Antibiotic Stewardship

Antibiotic stewardship is the responsible use of a critical and threatened health resource, namely the antimicrobial agents we depend on to prevent and treat infectious disease. Stewardship implies not only appropriate clinical decision-making for individual patients, but a population perspective that maximizes overall benefits, minimizes adverse events and costs, and, importantly, delays the onset of widespread microbial resistance to commonly used antibiotics.

Antibiotic stewardship is urgently needed because of rising rates of antimicrobial resistance, a limited manufacturing pipeline of new agents, and the morbidity burden and large costs associated with disease that is improperly treated. The misuse of antibiotics is an international problem. Infections with multi-drug resistant organisms kill about 25,000 people a year in Europe and around 19,000 in the United States. S African figures are not known but we do have the distinction of being a world leader in prevalence of gram-negative organisms with resistance (ESBL) to beta-lactam antibiotics.

Firstly, the Best Care…Always! campaign aims to raise awareness of antibiotic prescribing issues – highlighting both misuse, and appropriate use. Secondly it aims to test and implement a small set of defined interventions that measurably and positively impact the situation. Foremost among those interventions are ICU prescribing rounds, the development of tools that both document and assist prescribing decisions, including guidelines, and the development of a team approach that supports the prescriber.

Although the biggest infectious disease threats to our population, these epidemics are not currently the focus of the campaign or the antibiotic stewardship intervention. Clearly however, principles of good antimicrobial prescribing apply as much to TB and HIV/AIDS as to any other infectious disease.

This component of the campaign differs from the infection prevention interventions in that what works is not fully established. In that sense, this is both a research and an improvement initiative. Once we have learned what works, it can be spread to other sites.

No. The scientific evidence suggests that limiting choice to only a few antibiotics may be counterproductive and that diversity is important. On the other hand, many local and international experts believe it is time to change the rules of the game – “it may well be time now to challenge the right of doctors to prescribe whichever antibiotic they wish, including the dosage and duration” (G Richards, A Brink) and to guide clinicians towards optimal, evidence-based practice.