Share the article

Toolbox

Rational use

The RATIONAL USE focus area of the Toolbox describes the practical steps to begin or strengthen work to improve rational use of antibiotics in different settings.

What does the RATIONAL USE focus area cover?

  • Health care: Guidance on the process of setting up rational use initiatives or programs at health care facilities, core components for promoting rational use and possible interventions.
  • Food animals: Provides an overview of what can be done to improve antibiotic use in food animals.
  • Examples from the field highlights some initiatives aiming to improve the rational use of antibiotics.

The narrative text is accompanied by shorter case examples and “Selected resources” – hands-on materials and tools that may be used directly or adapted to your particular setting. Browse through then pick and choose what material is most helpful for you!

Why rational use?

All antibiotic use, whether appropriate or not, can promote the development of resistance in pathogenic and commensal bacteria. The goal of rational use is not always to reduce antibiotic use, but to ensure that the use is appropriate. Antibiotics are a precious but finite resource and the benefit of their use must be weighed against the risks for society and the patient.

Importantly, rational use is also a matter of making sure people have access to effective antibiotics. Access should not be seen as being at odds with rational use. Both are integral parts of an effective response to ensure sustainable access to antibiotics. This goes for both human and animal use.

In human medicine

Unlike other medicines, antibiotics target not the actual patient, but instead the growth and ecology of invading pathogens and commensal microorganisms. As resistant bacteria spread from one host to the next, the greatest burden of inappropriate use in many cases falls on public health instead of the consumer of the drug, complicating strategies to improve use. That said, rational use of antibiotics must also be considered an issue of patient safety, as antibiotic use can have direct negative side effects on the individual consumer, including allergic reactions, Clostridium difficile infection and antibiotic associated diarrhea/colitis. Learn more in UNDERSTAND: Why should I care?

The food animal sector

In the animal and agricultural sectors, antibiotics are also widely used to treat disease, to prevent disease and for non-therapeutic reasons such as to promote growth of animals. The antibiotic use is often inappropriate due to lack of proper guidelines, diagnosis or information on correct treatments.

A threat to human and animal health

Antibiotic resistant bacteria are frequently identified in studies and surveillance programs within the farm animal sector. These bacteria have the potential to spread to humans, by direct contact and indirectly via the food chain, water, air and manured and sludge-fertilized soils. The exact magnitude of transmission is not known, but there is an ever expanding volume of evidence reporting transmission of resistant bacteria between food animals and humans. A high antibiotic pressure is also a risk factor in the emergence and spread of new multidrug-resistant bacteria. Read more in UNDERSTAND – Antibiotics in the environment.

On top of the impact on human health, antibiotic resistance in animal pathogens can lead to therapy failure with a negative effect on animal health and welfare. There is also an increasing understanding within the veterinary sector that any upcoming new antibiotic will likely be preserved for human medicine only.

Multifaceted and coordinated approaches needed

Multifaceted, coordinated approaches to promote rational use are urgently needed as the prudent use of antibiotics is crucial to preserving existing antibiotics and improving patient outcomes. Initiatives can be done in a variety of settings and can range in size from a simple intervention to a full scale rational use program.

1.
Ohl C, Borlandc H. An Antimicrobial Stewardship Curriculum for Medical Students [Internet]. Wake Forest School of Medicine. 2014 [cited 2014 Aug 20]. Available from: https://school.wakehealth.edu/Departments/Internal-Medicine/Infectious-Diseases/CAUSE/Antimicrobial-Stewardship-Curriculum#View%20The%20Curriculum
1.
Catry B, Van Duijkeren E, Pomba MC, Greko C, Moreno MA, Pyörälä S, et al. Reflection paper on MRSA in food-producing and companion animals: epidemiology and control options for human and animal health. Epidemiol Infect. 2010 May;138(5):626–44.
1.
Gibbs SG, Green CF, Tarwater PM, Mota LC, Mena KD, Scarpino PV. Isolation of Antibiotic-Resistant Bacteria from the Air Plume Downwind of a Swine Confined or Concentrated Animal Feeding Operation. Environ Health Perspect [Internet]. 2006 Jul;114(7):1032–7. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1513331/
1.
Marshall BM, Levy SB. Food animals and antimicrobials: impacts on human health. Clin Microbiol Rev. 2011 Oct;24(4):718–33.
1.
Bengtsson B, Greko C. Antibiotic resistance—consequences for animal health, welfare, and food production. Upsala Journal of Medical Sciences [Internet]. 2014 [cited 2016 Apr 5];119(2):96–102. Available from: http://www.tandfonline.com/doi/full/10.3109/03009734.2014.901445
1.
Leverstein-van Hall MA, Dierikx CM, Cohen Stuart J, Voets GM, van den Munckhof MP, van Essen-Zandbergen A, et al. Dutch patients, retail chicken meat and poultry share the same ESBL genes, plasmids and strains. Clin Microbiol Infect [Internet]. 2011 Jun;17(6):873–80. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21463397
1.
Zhu Y-G, Johnson TA, Su J-Q, Qiao M, Guo G-X, Stedtfeld RD, et al. Diverse and abundant antibiotic resistance genes in Chinese swine farms. Proc Natl Acad Sci USA [Internet]. 2013 Feb 26;110(9):3435–40. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3587239/
1.
Price LB, Stegger M, Hasman H, Aziz M, Larsen J, Andersen PS, et al. Staphylococcus aureus CC398: host adaptation and emergence of methicillin resistance in livestock. MBio [Internet]. 2012;3(1). Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3502926/
1.
Dellit TH, Owens RC, McGowan JE, Gerding DN, Weinstein RA, Burke JP, et al. Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America guidelines for developing an institutional program to enhance antimicrobial stewardship. Clin Infect Dis [Internet]. 2007 Jan 15;44(2):159–77. Available from: http://www.ncbi.nlm.nih.gov/pubmed/17173212
1.
Sumpradit N. Antibiotics Smart Use Program: Thailand’s experiences in promoting rational use of antibiotics [Internet]. Powerpoint presented at; 2012. Available from: http://who.int/patientsafety/implementation/amr/presentation_NithimaSumpradit.pdf
1.
Pulcini C, Gyssens IC. How to educate prescribers in antimicrobial stewardship practices. Virulence [Internet]. 2013 Feb 15;4(2):192–202. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23361336
1.
European Commission. Action plan against the rising threats from Antimicrobial Resistance. Communication from the Commission to the European Parliament and the Council, COM (2011) 748 [Internet]. 2011. Available from: http://ec.europa.eu/dgs/health_consumer/docs/communication_amr_2011_748_en.pdf