As we head back into an era with fewer effective antimicrobials and little promise on the horizon for new ones to replace them, it’s time to rethink antimicrobial stewardship from the start.

Public education about antimicrobial resistance (AMR) has promoted the message that over time microbes can acquire resistance to antimicrobials from repeat exposure. Most antibiotic stewardship in the last 10 years has focused on conveying the message to the public that they need to complete their course of antibiotics to prevent resistant infections from developing, and to only take antimicrobials when advised by a GP. Unfortunately, the eventual development of resistance to antibiotics is inevitable due to evolution and we need to find better ways to understand and live with our microbes. The current messaging and education aren’t enough, and, in my opinion, we need to go further back and make clear to the public how and why it is important to avoid infection in the first place. These messages need to be bespoke, well-timed and aimed at the right audience using a wealth of research we already have.

It is clear that research into, and therefore general understanding of women’s health and disease, has been under funded and taboo for a long time. One of the most common infections of particular relevance to women are urinary tract infections (UTIs). We know that 60% of women in their lifetime will develop a UTI, with around 20-30% of these cases becoming untreatable. What is terrifying is that 92% of UTI causing organisms are estimated to be resistant to one antibiotic, and 80% are resistant to more than two.

We now face the very real prospect that in the near future we will be unable to treat UTIs.

There is a clear spike in ‘uncomplicated’ UTIs in females aged 14-24 due to the start and increase of sexual activity, with 33% women in this age group developing an infection by age 24, and 70% of these women presenting with re-infection within a year. In addition, if antibiotics are necessary and taken to treat a bacterial UTI, the disturbance of the vaginal microbiome can cause fungal species to take over and cause thrush. In most ‘uncomplicated’ cases we are therefore potentially talking about two antibiotics being given and used within a year, with up to two over the counter anti-fungals being used. This is an unthinkable amount of potentially avoidable antimicrobial use. Why has this become a ‘normal’ coming of age ritual for so many young women, who are forced to learn how best to care for themselves in such an uncomfortable and painful way? This situation clearly needs to change, and better resources and understanding of potential preventative measures at grass roots will help.

We need to rethink teaching of personal and sexual health and hygiene to young females before we are in a position where we can no longer treat them. We need to teach them how infection can occur, and how they could potentially mitigate these risks with good personal hygiene. We also need to emphasize how the long-term effects of UTIs, and antibiotics can cause disturbance to their microbiome, causing a cascade of effects we have barely scratched the surface of understanding (e.g. gut and mental health). I propose we teach understanding and good practices of keeping our microbes happy, healthy, and in harmony, so that we don’t even get to the point where antibiotics are needed. This could also prevent unnecessary appointments being used at the GP and reduce the number of sick days being taken. Win, win, win.

To do this we will need to work closely with teaching professionals, sexual health clinicians and young people themselves to provide them with the tools and knowledge they need to look after themselves AND their microbes.