Pekka Honkanen Prof. em. MD. Professor Emiritus of Oulu University and still practizing MD in Terveystalo
Antimicrobial stewardship can be passive or active. Passive intervention consists of evidence-based guidelines, education of clinical staff, development of algorithms and restriction of antimicrobials, among other things. Good clinical practice guidelines can be found on the internet and are free of charge for everybody. They include strict recommendations when and how antibiotics should be used. While the amount of clicks on these guidelines on the internet can be counted, how well the recommendations are followed in practice cannot be counted.
Active stewardship is based on doctor and patient-based data. Information regarding the way doctors diagnose infections and their prescription behaviour are derived from these records. Additionally, prospective audits and feedback given to individual doctors are used to gather information. The findings are compared to good clinical practice guidelines. The results are discussed with the doctor whose practice is being evaluated. If unnecessary prescription of antibiotics is noticed, a plan is made to correct the indication of antimicrobials. After some months, the assessment of the doctor is repeated. If necessary, the cycle will be repeated. Compared to passive stewardship, active stewardship is much more time-intensive. Moreover, it requires clinical expertise, relationship building and consent from the one whose work is evaluated.
Differences in the prescription of antibiotics between countries come from differences between institutions, which result from differences between individual doctors within institutions and can even vary within doctors depending on the time of day. Therefore, Pekka Honkanen believes that if we want to correct the use of antibiotics, the focus of action must be on every single physician prescribing antibiotics. It is time-, resource- and knowledge-intensive. If we want the change, we must accept it and be prepared for it. The question is: can we afford it, or rather, can we afford to reject it?