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Health care  –  Set up a program

Engage stakeholders

Experts working with rational use have described having a multidisciplinary committee with support from key stakeholders as a crucial first step in developing a rational use program. Committees should be made up of appointed persons, and should have clear objectives, functions and a defined scope of responsibilities.

Form a rational use committee

A multidisciplinary interprofessional committee should be formed with motivated individuals who are committed to promoting the rational use of antibiotics. This committee can be either stand-alone, or be part of an health care facility’s Drug and Therapeutics Committee. Ideally, the rational use committee should be led or supervised by an infectious diseases physician and/or a clinical pharmacist with infectious diseases training. The team should aim to include but not be limited to:

  • Doctors who prescribe antibiotics (for example specialists in infectious diseases, intensive medicine, paediatrics)
  • Specialist pharmacists (with infectious diseases training; will provide data on antibiotic use)
  • Nurses
  • Clinical microbiologists (will provide data about bacterial resistance)
  • Members of management
  • Members of the Infection Control Committee
  • Others may be appointed as needed (such as an information technology specialist, a hospital epidemiologist etc)

Obtaining success with limited personnel

While it is ideal for rational use programs to be supported by an infectious disease physician and clinical pharmacist, the reality is there are not enough specialists in any healthcare system, in both developed and developing countries. Examples from Vietnam and Denmark show that this gap can be addressed by partnering with a larger hospital with an established rational use program, and implementing targeted initiatives for recurring problems with irrational use.

With limited resources, it is crucial to ensure that programs are led by committed, influential, key stakeholders, rooted in existing infrastructure. As a patient safety issue, rational use should be a concern for all healthcare personnel and the contribution of nurses, pharmacists and data clerks can lead to measurable differences in antibiotic use. Clinical specialists provide extremely valuable technical expertise however the collective power of all healthcare workers interacting with patients must be harnessed for effective disease management and to reduce the spread of antibiotic resistance.

Collaborate with others

Rational use programs may overlap and intertwine with other initiatives or departments at the health facility and must be a collaborative effort that with support and by-in at all levels in the continuum of care. Rational use initiatives work closely together with both clinical microbiology laboratories and infection prevention and control programs. The clinical microbiology laboratory is responsible for identifying organisms, genotyping and determining susceptibility so that those working within rational use can prescribe the appropriate antibiotic for treatment. Through monitoring of resistance, the clinical microbiology laboratory also feeds information to infection control programs that work to prevent the spread of resistant infections. To facilitate the success of the program, good working relationships should be established with the :

  • Infection prevention and control committee
  • Clinical microbiology laboratory
  • Pharmacy and therapeutics committee
  • Healthcare epidemiologists
  • Clinical microbiology laboratory

Ensure support from stakeholders

Support is needed from health care facility administration, medical staff leadership, and all levels of healthcare providers. To begin, expected outcomes of the program should be agreed upon together with authorities. A strategic plan clearly stating goals and objectives, and including a timeline and budget should be presented to and approved by management. This will help to ensure support for education and training and that staff are allowed to devote time to rational use activities. Ideally, rational use committee members should be compensated appropriately for their time, and their commitments should be outlined in job descriptions and performance reviews.

Establish the role of the rational use committee

An agreement should be made with management that clearly states the mandate of the rational use committee, outlining their level of authority to perform tasks and the responsibilities of its members. Health care facility staff should be made aware of rational use activities and their importance. When possible, it is good to have rational use programs operate under the auspices of quality assurance and patient safety. The focus should always be on the safety and care of patients rather than a policing activity.

Strama – The Swedish experience

In Sweden, the Strama network is responsible for coordination of work on containment of antibiotic resistance. Strama engages stakeholders from different areas from within the Swedish health system and works with multi-disciplinary communication and local implementation.

Every year, the Strama network organize national “Strama Days” where groups from national and local levels are able to present opportunities for vertical (from local to national level and vice-versa) as well as horizontal (from one local representative to another) exchanges. This has been proven to be an important meeting point for this interplay, independent from commercial and pharmaceutical interest.

Selected Resources

Resource Description
Guidelines on Implementation of the Antimicrobial Strategy in South Africa: One Health Approach & Governance Guideline. Example of a country implementation guideline. ‘How to’, step-by-step guide for South African healthcare to enact the national strategy, addressing the governance framework at different levels of the health system. Section V covers governance at health facility level.

More from "Set up a program"

Public Health Agency of Sweden. Swedish work on containment of antibiotic resistance Tools, methods and experiences [Internet]. Stockholm, Sweden: Public Health Agency of Sweden; 2014 [cited 2014 Aug 21]. 133 p. Available from:
Ministerial Advisory Committee on Antimicrobial Resistance, National Department of Health and Affordable Medicines Directorate. Guidelines on Implementation of the Antimicrobial Strategy in South Africa: One Health Approach and Governance [Internet]. 2017 [cited 2017 Nov 22]. Available from:
International Federation of Infection Control - IFIC. IFIC Basic concepts of infection control [Internet]. Portadown: International Federation of Infection Control; 2016. Available from:
Strama network. Strama [Internet]. [cited 2016 May 20]. Available from:
Wertheim HFL, Chandna A, Vu PD, Pham CV, Nguyen PDT, Lam YM, et al. Providing impetus, tools, and guidance to strengthen national capacity for antimicrobial stewardship in Viet Nam. PLoS Med [Internet]. 2013;10(5):e1001429. Available from:
Moody J, Cosgrove SE, Olmsted R, Septimus E, Aureden K, Oriola S, et al. Antimicrobial stewardship: a collaborative partnership between infection preventionists and health care epidemiologists. Am J Infect Control [Internet]. 2012 Mar;40(2):94–5. Available from:
Andersen SE, Knudsen JD, Bispebjerg Intervention Group. A managed multidisciplinary programme on multi-resistant Klebsiella pneumoniae in a Danish university hospital. BMJ Qual Saf [Internet]. 2013 Nov;22(11):907–15. Available from:
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:
Charani E, Holmes AH. Antimicrobial stewardship programmes: the need for wider engagement. BMJ Qual Saf [Internet]. 2013 Nov;22(11):885–7. Available from: