Rational use initiatives in healthcare work to promote appropriate use of antibiotics, mitigate antibiotic resistance, and improve patient safety. Efforts should be implemented at all levels of care - in hospitals and in community settings.
Many activities to improve antibiotic use can be implemented at individual healthcare facilities. However, formally organized antibiotic stewardship programs are more likely to achieve sustained impact. These programs are coordinated, interprofessional efforts to monitor and improve antibiotic use. Effective stewardship programs can enhance patient care and safety, reduce costs, and, in some cases, help lower resistance levels. Where available, national guidelines provide a foundation for developing and implementing these programs.
The WHO has outlined overarching core elements for antimicrobial stewardship programs with a specific focus on low- and middle-income countries:
- Leadership commitment – For example dedicated financial support
- Accountability & responsibilities – Such as clearly defined collaboration between the antimicrobial stewardship and the infection prevention (IPC) programs, and having a multidisciplinary leadership committee.
- Antimicrobial stewardship actions – For example having up-to-date standard treatment guidelines, and regular review of antibiotic therapy.
- Education & training – Ensuring healthcare providers understand rational antibiotic use in the reality of their workplace (hospitals or primary care).
- Monitoring & surveillance – Such as tracking appropriateness of antibiotic use and resistance rates of key bacteria.
- Reporting & feedback – Sharing data to all stakeholders.
These core elements can be adapted and applied across different levels of care.
Community settings
Most antibiotic use occurs in community and primary care settings, making these settings a key focus for antimicrobial stewardship. Community-based programs should work to continuously improve infection prevention routines and antibiotic use practices for common infections. Important areas include provider and patient education, implementation of locally relevant treatment guidelines, monitoring of prescribing patterns, and access to diagnostic support. Together, such strategies enhance the quality of patient care and help preserve the effectiveness of antibiotics in the community.
Hospitals/ Inpatient settings
Hospitals are critical settings for antibiotic stewardship, as they are hotspots for the development and spread of antibiotic resistance. Stewardship programs in hospitals typically focus on high-risk patients, complex infections, and inpatient antibiotic practices. Core activities of these programs include regular audits of antibiotic use, the implementation of evidence-based guidelines, and the establishment of multidisciplinary antimicrobial stewardship (AMS) teams. These teams work together to review prescribing practices, provide feedback to doctors, and ensure antibiotics are used appropriately and effectively. Coordination with infection prevention and control programs further strengthens stewardship efforts, helping to reduce inappropriate antibiotic use, improve patient safety, and limit the spread of resistance in the hospital.
Diagnostics
Diagnostics are used to determine what disease a patient has and what is causing the disease. Diagnosis is based on the healthcare provider’s clinical assessment of symptoms, combined with results from diagnostic tests. This information guides the selection of appropriate therapy. Stewardship programs depend on good diagnostic capacity, including well-trained health workers and access to relevant diagnostic tests.
Learn more about diagnostics in these ReAct articles:
How to initiate or strengthen work on stewardship is covered in Getting Started, and examples, approaches and tools can be found in Interventions. Coordination with infection prevention efforts are also of great importance.
Selected Resources
| Resource | Description |
| Antimicrobial stewardship programmes in health-care facilities in low- and middle-income countries – a WHO practical toolkit | Toolkit with recommendations and guidance for setting up and implementing antimicrobial stewardship programs in LMICs. Chapter 3 specifies core elements at facility level. Available in English, Arabic, Russian, French and Spanish. |
| Core Elements of Antibiotic Stewardship | Frameworks describing core components and possible activities for implementation of antibiotic stewardship in healthcare facilities (by the US CDC): |
| Behavior-change interventions to improve antimicrobial stewardship in human health, animal health, and livestock agriculture: A systematic review | Systematic review of studies that describe behavior-change interventions aimed at improving antimicrobial stewardship and/or reducing inappropriate antimicrobial use in human and animal health, as well as in livestock agriculture. |