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Here you can find guidance and tools on how to plan an antibiotic rational use initiative or stewardship program to implement core components of rational use.

The multi-stakeholder committee should plan how to implement the core components of rational use of antibiotics, which interventions to use and how to evaluate progress.

Interventions can be combined to form a comprehensive and sustainable program that involves stakeholders from multiple specialties. Alternatively, smaller scale efforts may be used to begin with. Whichever methods are chosen, they should be based on local data, be routed in existing cultural structures of health care facilities, and tailored to the specific setting depending on factors such as the size, complexity, and resources available.

Antimicrobial stewardship programmes in health-care facilities in low- and middle-income countries: A WHO Practical Toolkit

The WHO practical toolkit aims to support low- and middle-income countries in implementing antimicrobial stewardship (AMS) programmes at national and health-care facility level. It describes the structures needed (i.e. AMS teams, clinical treatment guidelines and antibiotic resistance surveillance structures) and gives guidance on how to do relevant AMS interventions. The toolkit specifies important competencies of professionals involved, and suggests educational activities and strategies. It contains several step-by-step guides, including on how to establish a national AMS programme (to enable facility-based AMS) and how to set up a surveillance programme of antimicrobial consumption at facility level. Annex I to VIII contain relevant sample terms of references, forms and charts. The toolkit is available in multiple languages (English, Arabic, Russian, French and Spanish).

Develop aims and objectives

Setting aims and objectives will help the committee know where to focus its energy and how to direct its resources. Consider what you want to achieve, and what change can be made that will result in an improvement. When developing objectives it is important to make them SMART:

  • Specific
  • Measureable
  • Achievable
  • Results Oriented
  • Time Limited

Consider tools and strategies

Interventions can be built upon a combination of tools and/or strategies. Possibilities include provider/prescriber education, support for treatment decisions through diagnostics and guidelines, audits and feedback, and restriction in prescriptions to selected antibiotics, just to name a few. For further information, see the Interventions section.

Example strategies for rational use initiatives:

  • Education – Is an essential part of all rational use initiatives and functions to build knowledge of the importance of appropriate use of antibiotics and to influence prescribing behaviors among health care professionals.
  • Guidelines and clinical pathways – Development and distribution of standard treatment guidelines based on local microbiology and resistance patterns can positively impact rational use. Implementation of guidelines can be facilitated by provider education combined with feedback on antibiotic use and patient outcomes.
  • Prospective audit with intervention and feedback – Direct interaction and feedback to the prescriber has shown good evidence for reducing inappropriate use of antibiotics.
  • Formulary restriction and preauthorization – Has shown immediate and significant reductions in antibiotic use. Requiring preauthorization for prescription on selected antibiotics can have an impact, however long-term effects are unclear. Careful watch on overall trends in prescribing must be done to ensure that shifts in use do not increase the use of alternative antibiotics.

Supplemental elements:

  • Antibiotic Cycling – There is insufficient data to recommend use of this strategy
  • Antibiotic order forms – As a component of a larger program they can assist prescribers to follow treatment guidelines but do not exhibit an extensive impact on their own.
  • Combination therapy – Can be effective in treating critically ill patients facing infection from multi-resistant pathogens. However, insufficient data exist to suggest combination therapy to prevent resistance development.
  • Streamlining or de-escalation of therapy – After receiving culture results, the causative pathogen can be more effectively targeted to reduce antibiotic exposure and save costs.
  • Dose optimization – Consideration of the pharmacokinetic (PK) and pharmacodynamics (PD) factors influencing the ability to reach pharmacodynamics targets.
  • Parenteral to oral conversion – Can greatly reduce the length of hospital stay and therefore health care costs and risk for health care-associated infections

Efforts could also include raising awareness among patients, see the RAISE AWARENESS focus area for more information and guidance. Rational use efforts should also go hand in hand with infection prevention efforts.

Choose strategies

With many different options, it can be difficult to decide on which strategies will work best. Important questions to consider are:

  • Is there evidence to support the use of the strategy?
  • Has the strategy been used in a similar context?
  • How might the strategy need adaptation to this setting?
  • Are sufficient resources available?
  • Is approval required for implementation?
  • What type of training will be needed?
  • What issues does this strategy uniquely address?
  • How will this strategy help overcome identified barriers?

Develop an implementation plan

A good implementation plan will cover the steps in the process, what actions are needed to be taken, by who and when, as well as what resources are needed and how to measure progress. The implementation plan can include:

  • Communication plan: How will the plans be communicated to those directly and indirectly involved with the process?
  • Risk assessment: What are the inherent risks that might occur with implementation?
  • Monitoring and evaluation framework for monitoring progress of the program

Selected Resources

Resource Description
Antimicrobial stewardship programmes in health-care facilities in low- and middle-income countries – a WHO practical toolkit Guidelines from WHO on how to plan, perform and assess antimicrobial stewardship programs through a stepwise approach in low-resource settings. Contains guidance for both national and facility levels. See this Infographic for an overview of the process.

An online training course focused on this guideline is available. It comprises 7 learning modules and 1 guided simulation.

How to start an antimicrobial stewardship programme in a hospital A “How-to” review article to guide health care professionals to set up an antibiotic stewardship program. Provides step-by-step guidance through a 6-month process and links to relevant resources. Suitable for use worldwide.
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. Special focus on low-resource settings.

  • Guidance on the steps of the process, including how to evaluate results
  • Options for interventions, examples of successful interventions, and tools to use
Antimicrobial Stewardship Through Food Animal Agriculture Toolkit Module: Guidance for healthcare facilities and health professionals A toolkit that helps to include food animal production considerations into hospital-based antibiotic stewardship programs.