Interventions against AMR: General or specific? Top-down whole organization or small teams based? Jaime Chang, USAID 30 March 2012 An interesting "in a nut-shell" review. Not exactly a success story. My take... Not rocket science, but some of the probable causes for limited impact of interventions against inappropriate use of antimicrobials are that: - It is often approached from a general perspective that fail to engage stakeholders, i.e. decrease it "across the table", as opposed to aim for specific uses, e.g. "decrease inappropriate use of antimicrobials in children under five with respiratory infections". We chose the latter and did an eco-systemic analysis disclosing elements such as: most out-patient care events are or children under five, due to respiratory infections for which antimicrobials are prescribed in 71% of cases mostly unnecessarily; prescribers, dispensers and parents were prone to do the right thing for the under-five (taking the ill child to a health service, prescribing correctly, selling/buying the prescribed dosage, adhering to treatment); and led to a multi-prong intervention (introducing clinical guidelines, informing the community face to face and through media; improving quality assurance/control of antimicrobials, and local capacity to monitor antimicrobial resistance, etc.). For a description of the ecosystemic approach developed under USAID's South American Infectious diseases Initiative see http://usaidsaidi.org/extras/SAIDI_APPROACH_lo_f_012411.pdf and for technical reports, articles, materials produced under SAIDI see http://www.usaidsaidi.org/resources.shtml - Top down, whole of organization interventions often do not include necessary restrictive and enabling changes in working environment, are not sustained long enough, and fail to elicit ownership and buy-in. Probably, ¿motivated, enabled guerrilla¿ approaches sustained long enough will be better than approaches based on individual changes (as most KAP interventions are). Examples: The evidence-based intervention used to reduce the incidence of catheter-related bloodstream infections reported by Provonost years ago - See http://www.nejm.org/doi/full/10.1056/NEJMoa061115 -, and the initiatives based on it (e.g infection zero); and article by Gastmeier et al. in this journal http://www.aricjournal.com/content/1/1/8/abstract Competing interests None.