Antimicrobial Stewardship: A Useful Concept?
Eleanor Kashouris; AMR Insights Ambassador
Dr Eleanor Kashouris is a postdoctoral research fellow in Sociology at the University of Sussex, UK. Eleanor works on Marginalisation & the Microbe, a Wellcome Trust funded project which asks how to mobilise on antimicrobial resistance without increasing health inequalities. Her work on community-acquired urinary tract infection explores gendered experiences of this common illness. Here, she re-considers one of the basic conceptual tools in use in mobilisations against antimicrobial resistance globally: the concept of antimicrobial stewardship.
Antimicrobial stewardship (AMS) is a widespread concept in institutional and organisational responses to antimicrobial resistance (AMR), the increasing prevalence of microorganisms that are poorly responsive to antimicrobials. AMS gives us language to talk about what we are trying to do when we respond to AMRIt helps to underline the importance of actions we may take to ensure that, in the future, we have effective medicines to treat and prevent infection. In this blog, I explore the work the concept of AMS is put to and achieves in mobilisations against AMR.
AMS captures complex and contradictory actors and actions
AMS is capacious enough to include the many different actions and actors which may be an antimicrobial stewardship, beyond pharmaceuticals. Just as optimal use of antibiotics may be an antimicrobial stewardship, so may diagnostic stewardship, infection prevention, detection and surveillance and patient/practitioner engagement. We can start to recognise not just doctors, nurses and antibiotics and prescriptions as involved in AMS, but tests, water, sleep, pipes, regulatory frameworks, sick pay, childcare etc. Moreover, the concept of stewardship, similar to concepts such as ‘appropriate’ or ‘optimal’ prescribing, is useful because it notions to the good, without prescribing in advance what good might be. This is useful because optimal treatment may be achieved through contradictory measures. For example, in different settings, optimal treatment may be achieved by either increasing or decreasing access to antibiotics. Better diagnosis may be achieved through either increasing testing or decreasing testing. Stewardship is a useful concept in holding all of this work, work which in practice often requires high-level expertise, together all at once.
AMS pulls antibiotics out of routine clinical care for closer attention
One of the predominant modes of global AMS policy so far has been to try to raise awareness of the scale and gravity of the problem of AMR amongst prescribers. Engagement efforts are often aimed at changing prescriber behaviour to reduce the use of antimicrobials in clinical practice. Here, I argue that they do this by pulling antibiotics out of the daily work of clinical care. A good example is the slogan for World Antimicrobial Awareness Week 2020 which was ‘Antibiotics: Handle with Care’. AMS highlights antibiotic use as an area for heightened carefulness and greater reflection. For over-stretched or just busy clinicians, AMS messaging may be a useful reminder that antibiotics themselves need to be cared for, as they go about caring for patients. Raising awareness about AMR in this group, draws attention to the need for AMS amidst plenty of other reasons to prescribe antibiotics such as time pressure, diagnostic uncertainty and lack of other treatment options.
When prescribers make a decision about whether to prescribe antibiotics or not, they must decide if a patient stands to benefit more than they stand to be harmed by an antibiotic prescription, bearing in mind that the risks of antibiotic treatment have been vastly underestimated on a population and an individual level. Many prescribers will recognize their own practice in this description of good care.
However, this is best thought of not as antimicrobial stewardship, but as patient care. The concept of AMS itself, because of the way it pulls antibiotics out of care, works to create a concern with antibiotics which is separate from care. Because antibiotics have been thought of as cheap and harmless, and because it is very difficult to measure the risk of AMR at the patient level, it has been all too easy to transform prescribing risk/benefit decisions into a risk to the individual patient, in terms of not using antibiotics to manage infection, versus a benefit to society in terms of decreased risk of AMR. This can be amplified by public health messaging which emphasises the care that should be afforded to antibiotics themselves: ‘Antibiotics: Handles with Care.’ A concept of AMS holds antimicrobials centrally, so that there is some concern for antibiotics themselves, outside of a concern with care.
We should ask ourselves, what is at stake in between patient care and antimicrobial stewardship? The answer is ‘very little’; good care looks the same with or without antimicrobial stewardship. This should prompt a re-consideration of the concept itself. I ask with doubt whether the separation achieved by the concept of AMS between a concern for patient care and a concern for antibiotics is a useful separation.
By questioning the concept of AMS and speaking in terms of care, I argue, we can better describe what it is that is done in good clinical practice and avoid suggesting to patients that they are not being prescribed antibiotics for a reason other than for their own care. If we want to take seriously the ways in which antibiotics have historically not been handled with care, have not been thought of as drugs with un-anticipated and serious side effects, we need to locate our concern for antibiotics firmly within patient care.