Share the article

Rational use  –  Health care


This section describes interventions to help reduce inappropriate antibiotic use and limit the spread of antibiotic resistance in hospitals (inpatient) and primary care/community (outpatient) settings.

When designing interventions, the closer they are aimed at the provider/prescriber of antibiotics, as opposed to facility or national level, the more effective they have shown to be. It is also important to keep in mind how implementation of one intervention may affect the situation elsewhere. Restricting use of a specific antibiotic or targeting of a specific bacterial pathogen may lead to increased use of other antibiotics or have unintended effects on other bacteria. Each health care facility needs to do their own assessment to understand what is needed and appropriate for their setting, and how to evaluate the work. The section Set up a program provides guidance on how to implement interventions in a structured way.

Want to keep up to date and learn about relevant rational use initiatives?

The Center for Infectious Disease Research and Policy (CIDRAP) has compiled a variety of online materials within their antimicrobial stewardship project. Here, they link to resources, initiatives, organizations and more (US and international).

You can also sign up to CIDRAP’s weekly newsletter on antimicrobial stewardship here.

Persuasive interventions

Persuasive interventions are those that use one or more of the following methods for changing professional behavior: dissemination of educational resources, reminders, audit and feedback, or educational outreach.

Continual education of health care professionals can be a means to keep staff up to date, make them aware of policies, familiar with changes in pharmacotherapy, and allow them to share experiences and learn from discussion with peers. Ideally, passive education should be combined with active interventions; as a standalone initiative passive education has shown to provide only marginal results.

Educational intervention makes an impact on antibiotic prescription patterns at a hospital:

During an outbreak of extended-spectrum beta-lactamase (ESBL)-producing Klebsiella pneumoniae at a hospital in Sweden, an educational antibiotic intervention was performed aimed at reducing prescriptions of second- and third-generation cephalosporins and preventing increased use of fluoroquinolones and carbapenems.

New recommendations for empirical intravenous antibiotic treatment were communicated to prescribers throughout the hospital by infectious diseases physicians working with the Swedish strategic programme against antibiotic resistance. No restrictive measures were used. A radical immediate and sustained reduction was demonstrated for the cephalosporins targeted in the intervention. Fluoroquinolone and carbapenem use was essentially unchanged. The ESBL outbreak subsided and no increased resistance to the replacement drug was detected during the 2.5 year follow-up. This study clearly demonstrates that an educational intervention can have an immediate and profound effect on antibiotic prescription patterns at a large tertiary hospital.

Restrictive interventions

Restrictive interventions are initiatives that limit the freedom of prescribers/providers to select certain antibiotics. For example, prescriptions of the targeted antibiotics might require approval by an infectious diseases specialist, might be substituted by a pharmacist or completely restricted during the intervention period.

Multifaceted interventions

Multifaceted interventions are those that use a combination of approaches to influence the rational use of antibiotics. Persuasive and restrictive antibiotic interventions might be performed in parallel with structural changes or other approaches to improve prescribing practices. This might result a more profound immediate and sustained effect of the intervention than would have been achieved with any of the components alone.

See MEASURE to access tools and resources to assist in assessing the situation and evaluating the effect of interventions. It includes a variety of topics that relates to rational use:

Resources below have been divided into the following tables:

  • General resources
  • Hospital (inpatient)-specific resources

Additionally, educational resources (such as courses and training manuals) are collected in RAISE AWARENESS: Education and training. Further help to start or strengthen awareness raising initiatives can be found in RAISE AWARENESS: Set up a campaign.

Selected Resources

General resources

Resource Description
Antimicrobial stewardship programmes in health-care facilities in low- and middle-income countries: a WHO practical toolkit Guidelines on how to start an antimicrobial stewardship program. Recommendations and how-to guidance for setting up and implementing antimicrobial stewardship on both national and facility levels. Section 5 contains a selection of interventions.

An online training course on this guideline is available. Learning module 4 describes the different antimicrobial stewardship interventions that have successfully improved antibiotic prescribing practices at healthcare facilities in LMICs.

Antimicrobial Stewardship and Infection Prevention and Control in Low- and Middle-income Countries Article series that reviews the current evidence and best practices on antibiotic stewardship and IPC measures in LMICs, with specific focus on children. It also includes the experiences and lessons learned by clinicians working on rational use initiatives.
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 care professionals, health policy makers, CSOs/NGOs.

  • Guidance on all steps of the process, including how to evaluate results
  • Options for interventions and tools to use
Antibiogo Mobile app. A free app for measurement and interpretation of antibiotic susceptibility tests. Developed by Doctors Without Border. Described and evaluated in an article published in Nature communications.
Interventions to Reduce Antibiotic Prescribing in LMICs: A Scoping Review of Evidence from Human and Animal Health Systems Systematic review assessing evidence on interventions to change the practices of antibiotic prescribers and gatekeepers and to better understand the context of antibiotic use in LMICs.
Effects of intervention measures on irrational antibiotics/antibacterial drug use in developing countries: A systematic review Systematic review looking at the effect of educational, managerial, diagnostic tests, regulatory, economic and multifaceted interventions targeted on misuse of antibiotics in low- and middle-income countries.
TARGET antibiotic toolkit Campaign/intervention materials for optimizing antibiotic prescribing in primary care, includes for example audit toolkits and leaflets for patients. Developed in British context.
Communication toolkit for professionals in hospitals and other healthcare settings Toolkit from ECDC to support health-care professionals in optimizing antibiotic use. Consists of a variety of materials, including fact sheets, key messages for various professionals, checklist for prescribers and infographics about antimicrobial stewardship. A guidance note is available for download. See also the European Antibiotic Awareness Day campaign/intervention/education materials for professionals in primary care and hospitals.
Help Prescribing Clinicians Choose the Right Antibiotic Toolkits for establishing the use of an antibiogram in nursing homes, developed by the Agency for Healthcare Research and Quality:

Antibiotic use for acute respiratory tract infections (ARTI) in primary care; what factors affect prescribing and why is it important? A narrative review Review examining factors that affect prescibing desicions among primary care providers and strategies to limit overuse.
Antimicrobial stewardship initiatives throughout Europe: proven value for money Scientific article highlighting some of the success stories of proven cost-effective stewardship interventions in Europe. National, hospital, ward, and primary care level.

Hospital (inpatient)-specific resources

Resource Description
Interventions to improve antibiotic prescribing practices for hospital inpatients Systematic review of the effectiveness of interventions that alone, or in combination, are promoting prudent antibiotic prescribing to hospital inpatients (Cochrane). Update from 2017.
Antibiotic stewardship interventions in hospitals in low-and middle-income countries: a systematic review Systematic review with short description of interventions to improve antibiotic use for hospitalized patients, focusing on low-resource settings (27 studies included). Most studies report positive effects, but the low number of studies and shortcomings in study design makes it hard to draw general conclusions.
Global Point Prevalence Survey on Antimicrobial Consumption and Resistance PPS protocols and methodology – Ongoing project that welcomes new participants from across the world. This open to join project monitors antimicrobial prescribing and resistance in hospital patients on all continents 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 have participated). For documents such as protocols, data collection templates and presentations in different languages for personal use click here. Numerous scientific publications with results from the project have been published. Available in several languages.
Implementing an Antibiotic Stewardship Program Interventions and evidence. IDSA/SHEA recommendations that discusses a broad range of possible interventions for implementation of antibiotic stewardship in inpatient populations, and underlying evidence.
Antibiotic prescribing in hospitals: a social and behavioural scientific approach Review article that describes how the volume and appropriateness of antibiotic use in hospitals vary between countries, hospitals, and physicians. Determinants that influence use and improvement strategies are discussed (mainly articles from Europe and North America included). (Paywall)
CDC/IHI Antibiotic Stewardship Driver and Change Package (PDF) Conceptual model of key drivers for reducing inappropriate antibiotic use in hospitals, created by CDC and Institute for Healthcare improvement. Special emphasis on practicality and ease of implementation.
A Path to Better Antibiotic Stewardship in Inpatient Settings Case studies. Report including 10 case studies that maps how to improve antibiotic use in acute and long-term care facilities in the US.

More from "Health care"