Question 3 of our JMO pre-test survey asked about the aims of antimicrobial stewardship (yes, better ‘antimicrobial’ than ‘antibiotic’- antiviral, antifungal, antiparasitic resistance are issues as well). We gave you three options  and all except one responded with the correct answer – all three!  The order is important – treatment of the individual patient comes first:

1. Optimise the effectiveness of individual patient antimicrobial treatment for infection (implies that the right patients are identified for treatment and that correct treatment and follow-up occurs)
2. Improve patient safety by reducing unintended consequences of antimicrobial treatment (implies that we know our guidelines,  our drugs and our patients well)
3.  Ecology – reduce antimicrobial resistance by reducing antibiotic selective pressure on micro-organisms (selective pressure arises from any a/m exposure;  prolonged courses and/or broader spectrum agents worse ; unnecessary use also critical –  humans who have not ‘earned’ their antibiotics,  and many situations across agriculture and food production)

The global antimicrobial resistance dilemma we face is truly a ‘Tragedy of the Commons‘ :

“A dilemma arising from the situation in which multiple individuals, acting independently and rationally consulting their own self-interest, will ultimately deplete a shared limited resource, even when it is clear that it is not in anyone’s long-term interest for this to happen.”

Cooperative stewardship of the resource required. Technical solutions (e.g. finding a new antibiotic) alone won’t solve it!

References

• Del Mar, Rawlins, McKenzie.  Antimicrobial Stewardship – What’s it all about?  Australian Prescriber 2013. Excellent short read.
• Garret Hardin. The Tragedy of the Commons, Science, 1968. Full text link.  Deep thinking…
• WHO Information sheet on AMR (September 2016).
• Do you need to finish that antibiotic course or does that make resistance more rather than less likely?   See this posting on AIMED for some unpacking of this issue.
• Australian AMR strategy and implementation plan 2016.   For those who need to do some heavy lifting!