Appropriate, rational or prudent use of antibiotics are widely used terms when discussing the causes of and remedies for antibiotic resistance. Much like the term One Health, appropriateness of antibiotic use is intuitively appealing – its meaning seems obvious and most people would say that one should not use antibiotics inappropriately. But still we see a lot of misuse of antibiotics all over the world, so either there are many people who simply do not care about appropriate use of antibiotics, or perhaps the meaning is not so obvious as it first seems.
Five criteria for appropriateness
The five rights of safe medication have been discussed, defined and expanded upon for decades, giving guidance to health care workers on different levels about how to use medicines safely. Drawing from these, five “rights” for antibiotic use can be proposed:
1. Give antibiotics to the right patient
Right patient. The first step is of course to give antibiotics to the right patient; in this case identifying which patient needs antibiotics. One important aspect to be addressed here is the large proportion of patients who have a disease that is not of bacterial origin, such as a viral upper respiratory tract infection, viral diarrhea or malaria, but are given antibiotics wrongly for any of a multitude of reasons, including the lack of diagnostic tools. The second aspect to be considered are the large groups of patients who would benefit from antibiotic treatment, but do not have access to it. This lack of access may be due to for example that antibiotics are not available at all, that the bacteria are resistant to the available antibiotics or that the relevant antibiotics are too expensive for the patients. .
2. Right antibiotics to the patient
Right antibiotic. Once the decision to treat with antibiotics has been made, the next step is to decide which antibiotic to use. There are many types of antibiotics that are effective against different infecting bacteria, and widespread antibiotic resistance adds a layer of complexity. The general rule of thumb is that narrow-spectrum antibiotics, drugs that are active to only few species of bacteria, are to be preferred over drugs that have an effect on a larger group of bacteria. Here, national and international guidelines are very helpful in giving practical guidance in different situations. Another important aspect is microbiological diagnostics: identifying the actual pathogen and its susceptibility pattern.
3. Give antibiotics at the right time
Right time. It is a commonly known fact that in many severe infections such as sepsis, time is of the essence in order to lower mortality and morbidity. In these cases, immediate empiric broad-spectrum antibiotic therapy is appropriate until the pathogen can be identified. But other infections are not as time-critical, and a delay in antibiotic prescription may not only be harmless, but even beneficial as the infection may be cleared by the patient’s immune system without antibiotics.
4. Give the right dose of antibiotics
Right dose. In a worst case scenario, a too low dose of antibiotics not only fails to clear the infection, but also contributes to selection of resistant subpopulations that would have been inhibited by a sufficiently high dose of the drug. Here, access to knowledge about dosing principles and national guidelines are the health care workers best friends. Different patient characteristics, infecting pathogens and site of infection may give reason to adjust the dose for better effect. On the other hand, too high doses are also not good as the effects on the patients’ microbiomes are greater, toxicity may become an issue, the environmental impact will be greater, and costs for the antibiotics will increase.
5. Right duration of antibiotic treatment
Right duration. Similar to the right dose, right duration of treatment is important. It is affected by both the prescription itself and the patient’s adherence to the prescription. To prescribe the shortest antibiotic course likely to be effective is common practice in guidelines. However, a prescriber might want to prescribe a longer course of antibiotics just in case for a plethora of reasons such as an unclear diagnosis, risks for complications or severity of disease. On the other hand, patients may cease taking the drugs before the infection is cleared if they feel much better or if they cannot afford the full course. A system for following up the treatment by the prescriber or a community health worker might be appropriate in both these cases improve antibiotic use.
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Appropriate use does not equal decreased use
Defining appropriate use of antibiotics is not an easy task as appropriateness is context-specific. What is appropriate in one community may be inappropriate in another, depending on for example nutritional status or regional disease burdens, leading to differentiated risks for the individual patient or community. Appropriate use is therefore not necessarily linked to decreased use of antibiotics. Actually, appropriate antibiotic use could demand the opposite, such as increased use of antibiotics in regions where access to health care and antibiotics are limited or where the disease burden is high.
In order to increase the appropriateness of antibiotic use globally, we need a) implementation of guidelines for antibiotic use, adapted to local or regional situations based on available data, b) improved knowledge and behavior change in both patients and prescribers, and c) universal and affordable access to high quality health care, which includes access to the necessary diagnostic tools and antibiotics.