Antibiotic stewardship

Antibiotic Stewardship (ABS) describes a broad-based (international) concept for the responsible, targeted use of antibiotics in infectious diseases. By its very nature, ABS is dependent on national or regional conditions due to differences in health systems and health standards (Dyar OJ et al. 2017: we suggest viewing antimicrobial stewardship as a strategy, a coherent set of actions which promote using antimicrobials responsibly. We stress the continuous need for 'responsible use' to be defined and translated into context-specific and time-specific actions)

The German Society for Infectiology (DGI) describes ABS as "a programmatic, sustained effort by a medical institution to improve and ensure rational anti-infective prescription practice with strategies or measures that ensure the quality of anti-infective treatment in terms of selection, dosage, application and duration of use in order to achieve the best clinical outcome while minimizing patient toxicity".

Among the various groups of drugs, antibiotics can cause side effects - some of which are not insignificant - on the one hand and contribute to the development of resistance on the other. Their use must therefore be weighed up particularly carefully. The development of resistance following the use of antibiotics initially affects the individual patient, in whom the bacteria that have become resistant(er) may later cause disease and are then more difficult to treat with antibiotics (Septimus EJ 2018).

Further, however, these pathogens can also be transmitted - directly or via the environment - to other individuals and then cause disease in them and become less treatable. This makes the development of resistance a general, worldwide health problem (public health problem), also due to the high mobility of the population.

The use of antibiotics in livestock plays a serious special role; here, antibiotics are used not only for the immediate treatment of infections, but also for prophylaxis and animal fattening (Lloyd D et al. 2018: The antimicrobial stewardship program for veterinary use integrates infection prevention and control together with approaches emphasizing avoidance of antimicrobial agents). Note: In 2017, 733 tonnes of antibiotics were fed to chickens, pigs, cows and other farm animals). The increasing use of reserve antibiotics in animal husbandry also exacerbates the general and growing resistance problem.

ABS refers to a programmatic, sustained effort by a medical institution to improve and ensure rational anti-infective prescribing practices. This refers to strategies or measures that ensure the quality of anti-infective treatment in terms of selection, dosage, application, and duration of use to achieve the best clinical treatment outcome while minimizing toxicity to the patient (Septimus EJ 2018). ABS programs that bundle multiple ABS interventions have a favorable impact on resistance, cost, and consumption trends. Thus, ABS has a clear objective and that is to prevent or reduce infectious diseases or deaths caused by resistant bacteria (Every year 33,000 people die in Europe due to infections with multidrug-resistant germs). This programmatic objective involves targeted measures to reduce resistant bacteria in an affected individual but also in their environment. This can only be achieved by reducing antibiotic administration on the one hand but also by their targeted use on the other (Rice LB 2018).

Health policy framework: ABS can be applied wherever antibiotics are prescribed, such as in inpatient and outpatient medicine (about 80% of antibiotics used in humans are prescribed in the outpatient sector) and in veterinary medicine. There is now a global awareness of the need for ABS at all levels of health policy. The World Health Organization (WHO), the European Centre for Disease Prevention and Control (ECDC), the respective national health authorities (in Germany the Robert Koch Institute -RKI), but also various non-governmental organizations (NGOs) are programmatically involved. The aim is to formulate standards that can be applied in both industrialised and non-industrialised countries (see also Antibiotics, Notes on therapy). The measures naturally encompass a broad spectrum of interdisciplinarity. In addition to the individual disciplines of human medicine and veterinary medicine and their representatives, microbiology is always involved, as it provides information on pathogens and any resistance they may have in individual patients.

According to predictions by the English economist Jim O'Neil (2014 and 2016), we must expect 10 million deaths from multi-resistant germs in 2050, more than from cancer (8.2 million). This will mainly affect countries with unstable health systems (Asia: 4.7 million; Africa 4.1 million).

1. DGI (German Society for Infectiology): Definition Antibiotic Stewardship: https://www.dgi-net.de/fort-und-weiterbildung/antibiotic-stewardship-abs/
2. Dyar OJ et al.(2017) What is antimicrobial stewardship? Clin Microbiol Infect 23: 793-798
3. Lloyd D et al (2018) Antimicrobial Stewardship in Veterinary Medicine. Microbiology spectrum 6: 10.1128/microbiolspec.ARBA-0023-2017.
4. Rice LB (2018). Antimicrobial Stewardship and Antimicrobial Resistance. The Medical clinics of North America 102: 805-818.
5. Septimus EJ (2018) Antimicrobial Resistance: Antimicrobial/Diagnostic Stewardship and Infection Prevention Approach. The Medical clinics of North America 102:819-829.
6. Stalder S et al (2018). Descriptive study on antibiotic-free milk production in cattle Swiss Archives of Veterinary Medicine 160: 727-736