Innovative strategies to fight antimicrobial resistance: crowdsourcing to expand medical training

Introduction

Antimicrobial resistance (AMR) is a major public health threat. Reports from the World Health Organisation (WHO) global surveillance and Global Point Prevalence Survey show high rates of inappropriate antibiotic use¹, suggesting the need for enhanced antimicrobial stewardship. Yet public awareness of AMR remains low² and the pipeline from medical school into careers relating to infectious diseases is weak. The numbers of US trainees entering infectious diseases decreased 41% between 2009 and 2017³.

There is a need to respond to the lack of interest in infectious disease training through various methods, including expanding medical training on infectious diseases³. Most medical schools give limited teaching on AMR and even less on the use of diagnostics to reduce inappropriate use of antibiotics⁴. A European study reported that in all but one of seven medical schools studied, the majority of students wanted further education on antibiotic prescribing, which is an essential aspect of AMR management⁵. A US study also suggested that physicians receive inadequate training on the interpretation of antibiograms⁶. Other studies from the UK⁷, China⁸ and Ethiopia⁹, suggest the need for more AMR and diagnostics content in medical curricula. The WHO recently highlighted the importance of undergraduate training in prudent prescribing and research highlights the need for more AMR and diagnostics training for healthcare workers around the world¹⁰.

In response to this need, we organised a crowdsourcing project, soliciting clinical cases on diagnostics/AMR from medical students and physicians. Crowdsourcing is a bottom-up approach that allows many individuals to attempt to solve a problem and then shares solutions with the public¹¹. Crowdsourcing contests typically convene a steering committee, engage citizens or a particular group to participate, evaluate entries, recognize finalists and share solutions with the public (Table 1). It has been used in medical research and piloted as a tool to develop medical education materials¹².

Table 1. Steps in a crowdsourcing challenge contest.

STAGES	PURPOSE	RESULTS
Organize a steering committee	To support a strong community, buy-in from the start which resonates with local language/culture/ preferences	The contest had a steering committee of nineteen experts from seven WHO regions
Engage the community	To clarify the rules/guidelines of the contest for community members and encourage participation	The call for entries was promoted through a website, social media and in-person events. We received 25 entries received from 9 countries
Evaluate Entries	To determine a group of judges from the crowd, steering committee, or others to evaluate entries based on a pre-specified criterion	All entries were evaluated in 3 stages and 23 entries were eligible for judging. Fourteen judges evaluated the eligible entries after screening and three cases emerged as the finalists
Recognize Finalists/prizes	Announcement of finalists and through social media, other online platforms and in-person events	Three finalists were invited and supported to attend an AMR symposium to present their cases where they were presented with commendation certificate
Share solutions	To share finalists with national or local agencies, and to implement the final outcomes in the relevant context	Finalist cases published online in Partners ID Images and further developed into an open access learning module

WHO- World Health Organisation, AMR- Antimicrobial Resistance, ID-Infectious Disease

Our crowdsourcing approach focused on developing an educational resource for medical students and trainees on infectious disease diagnostics/AMR. The overall goal of the challenge contest was to spur enthusiasm for infectious diseases and increase infectious disease diagnostics/AMR knowledge to support antibiotic stewardship. The aim of the call was to encourage medical students, trainees, physicians, and others to collect or write clinical cases to develop educational materials for AMR.

Methods

Results

We received 25 clinical case entries from nine countries. Peru had the highest number of entries – seven (28%), followed by the US with six entries (17%). Other submissions were received from Nigeria (n=4), China (n=3), Australia (n=1), Canada (n=1), Ethiopia (n=1), Paraguay (n=1), and Zambia (n=1). After screening, 23 cases were eligible for the next stage of judging (see Underlying data¹³); two entries were excluded for not being relevant to the subject of the call. In total, 19 were original cases written by participants, and four were adapted from already published literature. All cases were submitted alongside a signed declaration of patients’ consent from the authors. The cases described clinical presentations of drug resistant organisms and the role of diagnostics in their management. An overview is given on the SESH Global website.

Out of the 23 eligible cases, three cases emerged as finalists with mean scores of seven or above. Most cases achieved scores greater than five; only six entries (26%) had mean scores less than five. Underlying data shows scores for each case¹³.

The crowd favourite was a clinical case on pyelonephritis caused by metallo-beta-lactamases producing Pseudomonas aeruginosa. All three finalist cases (see Extended data, Supplementary file 1)¹³ were further reviewed with medical education experts from partner organizations and integrated into an online diagnostics/AMR interactive learning module (see Extended data, Supplementary file 2)¹³. This was done with the help of the results of the Delphi approach (see Underlying data for results)¹³.

Discussion

Crowdsourcing provides several advantages in the development of medical training materials compared to conventional approaches, including duration of time needed, cost, and global coverage. Our challenge was able to solicit over 20 cases in less than two months, faster than most medical education development. The total cost of the challenge was less than having experts develop clinical cases. Finally, the global composition of our steering committee and case contributors allowed us to develop a resource that may be relevant in diverse global settings.

However, our crowdsourcing contest had several limitations that warrant consideration. This contest received fewer clinical cases than other crowdsourcing contests. The low number of cases may have been related to the lack of official partnerships with a larger conference or professional associations, the relatively high requirements – including need to obtain patient’s consent – in the guidelines for submissions, and the timing of the call. Our call for cases coincided with a similar call for clinical cases on infectious diseases from the Infectious Diseases Society of America. Despite the overall low number of submissions, we had sufficiently strong cases to create the learning module and develop new case content for the database.

One gap identified during the challenge was the limited strategic priorities within AMR medical education. The purpose of the learning module is to increase awareness and understanding of diagnostics and AMR in adult and paediatric medicine. This could be used as Continuing Medical Education (CME) or integrated into undergraduate medical curricula.

While we have created an open access learning resource on diagnostics and AMR (supplementary file 2), there is still a need for more educational resources related to AMR. Crowdsourcing may be a useful adjunct in the development of medical education materials. Crowdsourcing could be used in a variety of settings to encourage interest in infectious diseases, decrease unnecessary antibiotic use and promote antibiotic stewardship.

Data availability

Consent

Written informed consent for publication of their clinical details and/or clinical images was obtained from each of the patients.