear, consistent, and engaging messaging on AMR. ^{Reference Cawcutt, Marcelin and Silver20} Endless opportunities exist to engage healthcare professionals and the public using creative approaches such as infectious diseases memes, clue-based knowledge assessment quizzes, and personality quizzes. ^{Reference Langford, Laguio-Vila, Gauthier and Shah21} Antibiotic awareness messaging can be embedded in each engagement strategy, tailored to the captive audience.

8. Leverage awareness related to the COVID-19 pandemic

The lessons we learned during the COVID-19 pandemic can also apply to antimicrobial stewardship. ^{Reference Barlam, Al Mohajer and Al-Tawfiq22}

1. (1) Antibiotics don’t treat viral infections, whether it be COVID-19 or the common cold. In the United States, ∼44% of outpatient encounters include acute upper-respiratory infections. ^{Reference Fleming-Dutra, Hersh and Shapiro23} Despite the majority of illnesses being caused by viruses, many patients still receive antibiotics, suggesting a need for improved awareness of the risks and benefits of antibiotics in this setting. ^{Reference Arensman Hannan, Draper, Uecker-Bezdicek, Gomez-Urena and Jensen24}

2. (2) Infectious diseases can be devastating. Unlike COVID-19, AMR is not caused by a single organism and presents a more insidious threat. We need to act quickly to prevent these devastating consequences while we still can. The increased awareness regarding the importance of infection prevention and control during the pandemic should also apply to AMR and may help garner research funding and public-sector support. ^{Reference Seneghini, Rüfenacht and Babouee-Flury25}

9. Use evidence-based messaging in awareness campaigns

Antimicrobial awareness messages should be based on scientific evidence. A previously common message to “finish the antibiotic course, even if you are feeling better” was replaced with more nuanced messaging recognizing the growing evidence base for shorter and more tailored courses of therapy. ^{Reference Huttner, Saam and Moja6} In addition, behavioral science needs to be incorporated into campaigns and formally evaluate and disseminate findings to help inform future antimicrobial awareness activities. Of 60 campaigns surveyed by the WHO, only 25 were evaluated, and for most of these campaigns, the results were not published. ^{Reference Huttner, Saam and Moja6} Wellcome’s Reframing Resistance report provides a list of practical evidence-based suggestions for awareness campaigns, including shifting fear-based messaging to that focusing on personal impact and opportunities for immediate action. ⁷ Although there is evidence that fear-based messaging can be effective, it should be combined with empowerment to encourage action rather than apathy. ^{Reference Roope, Tonkin-Crine and Herd26}

10. Continue antimicrobial awareness activities all year

Antimicrobial awareness should not end after WAAW. Awareness of AMR is necessary but insufficient to change behavior. The impact of awareness campaigns on antibiotic use is mixed, but any impact will not be sustained without ongoing messaging. ^{Reference Bruyndonckx, Coenen, Hens, Vandael, Catry and Goossens27} Thus, World Antimicrobial Awareness Week should be considered the first step in a long and iterative process, combined with policy, economic, and social strategies to improve antibiotic use. ^{Reference Mathew, Sivaraman and Chandy28}

In conclusion, AMR is a global and universal issue, neither respecting borders nor confined to certain populations. AMR already has a significant impact on health, and if no action is taken, it will become increasingly burdensome. AMR is a solvable issue and awareness of antimicrobial overuse and its consequences is the first step to safeguarding antimicrobials. The 10 concepts discussed in this article can be applied to help maximize antimicrobial awareness efforts as a vital step in ensuring that we can continue to treat and prevent infectious diseases in the years to come.