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Rational use  –  Health care

Core components

Find here core components for work to promote rational use (stewardship) of antibiotics in different health care settings.

Rational use activities should take place at all levels of care (hospital, community/primary/outpatient care, and long-term care). Depending on the setting, different components may be relevant.

Twelve core components to promote the rational use of medicines

The WHO has outlined select core components to promote the rational use of medicines at the healthcare facility and national level

  1. A mandated multi-disciplinary national body to coordinate medicine use policies
  2. Clinical guidelines
  3. Essential medicines list based on treatments of choice
  4. Drugs and therapeutics committees in districts and hospitals
  5. Problem-based pharmacotherapy training in undergraduate curricula
  6. Continuing in-service medical education as a licensure requirement
  7. Supervision, audit and feedback
  8. Independent information on medicines
  9. Public education about medicines
  10. Avoidance of perverse financial incentives
  11. Appropriate and enforced regulation
  12. Sufficient government expenditure to ensure availability of medicines and staff

Core components specific for rational antibiotic use efforts in different health care settings have been outlined by for example the Centers for Disease Control and Prevention (CDC, USA). These highlight, among other things:

  • Leadership Commitment
  • Accountability
  • Action (implementation of at least one policy or practice)
  • Tracking and reporting
  • Education (of antibiotic prescribers/providers, and patients)

Diagnostics

Diagnostics are used to determine what disease a patient is afflicted by, and in the case of infectious diseases what is causing the disease. It is the clinical assessment of symptoms and results from diagnostic tests made by the healthcare provider. This information is then used to determine what the appropriate therapy is: for example a specific antibiotic, other medicines or bed rest. Rational use programs are dependent on good diagnostics, i.e. a well-educated health workers and access to relevant diagnostic tests.

Core components from different organizations and research groups are collected below.

How to initiate or strengthen work to implement the core components is covered in Set up a program. Possible strategies and actions to include can be found in Interventions.

Selected Resources

Resource Description
Promoting Rational Use of Medicines: Core Components Core components to promote the rational use of medicines at the healthcare facility and national level. WHO document, available in English, French and Spanish. Global
Core Elements of Human Antibiotic Stewardship Programs in Resource-Limited Settings: National and Hospital Levels Framework for implementation of antibiotic stewardship programs in resource-limited settings from the US CDC. It takes a tiered approach and covers a range of activities that a government or individual facility can implement based on the resources available. (PDF, 3MB). Resource-limited settings.
Global core standards for hospital antimicrobial stewardship programs, international perspectives and future directions Report from Leading Health Systems Network and CDDEP suggesting standards for rational use programs in hospitals. Includes checklists (also available in Spanish, Portuguese and Chinese) for hospital programs and identifies barriers to implementation with possible measures to overcome them. While overlapping with core components proposed by CDC and others, the checklists are designed to be applicable also in low-resource settings.
Core Elements of Hospital Antibiotic Stewardship Programs Core elements and checklist. Lists and describes core elements of stewardship programs in hospitals, such as leadership, accountability, drug expertise, action, tracking, reporting and education. Developed by the CDC (USA). See also companioning checklist.
Core Elements of Outpatient Antibiotic Stewardship Framework for antibiotic stewardship in outpatient clinics and health-care facilities by the US CDC.
Developing core elements and checklist items for global hospital antimicrobial stewardship programmes: a consensus approach Journal article that suggests global core elements of antibiotic stewardship programs, including checklist items, to be in place in all hospitals. Aims to facilitate the development of national guidelines as well as adoption by healthcare facilities across the world, regardless of resource availability. Global
The Core Elements of Antibiotic Stewardship for Nursing Homes Core elements for long-term care. Transfers the Core Elements of Hospital Antibiotic Stewardship from the US CDC into the setting of nursing homes (long-term care facilities).

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Pombo MHR, Gandra S, Thompson D, Lamkang AS, Pulcini C, Laxminarayan R. Global core standards for hospital antimicrobial stewardship programs, international perspectives and future directions [Internet]. 2018. Available from: https://www.leadinghealthsystemsnetwork.org/research
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Implementation Resources | Antibiotic Use | CDC [Internet]. 2018 [cited 2018 Oct 8]. Available from: https://www.cdc.gov/antibiotic-use/healthcare/implementation.html
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Pulcini C, Binda F, Lamkang AS, Trett A, Charani E, Goff DA, et al. Developing core elements and checklist items for global hospital antimicrobial stewardship programmes: a consensus approach. Clinical Microbiology and Infection [Internet]. 2018 Apr 3 [cited 2018 May 14];0(0). Available from: https://www.clinicalmicrobiologyandinfection.com/article/S1198-743X(18)30295-7/fulltext
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Sanchez GV. Core Elements of Outpatient Antibiotic Stewardship. MMWR Recomm Rep [Internet]. 2016 [cited 2017 Feb 24];65. Available from: http://www.cdc.gov/mmwr/volumes/65/rr/rr6506a1.htm
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World Health Organization - WHO. Promoting Rational Use of Medicines: Core Components - WHO Policy Perspectives on Medicines, No. 005, September 2002 [Internet]. 2002 [cited 2016 Mar 16]. Available from: http://apps.who.int/medicinedocs/en/d/Jh3011e/
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Centers for Disease Control and Prevention - CDC. Core Elements of Hospital Antibiotic Stewardship Programs [Internet]. National Center for Emerging and Zoonotic Infectious Diseases; 2014 [cited 2014 Aug 20]. Available from: http://www.cdc.gov/getsmart/healthcare/implementation/core-elements.html
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Centers for Disease Control and Prevention - CDC. The Core Elements of Antibiotic Stewardship for Nursing Homes [Internet]. The Core Elements of Antibiotic Stewardship for Nursing Homes. 2015 [cited 2015 Dec 14]. Available from: http://www.cdc.gov/longtermcare/prevention/antibiotic-stewardship.html