Tackling antibiotic resistance calls for high-level political commitment and more investment in drug research. But, as health experts and hospital systems are finding, there is a simpler but equally important tool: stewardship — that is, combining education with practical and administrative changes to improve the way antibiotics are prescribed and used.
Too often, the medicines are prescribed for viral infections such as flu or the common cold, where they have no effect but deplete essential gut microbiomes and can cause allergic reactions or side effects — such as nausea, vomiting and rashes. Meanwhile, this overprescription contributes to antibiotic resistance, which the World Health Organization describes as “one of the biggest threats to global health, food security, and development”.
In the US, the problem is acute, says Sarah Lessard, a pharmacist at the Mayo Clinic Health System in La Crosse, Wisconsin. She estimates that 30 to 50 per cent of antibiotics across the US are prescribed inappropriately, whether in type, dose or duration — or because they will be ineffective for the patient’s condition.
Nor is this problem limited to rich economies. A 2020 study published by the British Medical Association estimated that the inappropriate prescription rate was about 30 per cent in China and 50 per cent in India and Kenya.
To counter this trend, the focus is often on making it easier for nurses, doctors and pharmacists to prescribe the right medicines for the right conditions.
For example, Johns Hopkins Hospital and the University of Chicago’s data research institution NORC have developed a set of tool kits offering guidance on how to make the right antibiotic prescribing decisions.
With different tool kits tailored to hospitals, doctors’ clinics and long-term care facilities — and all of them available on the US Agency for Healthcare Research and Quality website — the aim is to expand the practice of stewardship.
“Stewardship programmes are small, and teams cannot be there observing the practice of antibiotic prescribing for every patient in the hospital,” says Sara Cosgrove, a doctor and director of the antimicrobial stewardship programme at Johns Hopkins Hospital in Baltimore, Maryland.
But while supporting and educating health professionals is essential, there are other hurdles. “We have heard from providers that they feel pressure to prescribe antibiotics coming from patients,” says Lessard.
This means going beyond educating healthcare professionals. At the La Crosse hospital and clinics, patients with viral infections receive “prescription sheets”, either on paper or digitally, that give tailored recommendations on how to treat their symptoms, whether coughs, congestion, fever or earache.
Instead of simply telling patients to maintain their fluids, get plenty of rest “and then they’re out the door”, says Lessard, the prescription sheets offer a more customised approach and can include information on why antibiotic misuse is harmful. “Patients leave the physician’s office feeling they’ve actually been heard,” she says. “And they have something in hand to tackle their symptoms.”
This, and other stewardship practices, are paying off. Between 2019 and 2021, the Mayo Clinic tracked “antibiotic never events” — antibiotics prescriptions for upper respiratory tract infections due to a virus — and found these fell by roughly half across its healthcare facilities, says Lessard.
Simply listening goes a long way, argues antimicrobial stewardship expert Sanjay Patel. When it comes to parents with a sick child, he says clinicians often assume they are seeking antibiotics. Yet many just want reassurance that their child does not have a serious illness.
“We need to have more meaningful conversations, as opposed to assuming we know what the other person is thinking,” says Patel, who is a paediatric infectious diseases and immunology consultant at Southampton Children’s Hospital in England.
As well as education of patients and healthcare professionals, stewardship measures can include streamlining paperwork to reduce the coding errors that often lead to unnecessary antibiotic prescribing, as well as the prevention of infections. Flu vaccinations, by reducing infections, can also cut the risk of inappropriate antibiotic use.
Management of stewardship varies, though. Research in the US led by Intermountain Healthcare, a Utah-based system of 33 hospitals, identified four approaches.
In the most common (40 per cent of the systems surveyed), dedicated leaders manage goals and accountability, and ensure that stewardship tools and technologies are universally implemented. In 30 per cent of systems, stewardship is managed through a formal structure with a central committee and some level of system-wide goals and accountability.
By contrast, in 15 per cent of the healthcare systems, programmes are informal, with limited accountability, voluntary participation and goals set by individual sites, rather than centrally.
And in 10 per cent, stewardship is led by external consultants, who provide the expertise, mentoring, goals, tools and technologies.
The researchers now plan to study which models prove most effective for different kinds of healthcare systems, as well as what works in outpatient settings, such as urgent care and general practitioner clinics.
For Lessard, one factor matters most: stewardship efforts need to be continual. “Providing a single education [session] to a group of providers at one time will help in the short term, but practices and providers change,” she says. “Ongoing engagement with providers is vital.”