Antibiotic Stewardship: Twenty Years in the Making

3 February, 2019

With thanks to amr-nap discussion forum:

'In this paper, Esmita Charani and Alison Holmes discuss global progress in antimicrobial stewardship over the past two decades, with particular attention to cultural changes in hierarchies and the relationships between specialties that have facilitated interdisciplinary work.'

Citation, abstract, selected extract below, with comment from me.

CITATION: Antibiotic Stewardship—Twenty Years in the Making

Esmita Charani and Alison Holmes

Antibiotics 2019, 8(1), 7; doi:10.3390/antibiotics8010007

ABSTRACT: In the last 20 years, efforts were made to optimize antibiotic use in hospitals across the world as a means of addressing the increasing threat of antibiotic resistance. Despite robust evidence supporting optimal practice, antibiotic decision-making remains sub-optimal in many settings, including in hospitals. Globally, resources remain a limiting factor in the implementation of antibiotic stewardship programs. In addition, antibiotic decision-making is a social process dependent on cultural and contextual factors. Cultural boundaries in healthcare and across specialties still limit the involvement of allied healthcare professionals in stewardship interventions. There is variation in the social norms and antibiotic-prescribing behaviors between specialties in hospitals. The cultural differences between specialties and healthcare professionals (1) shape the shared knowledge within and across specialties in the patient pathway, and (2) result in variation in care, thus impacting patient outcomes. Bespoke stewardship interventions that account for contextual variation in practice are necessary.


'In research published in 2004, using ethnographic methods, Gabbay and colleagues investigated general practitioner use of evidence-based guidelines. The study found that, rather than referring to evidence-based guidelines, clinicians use tacit sources of knowledge which the authors called “mindlines” [48]. These mindlines consisted chiefly of interactions with opinion leaders, patients, and their own and their colleagues’ experiences [48], i.e., culture. This study, though conducted across primary care, represents an early example of conducting qualitative research in order to understand the influence of context on clinical decision-making. In secondary care, culture is also a key determinant of behaviors.'

Comment (NPW): It would be interesting to understand better the drivers and barriers to rational prescribing of antibiotics over the past 20 years, and to reproduce this graphically. We know, for example, that access to reliable information on medicines is a prerequisite for rational prescribing, and yet it is not clear that the situation is improving. In 2011, WHO noted: ‘Globally, most prescribers receive most of their prescribing information from the pharmaceutical industry and in many countries this is the only information they receive.’ The British National Formulary is today *less* accessible outside the UK than it was in 2011 and its former collaboration with WHO appears to have ended. I am unaware of any equivalent free-access texts in English, let alone other languages, that can provide a basis for rational prescribing.

Best wishes, Neil

Joint Coordinator HIFA Project on Information for Prescribers and Users of Medicines

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HIFA profile: Neil Pakenham-Walsh is coordinator of the HIFA global health campaign (Healthcare Information For All - ), a global community with more than 19,000 members in 177 countries, interacting on six global forums in four languages. Twitter: @hifa_org FB: