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Policy  –  Implement the plan

Rational use of antibiotics

All antibiotic 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. To limit inappropriate use of antibiotics is crucial to preserve antibiotic effectiveness for both human and veterinary medicine.

Strategic objective 4 of the Global Action Plan on Antimicrobial Resistance advises to optimize the use of antimicrobial medicines in human and animal health.

  • 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 lacks 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.

For some bacterial infections, antibiotics are life-saving medicines. Likewise, treatment with antibiotics is necessary for certain diseases in animals, in order to ensure survival, welfare, productivity, and to reduce spread of disease. The goal of rational use initiatives is not always to reduce antibiotic use, but instead to ensure that the use is appropriate.

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. Which type of legislations that are most appropriate will differ 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. Providing quality education for health care professionals, farmers, veterinarians and other animal health professionals is key (see Implement the plan – Awareness and understanding). Creating or updating guidelines and making sure there is access to good quality essential antibiotics and diagnostics are other key areas.

Antibiotics crucial for human health

WHO, the European Medicines Agency (EMA) and others have taken steps to identify the antibiotics that are most ‘critical’ to human health, and to prioritize the reduction of their use in agriculture.

  • The WHO categorization focuses on the disease conditions treated by particular products, and the range of alternatives available. Substances are categorized into three groups: critically important, highly important, and important.
  • The EMA strategy adopts an alternative methodology based on a wider assessment of the risk of transmission of resistance from animals to humans.

The food animal sector

In the food animal sector, governments are recommended to provide appropriate regulations on the authorization, manufacturing, distribution and use of veterinary products through their veterinary legislation. The World Organisation for Animal Health (WOAH, founded as 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 to consider the Code of Practice developed by Codex Alimentarius, the WOAH list of antibiotics of veterinary importance, and the WHO guidance on the use of critically important antibiotics for human medicine.

Steps to optimize antibiotic use in food animal production includes:

  • Phase out the use of antibiotics for animal growth promotion
  • Restrict routine use of antibiotics

These efforts must go closely together with efforts to improve disease prevention and control in food animal production.

Several countries have banned the use of antibiotics for growth promotion. It is possible to phase-out antibiotics for growth promotion without negative effects on productivity, but it may require adaptation of production systems . It has been proposed that the growth response to antibiotics is marginal when nutrition, hygiene practices, and health status of the animal herd or flock are improved.

Awareness in the community

Promotion of rational antibiotic use in communities plays an important complementary role. Find more information in Awareness and understanding.

The resources below have been divided into the following tables:

  • Human sector
  • Food animals

Information for actors in health care and food animal production on how to take action is collected under RATIONAL USE, and guidance on measuring appropriate use is presented in MEASURE: Appropriate use.

Selected Resources

Human sector

Resource Description
The South-East Asia Region Antimicrobial Stewardship 2022 Webinar Series Webinar series organized by WHO to provide in-depth training on the development and implementation of comprehensive and integrated antimicrobial stewardship programs at national and healthcare facility levels in low-and-middle income countries.
WHO policy guidance on integrated antimicrobial stewardship activities Guidance on how to facilitate the implementation of national antimicrobial stewardship activities in an integrated and programmatic approach. Intended for national policy-makers at ministries of health, national antimicrobial resistance coordinating bodies or other national authorities responsible for the development, implementation and monitoring of national action plans.

WHO developed an online training course to facilitate a better understanding of this guidance. It comprises 4 learning modules, with each module focusing on a specific aspect of the WHO AMS Policy Guidance.

Antimicrobial stewardship programmes in health-care facilities in low- and middle-income countries: a WHO practical toolkit Document from WHO. Contains recommendations and how-to guidance for setting up and implementing antimicrobial stewardship (AMS) programmes on both national and facility levels. Specifies 19 essential core elements for AMS on national level, to facilitate development of relevant structures. Also available in  Arabic, Russian, French and Spanish.

An online course developed by WHO and focused on this toolkit for antimicrobial stewardship implementation can be found in this link.

WHO Model Lists of Essential Medicines Guidance. The WHO EML provides advice on which antibiotics should be available to treat bacterial infections. To assist rational use, it categorizes antibiotics into 3 groups: Access, Watch and Reserve. There are separate lists for adults and children.
Adopt AWaRe: Handle antibiotics with care Tool that provides advise on which antibiotics to use to treat common bacterial infections and support improvement of antibiotic use practices. It classifies antibiotics into three groups based on the potential to induce and propagate resistance: Access, Watch and Reserve (AWaRe Categorization). See also: List of antibiotics and recommended indications
WHO list of critically important antimicrobials for human medicine (WHO CIA list) Assessment and ranking of which antimicrobials are of highest importance to human health. Intended to help formulate and prioritize risk assessment and risk management of antimicrobial resistance due to non-human use. Substances are categorized into three groups: critically important, highly important, and important. Also available in French and Spanish. See also 2 page infographic summary.
Second WHO model list of essential in vitro diagnostics Guidance from the WHO. Presents in vitro diagnostic tests recommended for use at various levels of health care systems, including to assist antibiotic stewardship.
Core Elements of Human Antibiotic Stewardship Programs in Resource-Limited Settings: National and Hospital Levels Methodology 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).
Tailoring Antimicrobial Resistance Programmes (TAP) Quick Guide Handbook that provides a step-by-step approach to designing and implementing targeted behavioral change interventions to address drivers of antimicrobial resistance in humans and animals. Developed to assist national-level TAP working groups. The TAP Toolbox provides support tools for adopting each step of the TAP approach, and the TAP Process Poster provides a visual description of the TAP process.
Optimizing use of antimicrobial medicines Information portal on WHO’s guidance on optimal use of antimicrobial medicines.
Promoting Rational Use of Medicines: Core Components – WHO Policy Perspectives on Medicines, No. 005, September 2002 Core components of rational medicines use presented in a publication from WHO. 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 Pursuit of Responsible Use of Medicines: Sharing and Learning from Country Experiences 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.
Improving Medicines Access and Use for Child Health -A Guide to Developing Interventions 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.
Developing, Implementing, and Monitoring the Use of Standard Treatment Guidelines: A SIAPS How-to Manual Tool for developing and assessing use of standard treatment guidelines. End of document contains sample forms and surveys. Also provides links to useful additional documents.
Step-by-step approach for development and implementation of hospital and antibiotic policy and standard treatment guidelines Manual by WHO SEARO 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.

