Intended for healthcare professionals

We need stewardship programs in primary health care

After the UK Chief Medical Officer Sally Davies put antibiotic drug resistance on the national threat list in 2013, the WHO developed the global action plan to combat antimicrobial resistance (AMR) on a global scale. This strategy was approved by the World Health Assembly in 2015 (1). Simultaneously the Obama administration ordered the development of the US CARB-X initiative and currently, almost 100 countries have done similar (2, 3). AMR is recognized as a crisis that must be resolved by international collaboration and through local actions. One common action in most national action plans is the establishment of antibiotic stewardship programs in order to ensure evidence-based prescription practices and reduce the unnecessary prescription of these drugs.

UTI infections account for 25% of antibiotic prescriptions in Norway (4). They are often prescribed due to the chief complaint being pain. In a recent study, ibuprofen was found inferior to antibiotics for treating uncomplicated UTIs. More than half of the patients that did not receive antibiotics did recover spontaneously, but 7 out of 181 developed pyelonephritis. We cannot recommend NSAIDs alone as initial treatment to women with uncomplicated UTIs, especially for those above 65, as now published in the BMJ (5). Prescribers however need individual feedback on their prescription practice/prevalence compared to colleagues, as part of establishing primary care antibiotic stewardship programs.
The concepts of an efficient intervention in UTI cases are perceived by the health care provider. Perceived susceptibility, severity, benefits and barriers include all of the possible short term and long term adverse effects of initiated or prolonged antibiotic exposures varies for different patients (6, 7) . This varies for different patients. For babies future adverse effects will be weighed different than for those above 65 years. Clinical urgency, uncertainties and responsibilities varies for individual patients and the responsibility often lie on the individual clinician. It is therefore imperative that policy makers encourage primary health care stewardship programs and that guidelines follow evidence-based prescription practices (6). Stewardship programs should always include reserving broad-spectrum antibiotics for special risk cases and revising treatment once culture results become available in all patients as recommended for neonatals (8).

References
1. World Health Organization (2015). Global action plan on Antimicrobial resistance. Retrieved from: https://www.who.int/antimicrobial-resistance/global-action-plan/en/
2. The White House (2014). Executive Order -- Combating Antibiotic-Resistant Bacteria. Retrieved from: https://obamawhitehouse.archives.gov/the-press-office/2014/09/18/executi...
3. World Health Organization (2018). Antimicrobial resistance. Library on national action plans Retrieved from: http://www.who.int/antimicrobial-resistance/national-action-plans/librar...
4. Straand J, Rokstad KS, Sandvik H. Prescribing systemic antibiotics in general practice. A report from the Møre & Romsdal Prescription Study. Scand J Prim Health Care 1998; 16: 121 – 7.
5. Hay A, Antibiotic prescribing in primary care. BMJ 2019;364:l780
6. Lawrence KL, Kollef MH (2009). Antimicrobial Stewardship in the Intensive Care Unit Advances and Obstacles. Am J Respir Crit Care Med. 179:434-8
7. Paul SP, Caplan EM, Morgan HA, Turner PC (2018). Barriers to implementing the NICE guidelines for early-onset neonatal infection: cross-sectional survey of neonatal blood culture reporting by laboratories in the UK. J Hosp Infect. 98(4):425-428
8. Shipp KD, Chiang T, Karasick S, Quick K, Nguyen ST, Cantey JB (2016). Antibiotic Stewardship Challenges in a Referral Neonatal Intensive Care Unit. Am J Perinatol 33(5):518-24

Competing interests: No competing interests

01 March 2019
Ulf R. Dahle
Director - laboratories
Norwegian Institute of Public Health
Munkerudveien 26F