Certainly in the Canadian context, Antimicrobial Stewardship is a public service.

public service noun

1. : the business of supplying a commodity (as electricity or gas) or service (as transportation) to any or all members of a community
2. : a service rendered in the public interest

It fulfills both of these dictionary definitions perfectly. Stewardship programs provide a service to members of communities — The community of healthcare providers to aid in their provision of care and to the community at large to provide the ongoing benefits of the availability of effective antimicrobials. This is very much in the public interest.

More established public services such as the police, fire fighting and waste removal are easy to conceptualize and understand. Others such as fisheries and forest management are more difficult. Few would dispute that the management of common resources is important, however. Common to all are several elements.

Information
Could the Department of Fisheries perform its’ functions without information? Of course not. Just as information about fish stocks is necessary to define sustainable fish harvest quotas, information is necessary to manage antibiotics. Fortunately, much of the information needed to manage antibiotic use is readily available. Millions of susceptibility tests are performed and all antibiotics distributed for human use are under prescription and have records associated. We haven’t yet done a good job of collation, redistribution and display but it is only a small amount of idea and resource away.

Manpower
Nothing ever prospers as a “side of the desk” endeavour. Why would Antimicrobial Stewardship be any different? It needs dedicated thoughtful people with appropriate skill sets – just like anything else. The good news is that evaluations of established AS programs have shown cost savings even after taking account the increased expenditures on manpower. Antimicrobials have been so poorly managed that there is much wasted resource. There is a large potential to turn misused antimicrobials into excellent, well-paid, stable jobs for Canadians.

Policies and Procedures
Policies are informed by principles and guide procedures. Goal statements and metrics for evaluation are central. Nothing unusual about this. However, this is new in Canada and much trial and error is to be expected. The principles should be firmly established but procedures will necessarily be diverse as Canadian health delivery is diverse.

Education
The cornerstone of sustainability. All established conservation programs become easier to enact as the benefits are recognized by more and more people. They become the norm.

Canada is poised for a Antimicrobial Stewardship revolution. We have the enthusiasm, the people and the need. We just need some structure.

InfectionNet has a new look and hopefully some new followers.

After a reasonably long and patient courtship with Drupal, we have cast it aside in favour of WordPress. Terry (the web design master) and I think infectionNet scrubs up quite well with her new content management software. There is a bit of tweaking yet to do so don’t fret over a bit of messed up formatting.

The elements are all still there – articles, notes from medical school lectures and laboratory protocols and I have added some important new sections. Therapy guidelines are derived from the Vancouver Island Health Authority’s Antimicrobial Review Committee’s empiric guidelines that were produced during a recent collaborative antibiotic stewardship effort at Cowichan District Hospital.

The Discussions section has been revamped and, hopefully, is a more user-friendly way of finding answers to your questions and to interact with peers. It is now easy to sign up with your Facebook or Google IDs and have your say.

The Cases section is very lean on content at present but there are plenty of interesting cases and they need display. Keep checking back, or better yet tell me about yours.

Be sure to sign up for email updates, and follow us on twitter as infectionNet is going to be much more proactive and interactive. If you have any suggestions at all please let me know using the contact form.

Canada is a patchwork of private – public coverage for pharmaceuticals. All provinces have pharmacare plans but they vary widely in coverage. Saskatchewan and Manitoba have forms of universal coverage while other provinces cover specific groups such as those on social services and the elderly.

In 2005 the first ministers conference saw a plea for a national pharmacare plan endorsed by all premiers. It was widely discredited as a provincial grab for federal money as a response to pharmaceuticals being the most rapidly expanding sector of healthcare expenditure. It was scoffed at by the federal government and deemed to be “too expensive” for consideration. This despite overwhelming evidence that the buying power and reduced bureaucracy afforded by cooperation would result in significant savings.

How about just antimicrobials? The federal expense would not be prohibitive. Outpatient antimicrobials total less than a billion dollars annually. It could lay the groundwork for future expansion to other classes and most importantly it would distinguish antimicrobials as needing special regulatory attention.

A National Antimicrobial Pharmacare plan is a sensible approach to the ever-expanding problem of antimicrobial resistance.

I have been involved in the effort to improve antibiotic policy and practice for many years and a recent development may be a large help. Rather than advocating for prudence we are now recommending stewardship. Prudence – classically considered a virtue, in particular one of the four Cardinal virtues, conjures up the notion of morality. One who prescribes antibiotics poorly is immoral.

Stewardship is entirely different. It is an ethic that embodies cooperative planning and management of resources and conjures the notion of help and guidance. One who prescribes antibiotics poorly needs guidance.

I think this subtle shift in the language of antibiotic policy may help us immensely. Rather than demanding prudent use regulations that imply the stamping out of immorality we can offer frameworks for regulatory bodies to cooperatively guide prescribers. That guidance may necessarily have to include restrictive policies but with the restrictions arrived at in a more consensual fashion.

If you are interested in Antimicrobial Stewardship check out the International Society of Chemotherapy’s new Inventory of Antimicrobial Stewardship projects.

This graph depicts the change in percentage of antibiotics belonging to the 4C group – clindamycin, cephalosporins, co-amoxiclav, and ciprofloxacin (fluoroquinolones) in Grampian, Scotland NHS acute care hospitals. There is a strong association with reductions in C. difficile incidence.

This graph show the changes in the individual classes of 4 C’s. Very impressive reductions demonstrating the power of organized stewardship efforts.

Thanks to Dr. Ian Gould for sharing this. This project was specifically designed to reduce the incidence of C. difficile by reducing the use of antibiotics most associated with C. difficile disease. Read more about The 4 C’s Project here at the International Society for Chemotherapy’s World Inventory of Antimicrobial Stewardship site.

It appears that Scotland is making great strides in organized antimicrobial stewardship having established a country-wide multidisciplinary forum in 2008 referred to as the Scottish Antimicrobial Prescribing Group (SAPG). Read more about their efforts here at the SAPG website.