Infections due to antibiotic-resistant microorganisms are increasing in prevalence and of growing global concern. They may be associated with prolonged in-hospital stay, increased morbidity and mortality, and heightened cost [
]. Antibiotic overuse and misuse are major drivers of this problem, while the development of new effective antimicrobials has become more and more limited. Between 2000 and 2015, the global antibiotic consumption rate increased by almost 40%, and a major part of the increase was in low- and middle-income countries [
]. Inappropriate antibiotic prescribing has been documented in many settings—both in human and veterinary medicine—but the patterns of misuse as well as the reasons for it differ from country to country and from region to region. Also, misuse and overuse may be prevalent in hospital medicine, primary care or both, and clearly require different approaches to control and focussed quality improvement projects.
Antibiotic stewardship in human medicine can be defined as ongoing efforts by a healthcare institution—whether local, regional/national or international—to optimize antimicrobial use among patients with the aim to improve patient outcomes, ensure cost-effective therapy and reduce adverse sequelae of antimicrobial use including antimicrobial resistance. The overall aim is to preserve the efficacy of antibiotics for use in the future. The term antibiotic stewardship was probably first coined in 1996 by John McGowan and Dale Gerding [
], mentioned shortly thereafter in the 1997 joint guideline of the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA) [
], and later also used in the European context by Ian Gould [
]. On the political scene, a first position paper on antibiotic stewardship appeared as so-called Copenhagen Recommendations after a European Union conference on “The Microbial Threat” hosted by the Danish Government in Copenhagen in September 1998 [
]. The essential recommendations under the heading “Encouraging good practice in the use of antimicrobial agents” in this document were
Educational initiatives for both health professionals (human and animal) and the general public are of major importance for improving the use of antimicrobial agents.
Antimicrobials for therapeutic use should be prescription-only medicines and so should not be advertised to the public.
Antimicrobial teams (including infectious disease specialists, clinical microbiologists and other appropriate specialists) should be introduced in every hospital. They should have the authority to modify antimicrobial prescriptions of individual clinicians in accordance with locally accepted guidelines, always taking account of the needs of the patient. Clinicians should be given an opportunity to approve the remit and recommendations of the teams. The teams should also cover the community, including nursing homes and other residential institutions, and the primary/secondary care interface. Feedback should be provided to clinicians.
Guidelines for appropriate antimicrobial usage should be introduced in all aspects of both medical and veterinary practice.
Treatment should be limited to bacterial infections, using antibiotics directed against the causative agent, given in optimal dosage, dosage intervals and length of treatment with steps taken to ensure maximum patient concordance with the treatment regimen, and only when the benefit of the treatment outweighs the individual and global risks.
Steps must be taken to increase access to diagnostic testing for patients with infections, and the range of tests needs to be improved.
Only a few years later, the European Commission issued the Council recommendation “2002/77/EC” on the prudent use of antimicrobial agents in human medicine [
]. Surveys among the EU members regarding implementation of those recommendations followed in 2009, 2011 and 2015. Many initiatives regarding surveillance, research and education at the European and individual country level have been started since then. Stewardship as the way to promote responsible use has now also been recognized by the World Health Organization as one of the five essential global collective actions to address the problem of antimicrobial resistance (Global Action Plan on AMR [
], approved by the World Health Assembly in 2015).
Milestones and key projects at the European level
To facilitate and further develop surveillance in the areas of antibiotic resistance and antibiotic consumption at the European level, the new European Centre for Disease Control and Prevention (ECDC, founded in 2005) was a major step. Two surveillance projects most important for antibiotic stewardship were transferred to the ECDC in the following years. One was the European Antimicrobial Resistance Surveillance System (EARSS), established in 1998 and initially funded by the European Commission’s Directorate General for Health and Consumer Affairs (DG SANCO) and the Dutch Ministry of Health, Welfare and Sports [
]. The administration and coordination of this network was transferred in early 2010 and then renamed as the European Antimicrobial Resistance Surveillance Network (EARS-Net).
The second important surveillance programme, the European Surveillance of Antimicrobial Consumption (ESAC) project, also granted by DG SANCO, was launched in 2001. ESAC, at that time coordinated by the University of Antwerp, initiated an international network of surveillance systems, aiming to collect comparable and reliable data on antibiotic use in Europe. It was transferred to the ECDC in 2011 and renamed “ESAC-Net”. The ESAC investigators published a number of most critical papers on antibiotic use density in European countries at a population-based level [
]. ESAC also developed and refined the methodology of point-prevalence surveys later adopted by ESAC-Net and national focal points [
]. ESAC-Net eventually improved the European hospital antibiotic use database which now includes data from 24 countries (compared with 30 countries in the community antibiotic use database) [
Other most relevant initiatives in Europe were projects associated with the European Society of Clinical Microbiology and Infectious Diseases (ESCMID), namely the European Committee on Antimicrobial Susceptibility Testing (EUCAST) (
), a committee that standardizes antimicrobial susceptibility testing and harmonizes breakpoints, organized by ESCMID, ECDC and national breakpoint committees, and the ESCMID study groups for Antimicrobial Stewardship (ESGAP), for Antimicrobial Resistance Surveillance (ESGARS) and for PK/PD of Anti-Infectives (EPASG).
Particularly ESGAP, founded in 1999, was extremely active in addressing issues not covered well by other bodies, such as teaching/education of medical students in antibiotic prescribing, staffing of hospital antibiotic stewardship programmes, a review of hospital antibiotic stewardship best practices, coping with controversial topics in guidelines and with access to old antibiotics [
There have been many more projects internationally and at country level, of course, but the above European initiatives have been and still are key to providing essential surveillance data, insight und transparency, national benchmarking options and progress in laboratory standards in the field. And they have also fostered significant research and educational activities.
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