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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
Infographic: antimicrobial stewardship programmes in health-care facilities in low- and middle-income countries: a WHO practical toolkit Infographic that summarizes important steps for establishing a functioning antimicrobial  stewardship programme. Based on the WHO practical toolkit
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.
The ISID Guide to Infection Control in the Healthcare setting Guide that summarizes principles, interventions, and strategies to reduce healthcare associated infections. Contains more than 60 short chapters on a variety of topics including antibiotic resistance and antimicrobial stewardship in the hospital setting. The guide is also available in Spanish.
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
The Practical Guide Antimicrobial Stewardship in the Netherlands This guide from Netherlands is a practical resource for setting up an Antimicrobial Stewardship Program accounting for the suitability and feasibility of stewardship activities in the local situation, such as initial situation regarding prescribing behaviour and available infrastructure, manpower and means, etc. Developed for European hospitals.
National Quality Partners Playbook: Antibiotic Stewardship in Acute Care Practical strategies for implementing antibiotic stewardship programs in hospitals. The Playbook helps hospitals strengthen existing antibiotic stewardship initiatives or create new programs from the ground up. It is a complimentary resource to CDC’s Core Elements of Hospital Antibiotic Stewardship Programs.
Antimicrobial Stewardship Through Food Animal Agriculture Toolkit Module: Guidance for healthcare facilities and health professionals A toolkit that help in the process to include agricultural aspects into hospital-based antibiotic stewardship programs.
The Community Toolbox Toolkits. The Community Toolbox aims to offer people engaged in local and community work a depository of tools and advice for building healthier communities. See Chapter 6, Section 1 “Developing a plan for communication” that will help plan for good, consistent, clear, communications both internally and externally.
The Breakthrough Series: IHI’s Collaborative Model for Achieving Breakthrough Improvement The Breakthrough Series is designed to help create a structure in which interested organizations can easily learn from each other and from recognized experts in topic areas where they want to make improvements.
Toolkit: Implementation of Best Practice Guidelines, Second Edition This Toolkit was designed to assist health care settings in maximizing the potential of clinical practice guidelines, through systematic and well-planned implementation, developed by the Registered Nurses’ Association of Ontario (RNAO).
Enhancing Project Spread and Sustainability, NSW Clinical Excellence Commission Guide (PDF) This guide aims to provide helpful tips and practical advice to clinicians and health managers on how to improve and assess the spread and sustainability of clinical practice improvement projects in a systematic way.
NHS Guide to Sustainability Guide that provides practical advice for health care leaders to implement and sustain improvement initiatives aiming for increased quality and patient experience at lower cost.
International Society for Infectious Diseases - ISID. Guide to Infection Control in the Healthcare Setting.
World Health Organization - WHO. Interventions and strategies to improve the use of antimicrobials in developing countries – Drug Management Program. (2001).
Mendelson, M., Morris, A. M., Thursky, K. & Pulcini, C. How to start an antimicrobial stewardship programme in a hospital. Clinical Microbiology and Infection 26, 447–453 (2019).
Charani, E. & Holmes, A. H. Antimicrobial stewardship programmes: the need for wider engagement. BMJ Qual Saf 22, 885–887 (2013).
WHO. Antimicrobial stewardship programmes in health-care facilities in low- and middle-income countries: A WHO practical toolkit. (2019).
World Health Organization - WHO. Infographic: antimicrobial stewardship programmes in health-care facilities in low- and middle-income countries: a WHO practical toolkit. (2019).
Clinical Excellence Commission - CEC. Enhancing Project Spread and Sustainability: A companion to the ‘Easy Guide to Clinical Practice Improvement’. (2008).
National Health System: Institute for Innovation and Improvement. Sustainability Guide. (2009).
World Health Organization - WHO. The evolving threat of antimicrobial resistance: options for action. (World Health Organization, 2012).
Clinician Champions in Comprehensive Antibiotic Stewardship - CCCAS. Antimicrobial Stewardship Through Food Animal  Agriculture Toolkit Module: Guidance for healthcare facilities and health professionals.
National Quality Forum. National Quality Partners Playbook: Antibiotic Stewardship in Acute Care. (2016).
RNAO - Registered Nurses of Ontario. Toolkit: Implementation of clinical practice guidelines, 2nd edition. (2012).
Barlam, T. F. et al. Implementing an Antibiotic Stewardship Program: Guidelines by the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America. Clin Infect Dis. ciw118 (2016)
Ross-Degnan, D., Vialle-Valentin, C. & Briggs, J. Improving Medicines Access and Use for Child Health—A Guide to Developing Interventions. (2015).
Dutch Working Party on Antibiotic Policy. The Practical Guide Antimicrobral Stewardship in the Netherlands. (2015).
Work Group for Community Health and Development. Community Toolbox. Community Toolbox (2014).
IHI Innovation Series white paper. The Breakthrough Series: IHI’s Collaborative Model for Achieving Breakthrough Improvement. (2003).