All use, whether appropriate or not, can promote the emergence of resistance in bacteria. Unfortunately, inappropriate and excessive use of antibiotics is common in both high and low income countries, and in both the human and animal sectors.
Strategic objective 4 of the Global Action Plan on Antimicrobial Resistance advises to optimize the use of antimicrobial medicines in human and animal health. It is important to note that the goal of rational use initiatives is not always to reduce antibiotic use, but instead to ensure that the use is appropriate.
- To reduce inappropriate use is key to keep antibiotics effective, and is an important element of a national action plan.
- At the same time, a large proportion of the world’s population lack access to effective antibiotics. To increase access to antibiotics is therefore also essential, but this needs to take place within a framework of rational use. Read more about access versus excess here.
Regulations to reduce inappropriate use
Enforcing regulations to control the distribution and use of antibiotics will be necessary to minimize the development of resistance and conserve antibiotic effectiveness for as long as possible. However, which type of legislations that is most appropriate differs between countries. Regulations must take into account the financial, structural and geographical obstacles to finding a balance between access and excess, particularly in low-income countries.
Poor provider knowledge and lack of guidelines
Poor provider knowledge and lack of treatment guidelines are important contributors to inappropriate use of antibiotics. Information about how to take action on the issue in health care and food animal production is collected in the RATIONAL USE focus area, and guidance on measuring appropriate use is presented in MEASURE: Appropriate use.
The animal sector
Treatment with antibiotics is necessary for certain diseases in animals, in order to ensure survival, welfare, productivity, and reduced spread of disease.
In the animal sector, governments are recommended to provide appropriate regulations on the authorization, manufacturing, distribution and use of veterinary products through their veterinary legislation. OIE has supportive guidelines in this area, and EU recently published a guideline on prudent use of antimicrobials in veterinary medicine. If possible, antibiotics should only be used after prescription by a veterinary professional. Also, it is recommended that the Code of Practice developed by Codex Alimentarius and the WHO guidance on the use of critically important antibiotics are implemented.
Steps to optimize antibiotic use in the non-human sector includes to:
- Phase out the use of antibiotics for animal growth promotion
- Restrict routine use of antibiotics in food-animal production and agriculture
These efforts must go closely together with efforts to improve infection prevention and control to reduce the effects on livestock keeping.
Antibiotics that are crucial for human health
Steps have been taken both by WHO, the European Medicines Agency and US FDA to identify the antibiotics that are most ‘critical’ to human health, and to prioritize the reduction of their use in agriculture. However, progress in this field has to some extent been hampered by a lack of consistency in the definition of antibiotics critical to human use.
- The WHO, for instance, has established a categorization of antibiotics critical to human use, which focuses on the disease conditions treated by particular products and the range of alternatives available.
- However, the recent EMA strategy is based on separate advice from its own Antimicrobial Advice Ad Hoc Expert Group, which adopts an alternative methodology based on a wider assessment of the risk of transmission of resistance from animals to humans.
- The FDA, in turn, has its own methodology.
Limiting use in animals of critically important antibiotics is crucial to preserve antibiotic effectiveness for both human and veterinary medicine. This again highlights the need for disease prevention and sustainable animal husbandry practices.
Awareness in the community
The promotion of rational use of antibiotics in the community plays an essential and complementary role to rational use initiatives in health care facilities or aimed at providers. In the same way, public awareness campaigns can be important to promote food business operators, including retailers, to favor food produced in accordance with quality schemes and systems of production that apply the principles of prudent use. That is, that minimize the use of antibiotics and promote high standards of animal welfare.
Example options for action:
- Arrange public awareness campaigns on rational use
- Provide independent and unbiased information on medicines for consumers as a function of the Ministry of Health
- Introduce rational use of medicines in life sciences or health education components of school curricula (throughout education) and adult education programs
The resources below have been divided into the following tables:
- Human sector
- Animal sector
|Revising Preservice Curriculum to Incorporate Rational Medicine Use Topics: A Guide||This SIAPS/USAID document guides stakeholders, including university faculty and staff in the fields of medicine, pharmacy, nursing, and public health, through the process of integrating rational use of medicine into the curricula for medical, nursing, pharmacy, and public health students. It includes sample documents from successful projects and templates that can be adapted for new initiatives. details how to incorporate RMU components in health professional training programs and includes several tools and templates to facilitate the process.|
|Core Elements of Human Antibiotic Stewardship Programs in Resource-Limited Settings: National and Hospital Levels||Guide from US CDC providing a framework for implementing antibiotic stewardship programs in resource-limited settings. It covers a range of activities that a government or individual health facilities can implement based on the resources available. (PDF version, 3MB)|
|Optimal use of antimicrobial medicines in human and animal health||Landing page of “Optimal use of antimicrobial medicines in human and animal health” of the World Health Organization.|
|Promoting Rational Use of Medicines: Core Components – WHO Policy Perspectives on Medicines, No. 005, September 2002||This WHO publication defines the rational use of medicines. It discusses the problems associated with irrational use of medicines and sets out twelve core interventions that policy makers should consider to address the challenge. The document is also available in Spanish and French.|
|The Pursuit of Responsible Use of Medicines: Sharing and Learning from Country Experiences||In this publication by the WHO, methods for the implementation of cost-effective and rational use policies for medicines are explored. The report includes a review of antibiotic stewardship policies and awareness raising campaigns from different countries.|
|Critically important antimicrobials for human medicine, 5th revision||Assessment of which antimicrobials are of highest importance to human health. Substances are categorized into three groups: critically important, highly important, and important.|
|Improving Medicines Access and Use for Child Health -A Guide to Developing Interventions||Practical manual for those developing interventions to improve access to and use of medicines, including antibiotics, for child illness. Target groups: health policy makers, CSOs/NGOs and health care professionals. Contains guidance on all steps of the process, as well as examples of instruments and interventions. Special focus on low-resource settings.|
|Step-by-step approach for development and implementation of hospital and antibiotic policy and standard treatment guidelines||WHO SEARO document that focuses on the mechanism to develop a practical hospital antibiotic policy and standard treatment guidelines. It also contains information on national policies to contain antibiotic resistance.|
|CODEX ALIMENTARIUS: Codex Texts on Foodborne Antimicrobial Resistance (PDF)||The “Code of practice to minimize and contain antimicrobial resistance (CAC/RCP 61-2005)” from CODEX ALIMENTARIUS describes the responsibilities for regulatory authorities, veterinary pharmaceutical industry, wholesalers, retailers, veterinarians and farmers. The document also contains a second guideline: “Guidelines for risk analysis of foodborne antimicrobial resistance”. English, French and Spanish versions included.|
|WHO guidelines on use of medically important antimicrobials in food-producing animals||WHO recommendations on antibiotic use in animals, and evidence base: Urges farmers and the food industry to stop using antibiotics routinely to promote growth and prevent disease in healthy animals.|
|The Evolving Threat of antimicrobial resistance – Options for Action||Chapter 4 describes examples of policy activities that focuses on reducing antimicrobial use in animal husbandry in different parts of the world, with the aim of raising awareness and in particular to stimulate further coordinated efforts.|
|Antibiotic resistance: what the agriculture sector can do (PDF)||Poster from FAO: What resistance is and what the agriculture sector can do.|
|Improving biosecurity through prudent and responsible use of veterinary medicines in aquatic food production||Guidance from FAO that discusses the use of veterinary medicines in aquaculture and gives examples of good practice and disease prevention measures.|
|OIE Aquatic Animal Health Code||OIE guide to development and harmonisation of national antimicrobial resistance surveillance and monitoring programmes for aquatic animals. Chapter 6.5: Risk analysis for antimicrobial resistance arising from the use of antimicrobial agents in aquatic animals.|
|OIE Terrestrial Animal Health Code||Chapter 6.11: Risk analysis for antimicrobial resistance arising from the use of antimicrobial agents in animals.|
|Guidelines for the prudent use of antimicrobials in veterinary medicine (2015/C 299/04)||Guidelines from the European Commission that provide authorities and stakeholders with recommendations and practical examples for development and implementation of strategies to promote the prudent use of antimicrobials in veterinary medicine. Available in a number of languages.|
|Good practices AMR from EU Member States||A compilation of examples from EU member states of work to address the antibiotic resistance problem within the non-human sector, published by the Dutch EU Presidency 2016.|
|Reduced and Responsible: use of antibiotics in food-producing animals in the Netherlands||This leaflet outlines the Dutch policy on use of antibiotics in food-producing animals. It emphasizes the role of public-private partnerships, and presents key elements of the work, such as transparency and benchmarking of antibiotic use per herd and per veterinarian, improved herd health and clear reduction targets for antibiotic use.|
|A review of antibiotic use in food animals: perspective, policy, and potential||This review summarizes the literature on the role of antibiotic use in food animals in the development of resistance and its risk to human health. It also lists different guidance and policy documents on antibiotic use in the animal sector.|
|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.|
|Combating antibiotic Resistance: A Policy Roadmap to Reduce Use of Medically Important Antibiotics in Livestock||A policy roadmap with 11 core policy recommendations aimed at a broad set of stakeholders: policymakers, food companies, institutional food purchasers (i.e. hospitals, schools and universities), and medical groups. The recommendations are divided into three key areas: 1) decreasing livestock use of medically important antibiotics; 2) monitoring livestock antibiotic use, and 3) enhancing surveillance and data integration to inform antibiotic resistance policy.|
|Global Antimicrobial Use in the Livestock Sector (PDF, 1MB)||This report includes an estimate of the order of magnitude of antimicrobial use, and the economic value of antimicrobial use in the livestock sector.|