Antibiotic stewardship programmes explained

Antibiotic stewardship refers to a set of coordinated strategies designed to promote the responsible use of antibiotics. Unlike medicines that treat chronic conditions, antibiotics lose their effectiveness over time if used inappropriately, leading to antimicrobial resistance (AMR). The primary goal of stewardship is to ensure that these medicines are only prescribed when truly necessary, and that when they are used, the correct drug, dose, and duration are selected to treat the infection effectively. As resistance rates continue to rise globally, stewardship programmes have become a critical tool in preserving the effectiveness of existing antibiotics, safeguarding patient safety, and protecting public health.

What antibiotic stewardship programmes aim to do

At its core, an antibiotic stewardship programme (ASP) aims to optimise clinical outcomes while minimising the unintended consequences of antimicrobial use. These unintended consequences include adverse drug reactions, the disruption of normal healthy bacteria in the body, and the selection of drug-resistant pathogens. Stewardship involves a multidisciplinary approach, typically led by infectious disease physicians, clinical microbiologists, and clinical pharmacists.

By establishing clear guidelines, these programmes help prescribers distinguish between viral and bacterial infections—since antibiotics are ineffective against viruses. They also guide the transition from empiric therapy (treatment started before the exact bacteria is identified) to targeted therapy once laboratory results are available. The focus is on using narrow-spectrum agents that target the specific bacteria causing the infection, rather than broad-spectrum antibiotics that affect a wide range of organisms and drive resistance.

Hospital and community programmes

The structure of a stewardship programme varies depending on the healthcare setting. In hospitals, where antibiotic use is intensive and patients are often severely ill, stewardship often involves formulary restrictions (where certain powerful antibiotics require prior approval from an expert), intravenous-to-oral switch protocols once a patient can take medicines by mouth, and daily reviews of patients on antibiotics by specialist teams.

In community and primary care settings, the challenges differ. Clinicians frequently face patient expectations for antibiotics during respiratory infections that are typically viral in origin. Community stewardship focuses on providing clear clinical guidelines, promoting delayed prescribing strategies—where a prescription is provided but only dispensed if symptoms do not improve—and running public awareness campaigns. In South Africa, the National Department of Health drives these efforts through national guidelines, while patients can use platforms like HealthSA to verify the registration status and pricing of prescribed antibiotics under the Single Exit Price framework.

The global action plan on AMR

Antibiotic stewardship is a central pillar of the World Health Organization’s (WHO) Global Action Plan on Antimicrobial Resistance, adopted in 2015. This plan outlines a "One Health" approach, recognising that human health is intimately connected to the health of animals and our shared environment, and that resistance can spread across all these sectors.

To guide stewardship at a global level, the WHO introduced the AWaRe (Access, Watch, Reserve) classification system. This framework groups antibiotics based on their impact on resistance and their necessity in medicine. "Access" antibiotics are first-line treatments for common infections and should be widely available, while "Watch" and "Reserve" antibiotics are reserved for severe or multi-drug-resistant infections. National regulatory authorities, including the South African Health Products Regulatory Authority (SAHPRA), incorporate these global standards into local drug regulation and policy to curb inappropriate use.

Measuring success and outcomes

For an antibiotic stewardship programme to be effective, its impact must be measured over time. Hospitals and health systems track several key metrics to evaluate success. Antibiotic consumption is frequently monitored using Defined Daily Doses (DDD), a standardised statistical measure of drug consumption that allows for comparisons across different wards or facilities. Facilities also track the proportion of "Access" versus "Watch" antibiotics used, adherence to local treatment guidelines, and the overall duration of therapy.

Beyond consumption metrics, clinical outcomes are closely watched. Programmes monitor local antibiograms (charts showing which antibiotics are effective against local bacteria) and track rates of secondary infections, such as Clostridioides difficile, which can occur when broad-spectrum antibiotics disrupt normal gut flora. By regularly auditing these metrics and feeding the data back to prescribers, health facilities can identify areas for improvement and continuously refine their strategies against evolving resistance patterns.