Nearly a century after the discovery of penicillin, a global health menace is threatening to undue the effectiveness of antibiotics and other antimicrobial drugs that have transformed the treatment of infectious diseases.
The menace is antimicrobial resistance (AMR), which occurs when bacteria and other microbes evolve in ways that allow them to survive the medicines designed to kill them. AMR is making once-treatable ailments like pneumonia and post-surgical infections harder, and sometimes impossible, to cure.
The consequences are already substantial. AMR is associated with more than one million deaths worldwide each year and is projected to impose more than $1 trillion in annual health care costs by 2050. Its rise is often attributed to the overuse and misuse of antimicrobial drugs in medicine and agriculture, along with inadequate sanitation, hygiene, and infection prevention.
But Ashley Styczynski, MD, adjunct clinical assistant professor of Infectious Diseases, has learned that the forces driving resistance often extend beyond antimicrobial use practices.
Styczynski is currently a medical officer in the International Infection Control Branch at the Centers for Disease Control and Prevention (CDC). She investigates the burden of drug-resistant microbes across six countries, including Bangladesh, where she spent a year of immersion during a 2019-20 fellowship with the Global Health Emerging Scholars (GHES) program supported by the Stanford Center for Innovation in Global Health (CIGH) and the National Institutes of Health (NIH) Fogarty International Center.
Benefitting from Local Knowledge
She says the relationships she cultivated and the deep-rooted local knowledge she gained during her fellowship remain invaluable assets in her ongoing work.
Styczynski pursued the fellowship after learning about alarming rates of infection with drug-resistant bacteria among newborns in Bangladesh from her mentor Stephen Luby, MD, the Lucy Becker Professor of Medicine. She was working with Luby as a Stanford infectious disease fellow at the time.
“I realized that, to have an impact, I needed to spend time on the ground in Bangladesh understanding the local context and being more directly connected to the people affected by the problem,” she recalls. “It’s very important to have dedicated time and space to build relationships and become attuned to asking the right questions.”
I realized that, to have an impact, I needed to spend time on the ground
During her fellowship, Styczynski established critical relationships with researchers at the International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b) that shaped her understanding of local priorities and realities.
“I wanted to leverage their ongoing research and then go deeper to understand the reservoirs and transmission sources of antibiotic-resistant bacteria to newborns,” she says.
During her time in Bangladesh, she gained empathy for the day-to-day challenges physicians faced. She witnessed their constraints and dilemmas and saw how a lack of access to diagnostics and inadequate infection prevention and control led clinicians to resort to overprescribing antibiotics.
A Worldwide Problem
While Styczynski’s work was focused on Bangladesh, what she observed there is evident around the world.
“Irrational antibiotic use is a term commonly used to explain the high burden of AMR globally. I have heard the term used by researchers, physicians, and public health practitioners across a range of global settings – from the U.S. to Bangladesh to Kenya – but I saw that widespread use of antimicrobials can absolutely be rational on the part of a health care professional who can’t bear to see another child die,” she says.
In reality, antibiotic use patterns in many low-resource settings are more often driven by a fear of adverse patient outcomes where other tools and solutions aren’t available.
“This understanding has helped me in having conversations with other stakeholders who work in global AMR to say, ‘there’s nothing irrational about it; it’s a systems problem that needs to be fixed at a larger scale.’”
Styczynski’s 2020 fellowship also moved her to better understand the causes of high stillbirth rates in Bangladesh, a problem that her icddr,b collaborators shared with her. Recognizing that Stanford might help address the problem, she applied for and was awarded Stanford Health Policy’s prestigious Rosenkranz Prize, which provided funding for her to investigate the problem with local team members.
“That work was really born out of having those kinds of relationships and connections with people who knew the context and could say, ‘this is a problem that has been going on here, and nobody’s looking at it,’” she says.
Although she is based in Atlanta at the CDC, Styczynski remains active at Stanford, including ongoing research in many projects that were catalyzed by the time she spent in Bangladesh through the GHES program.
Styczynski also teaches a two-week intensive course hosted by CIGH for Stanford medical residents and fellows about the ethics and practicalities of overseas clinical work and research. Styczynski and Cybele Renault, MD, clinical professor of Infectious Diseases, co-instruct the course, which is one of the most popular electives in internal medicine.
At the CDC, Styczynski is investigating what is causing the growth of antimicrobial resistance in communities and health care facilities globally, and she is identifying strategies to lessen the effects of AMR.
“I feel so much more qualified for this role because of the extended, immersive time I spent in-country, which is a rare opportunity,” she explains. “I have a much deeper understanding of the realities people face in Bangladesh and other similar low-resource settings, which is so important when thinking about designing research questions and making recommendations. Seeing the challenges first-hand has provided a complete shift in my perspective.”
