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Toolbox  –  Measure

Appropriate use of antibiotics

It is important to understand if antibiotics are used appropriately for the right infections and according to treatment guidelines. This section provides resources to help measure appropriateness of antibiotic use in human and animal settings.

Data on the inappropriate use of antibiotics may provide an idea of the magnitude of the problem and help to inform policy decisions and in planning an intervention. Unfortunately, however, much of the data is limited to high-income settings. For information on how to set up initiatives promoting the rational use of antibiotics in a systematic way, and interventions to use in such efforts, see the RATIONAL USE focus area.

It is estimated by the World Health Organisation (WHO) that 50% of medicines used in human medicine are prescribed, dispensed or sold inappropriately. In addition, the United States Center for Disease Control and Prevention estimates that 20-50% of antibiotics prescribed in acute care hospitals in the United States are either inappropriate or not necessary. The situation may be even worse in low-and middle-income countries with limited resources for surveillance.

In many parts of the world, antibiotics are given routinely to livestock in order to promote growth or to prevent bacterial diseases. According to WHO, more antibiotics are given to healthy animals than to unhealthy people. It is also common that antibiotics are available without a veterinary ordination.

What is considered appropriate may vary from different geographical locations and different prescribing and clinical guidelines.

Measure appropriateness of antibiotic use: Human medicine

It is important to understand if the right antibiotic at the right dosage and duration is being used for the right bacterial infection. This can be referred to as the quality or appropriateness of prescribing, dispensing or use. Data on the appropriate use of antibiotics can help to monitor compliance with treatment protocols, provide targets for quality improvement or to plan rational use initiatives.

Evaluations on appropriateness of antibiotic use may address the following:

  • Who the prescribers or providers are
  • Why antibiotics are prescribed and for whom
  • Choice of antibiotics, dosage and treatment duration
  • Adherence to treatment guidelines
  • Whether patients take their antibiotics correctly

In health care settings, appropriateness of use can be defined as adherence to guidelines. Reviewing patient medical records and comparing prescriptions to clinical indications is a method to measure appropriateness of use. Point prevalence studies can be useful to get a snapshot of prescribing practices and explore potential opportunities for improving antibiotic use. Outside of health care settings, knowledge, attitude, beliefs and practices (KABP) surveys can be used to gather insight into how patients are consuming antibiotics at home.

Measure appropriateness of antibiotic use: The animal sector

In the animal sector, antibiotics are used to treat diseases, to prevent and control diseases and to promote animal growth. Thus, part of the antibiotic use is for non-therapeutic purposes, and according to WHO, greater quantities of antibiotics are used for healthy animals than in unhealthy humans. As in human medicine, inappropriate use of antibiotics increases the risk of development of antibiotic resistance in bacteria, which can lead to therapy failure, bringing negative consequences for animal welfare as well as economic losses.

Evaluations on appropriateness of antibiotic use in the animal sector may address the following:

  • Record keeping of antibiotic use at both farm level and individual veterinary level
  • Antibiotic use as growth promotors
  • Other non-therapeutic use, such as routine prevention during certain risk-periods (e.g. weaning of piglets)
  • Use of critically important antibiotics and under which indication
  • Are antibiotics prescribed by a veterinarian?

The resources below have been divided into the following tables:

  • Human medicine
  • The animal sector
  • Data and reports: Human sector
  • Data and reports: Animal sector

Selected Resources

Human medicine

Resource Description
Global Point Prevalence Survey on Antimicrobial Consumption and Resistance Open PPS survey and protocols. This open to join initiative allows participating hospitals to monitor antimicrobial prescribing and resistance in hospital patients through a “one day survey” and helps design hospital interventions to promote prudent use. Hospitals are welcome to join survey and network (already more than 300 institutions from over 50 countries worldwide have participated). For documents such as protocols, data collection templates and presentations in different languages for personal use click here. A scientific article with results from the project has been published in the Lancet Global Health.
How to Investigate Antimicrobial Use in Hospitals: Selected Indicators Manual that defines indicators to help assess the management and use of antibiotics in hospitals and provides tools and step-by-step instructions for designing and carrying out assessment activities. Also available in French and Spanish.
How to Investigate Drug Use in Health Facilities: Selected Drug Use Indicators – EDM Research Series No. 007 Manual that defines a limited number of objective measures that can describe the drug use situation in a country, region or individual health facility.
How to investigate drug use by consumers Manual that provides a practical guide to the methods that can be used to investigate the use of medicines by consumers to identify problems, design interventions, and measure changes.
Quality Rand/UCLA appropriateness of use method Manual that presents step-by-step guidelines for conceptualising, designing, and carrying out a study of the appropriateness of medical or surgical procedures (for either diagnosis or treatment) using the RAND/UCLA Appropriateness Method.
Behavioral Approach to Appropriate Antimicrobial Prescribing in Hospitals Journal article describing an intervention on appropriate antibiotic prescribing grounded in behavioral theory. A root cause analysis of inappropriate prescribing was performed, and then prescribers were offered a free choice of how to improve their antimicrobial prescribing based on this analysis. The Root Cause Analysis Interview Topic List can be found in supplemental content.
Antimicrobial Resistance, Antibiotic Usage, and Infection Control – A Self-Assessment Program for Indonesian Hospitals (PDF, 2MB) Method. Page 10 describes a method to measure the quality of antibiotic prescribing. Attachment 7  Form ‘Quality assessment of antibiotic use’ and Attachment 8 Flow chart ‘quality assessment antibiotic use’ can be adapted and used.
The European surveillance of antimicrobial consumption (ESAC) point-prevalence survey of antibacterial use in 20 European hospitals in 2006 Journal article describing use of a standardized point-prevalence survey to measure antibacterial use in hospitals within different health care systems and aimed to identify targets for quality improvement.
Survey protocol in nationwide hospital point-prevalence surveys in Sweden, 2003-2010 Data collection form for a point-prevalence survey performed nationwide in Sweden during 2003-2010. The results were published in Eurosurveillance.
Assessment tools for antibiotic use
Assessment tools from the CDC that can help facilities explore potential opportunities for improving antibiotic use overall in hospitals and for urinary tract infections, community-acquired pneumonia, resistant gram-positive infections, and for inpatients. At bottom of page.