Food animals

Resource Description
CODEX ALIMENTARIUS International Food Standards: Antimicrobial Resistance Standards for the responsible use of antimicrobials in food-producing animals. The “Code of practice to minimize and contain antimicrobial resistance” (CAC/RCP 61-2005) describes the responsibilities for regulatory authorities, veterinary pharmaceutical industry, wholesalers, retailers, veterinarians and farmers. “Guidelines for Risk Analysis of Foodborne Antimicrobial Resistance” (CAC/GL 77-2011) gives guidance on assessing the risk to human health from foodborne antibiotic resistant bacteria, and determining appropriate management strategies to control those risks. Available in English, French and Spanish.
WOAH Aquatic Animal Health Code Standards for improvement of aquatic animal health worldwide, to be used by the Competent Authorities. Guide to development and harmonization of national antimicrobial resistance surveillance and monitoring programmes for aquatic animals. See for example Chapter 6.5: Risk analysis for antimicrobial resistance arising from the use of antimicrobial agents in aquatic animals.
WOAH Terrestrial Animal Health Code Standards for the improvement of terrestrial animal health and welfare and veterinary public health worldwide. Intended for use by Veterinary Authorities. Chapter 6.11: Risk analysis for antimicrobial resistance arising from the use of antimicrobial agents in animals.
WOAH list of antimicrobial agents of veterinary importance Assessment and categorization developed by WOAH describing the most important antimicrobial agents in veterinary medicine. Substances are categorized into three groups: Veterinary Critically Important Antimicrobial Agents, Veterinary Highly Important Antimicrobial Agents and Veterinary Important Antimicrobial Agents. Provides specific notes on uses of different classes and specific diseases for which certain antimicrobials are of high importance, and considerations for their use.
WHO guidelines on use of medically important antimicrobials in food-producing animals Guidelines. 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.
Procurement criteria: Responsible antimicrobial use in products of animal origin Document developed by Health Care Without Harm that provides procurement criteria to incentivize food producers to ensure responsible antimicrobial consumption. Procurers can adapt this set of criteria according to their own local policies and procurement practices.
Criteria and questionnaire for responsible use of antibiotics in food-producing animals Manual from Axfoundation with criteria that aim to ensure responsible use of antibiotics in the food animal sector. Primarily intended for use by Swedish food companies as they interact with suppliers of food products, but has applicability and can be an inspiration also in other settings. Contains an appendix with guiding questions to assist in follow-up discussions with suppliers.
The Evolving Threat of antimicrobial resistance – Options for Action Policy brief. Options for action from WHO (predates the global action plan). 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.
Guide to good farming practices for animal production food safety Manual for Competent Authorities assisting farmers and other stakeholders in keeping livestock to produce safe food. Spanish and French versions included.
Improving biosecurity through prudent and responsible use of veterinary medicines in aquatic food production Report from FAO that discusses the use of veterinary medicines in aquaculture and gives examples of good practice and disease prevention measures.
Antibiotic resistance: what the agriculture sector can do (PDF) Poster from FAO: What resistance is and what the agriculture sector can do.
Guidelines for the prudent use of antimicrobials in veterinary medicine (2015/C 299/04) Example 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.
EMA and EFSA Joint Scientific Opinion on measures to reduce the need to use antimicrobial agents in animal husbandry in the European Union, and the resulting impacts on food safety (RONAFA) Journal article detailing a Joint Scientific Opinion from EFSA and EMA, upon request from the European Commission, on measures to reduce use of antimicrobial agents in the food animal sector.
FAO case study series: Tackling antimicrobial use and resistance in pig production Country examples describing work towards more prudent use of antibiotics in food animals. The first case study describes the Danish campaign to reduce antibiotic use in pig production. Includes monitoring of antibiotic use, initiatives made and lessons learned. Available in English, Spanish and Chinese.
A review of antibiotic use in food animals: perspective, policy, and potential Review that 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 Journal 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 Policy brief. 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.
Reducing antimicrobial use in food animals Policy brief. This paper illustrates the threats of AMR’s rise in zoonotic pathogens and the global trends of antimicrobials consumption in livestock. In addition, it discusses some solutions and policies in the area of regulations, user fees, and consumption habits to reduce antimicrobial use in food animals.
Global Antimicrobial Use in the Livestock Sector (PDF, 1MB) Report that includes an estimate of the order of magnitude of antimicrobial use, and the economic value of antimicrobial use in the livestock sector.