Making good antimicrobial stewardship sustainable
Conflicts between private and public interests in the affordability and accessibility of drugs are at odds with the sustainability goal of antimicrobial stewardship.
With pathogens causing easy-to-acquire urinary tract infections (UTI), hospital-associated infections, and respiratory and sexually transmitted infections (WHO Priority pathogen list) already becoming untreatable using existing antimicrobials, the chances of contracting an untreatable infection are quite high. With an estimated 10 million deaths per year expected by the year 2050, antimicrobial resistance (AMR) as a silent epidemic is becoming a leading cause of death worldwide.
In previous posts, I talked about how our approaches to tackling human and animal health concerns contribute to increasing antimicrobial resistance. In this post, we will explore what good antimicrobial stewardship is, why it is not sustainable and discuss an approach to make it sustainable.
Good antimicrobial stewardship is crucial to minimise the occurrence of resistance and tackle the rise of untreatable infections. Good stewardship in the context of AMR is defined as the responsible and appropriate use of antimicrobials to maximise therapeutic impact while minimizing the development of resistance. Key components of good antimicrobial stewardship are:
Responsible and appropriate antimicrobial prescribing
Minimising inappropriate use to limit resistance
Customising treatment regimens to specific clinical situations (resistance diagnosis)
Infection control and transmission prevention
Coordinated and equitable approach across multiple sectors
Ensuring sustained access to effective therapies
While the need for good stewardship and how it helps to address the challenge of AMR is clear, implementing such practices is not sustainable due to misaligned incentives.
Good antimicrobial stewardship includes prescribing antimicrobials only when needed according to evidence-based recommendations, selecting optimal drug regimens, doses, and durations tailored to the indication and patient factors, and preventing transmission of resistant pathogens through infection control strategies.
Sustainability problem
Good antimicrobial stewardship requires multiple stakeholders with misaligned incentives to work together and demonstrate good behaviour for the greater good of the community. This is hard currently, with traditional organisational structures limiting effective solutions.
Pharmaceutical companies lack economic incentives to develop new antibiotics, as they offer poor financial returns compared to drugs for chronic conditions. The sale of new antibiotics must be strictly controlled to preserve efficacy, further limiting profit potential. At the healthcare provider level, there are incentives to overprescribe antibiotics to satisfy patient demands and prevent poor reviews, even when inappropriate. There is also a lack of rapid diagnostics to guide targeted prescribing.
For public health officials, implementing stewardship programs and infection control measures represents an added cost for already resource-constrained health systems. Politicians often prioritise more visible issues, therefore limiting investments in this area.
Agricultural usage of antibiotics for livestock growth promotes resistance but aligns with industry goals of efficiency and profitability and is less about minimising the incidence of resistance. Policy restrictions requiring good behaviour usually face pushback.
In summary, conflicts between private and public interests in the affordability and accessibility of drugs are at odds with the sustainability goal of antimicrobial stewardship. The societal cost of resistance does not get incorporated into market pricing mechanisms.
Overcoming these requires coordinated efforts across different sectors to enact stewardship-promoting policies, innovative funding models, behaviour change strategies, and robust surveillance networks to preserve antimicrobials as a global public good.
Empowered communities through Decentralised Autonomous Organisations (DAOs) are a solution to this problem
The key issue blocking good antimicrobial stewardship is the misalignment of incentives across sectors. Traditional hierarchical institutions concentrate power and decision-making authority in a central body (government, expert panels, industry consortia) which enforces stewardship policies through top-down control. This inevitably faces conflicting interests and pushback from the bottom, limiting impact.
Over the last couple of years, I have been exploring how decentralised communities and the web3 infrastructure could offer a solution that traditional organisational structures do not. An area that I have been particularly exploring is in the context of tackling antimicrobial resistance. In this whitepaper for microDAO, I discuss in more detail how a community coming together as part of a DAO could ensure that good antimicrobial stewardship is sustainable and impactful.
DAOs could organise coordination and collective action on stewardship through a decentralised, autonomous “rules-based” governance structure tied to expert advice and community consensus. By giving key stakeholders (physicians, public health officials, patients, pharma, agriculture) representation and voting power to codify stewardship-promoting policies, incentives get realigned.
Policy decisions reflect distributed knowledge and local contexts. Compliance with established rules (evidence-based prescribing, infection control) is internally incentivised through token rewards and flexible procurement schemes, not externally enforced. Sustainable funding models can subsidise antibiotic R&D.
This collaborative, transparent algorithmic governance minimises bureaucracy, confusion, and duplication of efforts across governments that current international organisations struggle with on global action for AMR. It enables public healthcare, private healthcare, scientific experts, and industry to own stewardship as a common goal.
In summary, decentralisation breaks down the traditional central authority limitations in surfacing diverse views and local insights needed to balance the complexity of factors driving antibiotic misuse. It curbs misaligned incentives using community consensus and participation built into the governance.
microDAO & MICRO: A token for sustainable antimicrobial stewardship
microDAO is a decentralised community focused on leveraging tokenomics to align incentives across healthcare, pharma, public health and agriculture sectors to tackle the urgent threat of antimicrobial resistance. It aims to address the challenge of making good antimicrobial stewardship sustainable by developing tools for stakeholders involved in implementing good antimicrobial stewardship and using funds generated by the use of these tools to fund the development of new antibiotics.
MICRO, the governance token for microDAO, will provide a token owner with voting power on various decisions for the DAO and empower the community to align incentives for stakeholders involved in good antimicrobial resistance to a shared common good.
A structure like this has the potential to break down the traditional central authority limitations in surfacing diverse views and local insights needed to balance the complexity of factors driving antibiotic misuse. It can curb misaligned incentives using community consensus and participation built into the governance.
The token MICRO encapsulates the collective goal of preventing drug resistance while benefiting each party by creating a shared goal to align on. As the DAO funds new antibiotics and its impact grows through the market entry of new antibiotics, the token value should increase due to royalties and IP sharing agreements agreed with recipients of funding from the DAO, and token launch generating an influx of revenue into the DAO’s treasury which will be used to fund different activities of the DAO.
A non-exhaustive list of activities carried out by the community at microDAO includes:
developing new tools that pharma, public health organisations, governments and academic researchers can use to diagnose, predict and monitor the emergence of antimicrobial resistance and provide decision support to improve the prescription of antibiotics
funding research into antibiotics to support academic researchers, small biotechs and startups
running events to increase awareness about tackling AMR and challenges investing in drug discovery for infectious diseases
contributing to regulatory and public health policies in this space
With these activities and community-powered decision-making, microDAO will change the status quo and provide a new alternative approach to prepare us for defending against the next big drug-resistant infectious agent.
If you are interested in learning more about microDAO and the vision for the community or getting involved, please visit the website and read the early draft whitepaper for the community.
There is more to be done in defining the governance structures and tokenomics of the community. If you have this experience, do reach out to the team via the contact form at https://microdao.bio/