The animal sector

Resource Description
Keeping veterinary medicine records Guidance on how to keep veterinary medicine records. Includes an example format on record keeping (word document). Guidance for England, but can be used for inspiration/adapted for other contexts.
Relationship between biosecurity and production/antimicrobial treatment characteristics in pig herds Article describing the determination of biosecurity status of pig herds through the use of a risk-based weighted scoring system, and the simultaneous collection of data relating production-characteristics and prophylactic antimicrobial use of antimicrobials.
OIE Terrestrial Animal Health Code Chapter 6.10: Responsible and prudent use of antimicrobial agents in veterinary medicine.

Data and reports: Human sector

Resources Description
Improving rational drug use in Africa: the example of Sudan This review gives an overview of studies describing patterns of drug prescribing, dispensing and self-medication in Sudan. It identifies high rates of inappropriate prescribing, dispensing practices and prevalence of self-medication with antimicrobials despite implementation of interventions. Multifaceted interventions are recommended to address the irrational drug use.
Inappropriate antibiotic prescribing and demand for antibiotics in patients with Upper respiratory tract infections in primary care A posthoc analysis of a cross-sectional study of patients with upper respiratory tract infections from Argentina, Denmark, Lithuania, Russia, Spain and Sweden (happy audit project) found 45% of the prescribing cases to be unnecessary.
Antimicrobial resistance and causes of non-prudent use of antibiotics in human medicine in the EU Report that describes results of the ARNA (‘Antimicrobial resistance and the causes of non-prudent use of antibiotics’) project, focusing on reasons for non-prescription use of antibiotics in the EU, and actions to prevent such use. Carried out under a contract with the European Commission.
Appropriateness of Antimicrobial Therapy Measured by Repeated Prevalence Surveys The study identified that inappropriate antimicrobial therapy was given to a substantial number of patients in a teaching hospital in the Netherlands.
Different Patterns of Inappropriate Antimicrobial Use in Surgical and Medical Units at a Tertiary Care Hospital in Switzerland: A Prevalence Survey An audit of antimicrobial use at regular intervals among all patients hospitalized in predefined surgical, medical, haemato-oncological, or intensive care units found 37.0% of therapeutic and 16.6% of prophylactic prescriptions to be inappropriate.
Association of Adverse Events With Antibiotic Use in Hospitalized Patients A paper describing adverse events related to antibiotic use. The authors conclude that adverse drug reactions are common during antibiotic therapy, and that many events can be avoided with better antibiotic use.

Data and reports: Animal sector

Resources Description
Restricting the use of antibiotics in food-producing animals and its associations with antibiotic resistance in food-producing animals and human beings: a systematic review and meta-analysis Systematic review on the effect of interventions restricting antibiotic use in food animal production. Provides evidence that restricting use lowered the presence of antibiotic resistant bacteria in the animals. The appendix lists all studies (2MB) included in the review and provides a quality assessment.
Usage of antibiotics in agricultural livestock in the Netherlands in 2015. Trends benchmarking of livestock farms and veterinarians, and a revision of the benchmarking method The Dutch livestock sector have managed to decrease antibiotic use significantly during the past few years. This report from the SDa expert panel provides information on how the usage of antibiotics have changed sinced 2011 of the various livestock sectors in the Netherlands.
Reduction of Veterinary Antimicrobial Use in the Netherlands. The Dutch Success Model This article describes and analyses the processes and actions behind the transition from abundant antimicrobial use in farm animals in the Netherlands towards a more prudent application of antimicrobials.
Effects of Banning the Use of Antibiotics as Growth Promoters in Denmark and Scandinavia This fact sheet contains links to major reports and journal articles describing the experiences in the Scandinavian countries of banning the use of antibiotics as growth promoters (The PEW Charitable Trusts).
Restrictions on antimicrobial use in food animal production: an international regulatory and economic survey Article comparing governmental policies on antimicrobial use in food animal production, showing that antibiotic use differs widely, from no restrictions to strict restrictions.