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Antibiotics and Antimicrobial Stewardship

This article outlines what antimicrobial stewardship is, and why it is important.
A hand holding a selection of pills

Antimicrobial Stewardship (AMS) is an essential element of clinical practice to safeguard the effectiveness of antibiotics. AMS can be defined as:

“The optimal selection, dosage, and duration of antimicrobial treatment that results in the best clinical outcome for the treatment or prevention of infection, with minimal toxicity to the patient and minimal impact on subsequent resistance.”
Alternatively, the World Health Organization (WHO, 2019) defines AMS as:
“A coherent set of actions which promote the responsible use of antimicrobials.”
The need for AMS is highlighted by the mismatch between antibiotic usage and the actual need for antibiotics. There are two solutions to solve the mismatch problem:
  1. Reduce antibiotic usage
  2. Align reduced usage with actual need
Antibiotic usage can be reduced by prescribing less and ensuring that only those who need to receive antibiotics do so. AMS programmes are fundamental to reaching these solutions.
Note while other antimicrobials (antifungals, antivirals etc) are also relevant when talking about AMS, this course will primarily focus on the group of drugs with the highest impact on AMR; antibiotics.
The image below provides an overview of elements that contribute to excessive prescribing and how this could be minimised. Some of these interventions will be explored in more detail in weeks two and three.
Click here to see a larger version of this image.

Antimicrobial Stewardship programmes

Strategies to reduce antibiotic overprescribing make up some of the core activities of AMS programmes. The WHO AMS toolkit defines an AMS programme (ASP) as:
“An organisational or system-wide healthcare strategy to promote appropriate use of antimicrobials through the implementation of evidence-based interventions”.

The evidence to support the effectiveness of hospital-based ASPs are supported by an important Cochrane systematic review. This review demonstrated the effectiveness of ASPs on a range of outcomes. Click here to read a commentary on the systematic review, or here to read the full review.

In 1988 Avedis Donabedian published the “integrated model of quality assessment”. This model demonstrated that in healthcare having core structures and effective implementation of key processes could achieve good outcomes. This model can be adapted for developing, implementing and evaluating ASPs. The importance of effective implementation supported by an enabling culture is highlighted as a key component in this model (see a summary of the model in the image below).

A visual representation of the integrated model of quality assessment. The text reads as follows. 1. Antecedents. Factors that can influence structure and process, e.g. environmental and patient. 2. Structure. Organisational characteristics; e.g. management, culture, organizational design, information management and incentives. 3. Process. Interactions between healthcare practitioner and patient; e.g. diagnosis and treatment. 4. Outcome. Changes, desirable or undesirable in individuals and populations; e.g. morbidity, mortality, service quality. Structure + Process = Outcomes.

Click here to see a larger version of this image.

In 2019 the seven core elements outlined below were highlighted to help healthcare facilities build the necessary structures at various levels to enable hospital AMS programmes.

List of the seven core elements to enable AMS programmes. 1. Leadership and commitment 2. Accountability and responsibility 3. Expertise on infection management 4. Education and training 5. Additional AMS actions 6. Monitoring and surveillance 7. Reporting and feedback

The animated video below also provides an engaging summary of the importance and impact of AMS programmes. Please note: the messages in the video are from HICs but are applicable to LMICs.

This is an additional video, hosted on YouTube.

For a summary of the above video, please click here.

In addition to these core elements, the Antibiotic Stewardship and Resistance Working Groups of the International Society for Antimicrobial Chemotherapy (ISAC) have set some basic clinical principles to guide appropriate antibiotic prescribing. These ten key points are good for supporting and educating prescribers to use antibiotics better.

This infographic is also available as a screen-reader compatible PDF.

Click here to see a larger version of this image.

Note: point 6 (avoiding antibiotics with a higher likelihood of promoting drug resistance) forms the basis of the WHO AWaRe (Access, Watch, Reserve) classification scheme for antibiotics. We will learn more about this in week 2.

The global approach to AMS

Aware of the public health risk of AMR, the May World Health Assembly formed an action plan for tackling AMR. Click here to read more.

Now you know what AMS is, we will look next at the core objectives of an AMS programme.

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How to set up an Antimicrobial Stewardship Programme

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