Stewardship and One Health

Define Antimicrobial Stewardship

‘healthcare-system-wide approach to promoting and monitoring judicious use of antimicrobials

to preserve their future effectiveness'

What is the principle of lab stewardship in antibiotic susceptibility reporting?

Only appropriate results should be reported—those aligned with local policy and favouring the narrowest effective spectrum; broad-spectrum or irrelevant antibiotics should be suppressed, while resistant results are generally reported to guide treatment and highlight local resistance trends.

What are the key principles of the “Start Smart” approach to antibiotic use?

Start antibiotics promptly when indicated, obtain cultures before the first dose where possible, follow guidelines for empirical treatment, and document the indication along with a stop or review date.

What does the “Then Focus” step involve in antibiotic stewardship?

Review treatment at 48 hours to stop if possible, switch from IV to oral, de-escalate to narrower-spectrum agents with lower Clostridioides difficile risk, and discontinue antibiotics if cultures are negative unless clinically indicated.

IV →Oral Switch

• Reduced risk of bacteraemia from line

• Reduced risk of thrombophlebitis

• Saves medical and nursing time

• Increased convenience, comfort and mobility

• Significant cost reduction (x10)

• Reduced risk of administration errors

• Earlier discharge from hospital

• Switch when patient clinically stable

What are key antibiotic stewardship strategies in primary care?

Effective strategies include good communication with patients, use of clinical scoring systems and point-of-care tests, providing feedback to practices and GPs, and using delayed prescriptions where appropriate.

Recall the 6 Rs

• Reassurance - reassure the patient about the infection

• Reasons - explain why antimicrobials are not normally necessary and side effects

• Relief - suggest suitable over-the-counter preparations for symptom relief e.g. paracetamol for pain

• Realistic - give a realistic time when patient can expect to start feeling better

• Reinforce - written information and repeat key message - not to take antibiotics unless they don’t start to improve

• Rescue - give safety netting advice i.e. when to seek further help

What is the significance of acute respiratory infections in primary care?

They account for around 17% of all GP consultations; acute bronchitis is common, and community-acquired pneumonia makes up about 5–12% of lower respiratory tract infections managed by GPs.

What is the role of C-reactive protein (CRP) point-of-care testing (POCT) in clinical practice?

It is a blood test measuring inflammation levels via CRP; elevated levels may indicate infection or chronic disease, and while useful for aiding diagnosis, it does not replace clinical judgement.

What is back-up (delayed) prescribing and what are its main strategies?

It involves delaying antibiotic use for self-limiting illnesses, with strategies including patient re-contact for a prescription, post-dated prescriptions (24–72 hours), collection from reception, or issuing a prescription with advice to use only if necessary; it is recommended by NICE and helps reduce unnecessary antibiotic use and change patient attitudes.

What is One Health?

• An approach to designing and implementing programmes, policies, legislation and research

in which multiple sectors communicate and work together

• One Health approach is particularly relevant in food safety, the control of zoonoses (diseases

that can spread between animals and humans) and combating antibiotic resistance

What did the 2013 UK One Health report reveal about antibiotic use?

It showed that 531.2 tonnes of antibiotics were prescribed to humans and 418.7 tonnes were used in animals, meaning only 56% of total antibiotic use was in humans.

How are antibiotics used in agriculture?

• to treat disease when animals get sick

– Ethical - prevent suffering

– Prevent sick animals entering food chain.

• to prevent disease, such as when animals are

‘stressed’, or if a few animals in the herd are sick.

– ‘whole herd treatment’

– ?reflection of inadequate hygienic conditions on farms

– ? better husbandry would reduce this prophylactic

use.

• growth promotion

What does it mean that antibiotics are used as “growth promoters” in food animals?

Since the 1940s, small doses of antibiotics have been given to livestock to increase growth, sometimes doubling weight without extra feed.

What did the UK 2015 review and EU regulations reveal about antibiotics as growth promoters?

Modern growth promoters only increase animal weight by 1–3% in advanced farming, and the EU banned their use in animals entirely in 2006.

How did antibiotic sales change between 2013 and 2017 in veterinary and human medicine?

Antibiotic sales fell by 35% in animals and by 6% in humans during this period.

Ethical considerations

• Is it right to ban the use of growth promoters in developing countries where their efficacy

may be greatest and most beneficial?

• Should farm animals receive antibiotics for illness?

• Should pets?

• What about rare/endangered zoo animals?