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European Journal of Pediatrics

, Volume 177, Issue 2, pp 279–283 | Cite as

European Antibiotic Awareness Day 2017: training the next generation of health care professionals in antibiotic stewardship

  • Lenneke SchrierEmail author
  • Adamos Hadjipanayis
  • Stefano del Torso
  • Tom Stiris
  • Marieke Emonts
  • Hans Juergen Dornbusch
Open Access
EAP Statement

Abstract

Antimicrobial stewardship (AMS) aims to optimise treatment, minimise the risk of adverse effects and reduce health care costs. In addition, it is recognised as a key component to stop the current spread of antimicrobial resistance in Europe. Educational programmes are particularly important for the successful implementation of AMS. Training should start during medical school, continue during clinical training and be reinforced throughout postgraduate training. National core curricula for paediatric training should include passive and active training of competencies needed for AMS and future paediatricians should be skilled in taking leadership roles in AMS initiatives. Other core members of the paediatric AMS team should also receive training focused on the unique medical needs of the paediatric patient.

Conclusion: Ideally, all communities, hospitals and health regions in Europe should have AMS that serve all patient types, including children. We all have the responsibility to ensure that existing antibiotics remain effective.

What is Known:

Antimicrobial stewardship (AMS) is a key component to stop the current spread of antimicrobial resistance

Educational programmes are particularly important for the successful implementation of AMS

What is New:

All medical doctors in Europe who will be undertaking significant practice in child health should master the competencies needed to prescribe antibiotics to children rationally as described in the European Academy of Paediatrics (EAP) Curriculum for Common Trunk Training in Paediatrics

Interdisciplinary approaches of education need to be developed, as all hospitals and health regions in Europe ideally should have AMS programmes that serve all patient types, including children

Keywords

Antimicrobial resistance Postdoctoral training Paediatrics Antibiotic stewardship Antibiotics 

Abbreviations

AMR

Antimicrobial resistance

AMS

Antimicrobial stewardship

CRP

C-reactive protein

EAP

European Academy of Paediatrics

ESPID

European Society for Paediatric Infectious Diseases

Introduction

Antimicrobial resistance (AMR) poses a serious and increasing threat to public health as infections caused by bacteria that are resistant to antimicrobials lead to approximately 25,000 deaths in the European Union every year [7]. In children, a significant increase in the prevalence of multidrug-resistant bacterial infections has occurred during the past couple of decades [5]. Over the last few years, there have been significant shortages in the development and availability of new antibiotics, and the number of targeted studies on antibiotics in children remains strikingly low [23]. Therefore, the implementation of strategies to preserve the efficacy of existing antibiotics is an urgent public health priority, both in hospital and community settings.

Antimicrobial stewardship (AMS) aims to appropriately and safely prescribe antibiotics to patients, while reducing unnecessary or suboptimal use of antibiotics, thus maximising outcomes for the patient [2]. AMS is recognised as a key component to stop the current spread of AMR in Europe. AMS programmes have the ultimate goal of minimising selective pressure on the emergence of drug-resistant strains. Successful AMS programmes are characterised by the ability to break down activities into specific interventions that can be more easily implemented, monitored and evaluated [3]. Successfully implemented AMS programmes have a significant impact on reducing antimicrobial use in paediatric patients, costs and prescribing errors without negative impacts on patient safety, and actually resulting in improved patient outcomes [13, 23, 24]. The identification of paediatric conditions with both frequent and variable antimicrobial use could guide the prioritisation of high-impact targets for AMS interventions [10]. Paediatric AMS should not be limited to the hospital setting and collaboration among hospital and outpatient health care facilities is of paramount importance [12, 14]. Indeed, AMS can be effective in reducing antibiotic misuse in community settings [9, 11, 26], and potential strategies to promote these programmes in community-based settings have been published [14].

Training in antimicrobial stewardship

As active participation of clinical professionals at all levels of care is required for AMS to succeed, educational programmes are particularly important for the successful implementation of AMS [25]. Education of health care providers on appropriate antibiotic prescribing has been shown to enhance other antimicrobial stewardship interventions [22]. Therefore, the European Academy of Paediatrics (EAP) Curriculum for Common Trunk Training in Paediatrics [6] includes specific knowledge and skills related to AMR and the European Society for Paediatric Infectious Diseases (ESPID) and other national (paediatric) infectious diseases groups run specific courses on AMR (Table 2). The syllabus for Core Training sets out a European road map for common paediatric training. It is intended as a guide for national paediatric societies to help them understand the principles of core training. The EAP recognises that in many countries in Europe, training does not conform to these recommendations, but as such differences gradually diminish, quality, content and assessment of training, including training related to the principles AMR, will become more uniform across Europe. At the same time, it is recognised that differences in regional epidemiology and healthcare infrastructure require a tailor-made approach, also for AMS. Recently, recommendations were published for key points to be included in clinical curricula, in order to develop the necessary skills to participate in AMS [20, 22]. These are summarised in Table 1. It is important that assimilation of knowledge about AMS starts already during medical school, is continued during clinical training and is reinforced throughout postgraduate training. Passive educational techniques like large and small group presentations are modestly effective for increasing knowledge. However, interactive or dynamic techniques influence prescribing behaviour. This includes education associated with specific episodes of patient care. Interactive small group sessions, e-learning, educational outreach, periodic retrospective audit and feedback and one-on-one patient-directed education have been shown to be moderately to highly effective in optimising antibiotic use and patient outcomes [22]. In particular, internet-based education shows encouraging results [15, 17, 18]. The advantages of e-learning include improved access to education in rural or low-resource areas and the potential to develop an interactive platform. Several examples of e-learning tools are listed in Table 2. In addition, AMS was recently taught during the EAP MasterCourse 2017 and is included in the upcoming European Academy of Paediatric Societies congress in Paris, 2018. In addition, AMS is always covered during the annual residential ESPID-Oxford Course.
Table 1

Key points to include in clinical AMS curricula [adapted from [20, 22]

 

Learning objective(s)

Topics

Effect of AMS initiatives on clinical outcome

The participant learns about how AMS contributes to accurate and safer prescribing of antimicrobials, resulting in improved clinical outcomes

Effective treatment

Clinical outcomes (mortality and morbidity)

Reduction of side effects

Population specific approaches

Effect of AMS initiatives on bacterial resistance

The participant learns about antibiotic resistance mechanisms, including causes and extent

Epidemiology (global)

Genetics and mechanisms

Relationship to antibiotic use

Discussion of AMS initiatives like prospective audit with feedback and formulary restriction

The participant learns how AMS reduces the spread of antimicrobial resistance

Diagnosis of infection

The participant learns how to accurately interpret laboratory reports in order to make clinical treatment decisions in neonates, infants, children and adolescents;

Proper use and interpretation of bacterial Gram stain/culture, rapid and point-of-care tests, serology, and biomarkers of infection

Establishment of standardised diagnostic criteria for specific infections

The participant learns how to diagnose an infection in a standardised manner;

Principles of infection management in children

The participant learns how to make informed treatment decisions early in the course of disease in order to positively influence treatment outcomes;

Promptly identify patients who require antibiotics

Timely and appropriate initiation of antibiotics

Obtain cultures before starting antibiotics

Do not give antibiotics with overlapping activity or combinations not supported by evidence or guidelines

The participant learns how to de-escalate antibiotic use in order to more effectively treat an infection while limiting exposure to broad-spectrum antimicrobials

Determine and verify antibiotic allergies

Consider local antibiotic susceptibility

Specify expected duration of therapy based on evidence and national and hospital guidelines

Ensure appropriate administration (intravenous versus oral)

Give antibiotics at the right dose and interval

Stop or de-escalate therapy promptly based on the culture and sensitivity results or establishment of an alternative diagnosis

Reconcile and adjust antibiotics at all transitions and changes in patient’s condition

Monitor for toxicity reliably and adjust agent and dose promptly

Prescribing of antibiotics

The participant learns the basics needed to prescribe antibiotics for infections caused by susceptible and resistant organisms

Pharmacokinetics and mechanism of action of different classes of antibiotics (‘bug-drug’ coverage)

Pharmacology and adverse effects, including risk of C. difficile infection

Principles of empirical versus directed therapy

Drug purchasing and dispensing costs

Guidelines for diagnosis and management of most frequent infections in children

 

Specific instruction for these common infections using principles outlined above

Use of national and local guidelines and public health guidance

Prevention of infection

The participant learns about the importance of preventive measures to limit the development of antimicrobial resistance

Hand hygiene

Prudent use of catheters and devices

Principles and duration of surgical prophylaxis

Communication skills

The participant learns how to apply communication techniques to talk with patients and families about prudent antibiotic use

 
Table 2

Available e-learning tools

AMS (general)

Collection of AMS online courses made by the European Centre for Disease Prevention and Control:

https://ecdc.europa.eu/en/publications-data/directory-guidance-prevention-and-control/training-antimicrobial-stewardship

Massive Open Online Course on Antimicrobial Stewardship (University of Dundee, UK):

https://www.futurelearn.com/courses/antimicrobial-stewardship

Antimicrobial Stewardship Online CME Courses (Stanford University School of Medicine, USA):

https://med.stanford.edu/cme/learning-opportunities/antimicrobialstewardship.html

Paediatric AMS

European Society for Paediatric Infectious Diseases (ESPID) online course on paediatric AMS: http://www.espid.org/content.aspx?Page=ESPID%20Online%20Antibiotic%20Management%20Course

Although many of the overarching principles of AMS apply to children and adults alike, many factors related to paediatric AMS are unique to children. Children have high rates of infection and frequently present with non-specific symptoms adding to diagnostic uncertainty. Patterns of infection and resistance vary significantly by age, thus age-specific antibiotic panels for antibiograms should preferably be used to guide antibiotic choices for selected infections. Children are more prone to infection with resistant organisms due to a future lifetime of antibiotic exposure. In addition, considerations related to age-appropriate dosing and formulations pose challenges to the prescription of antibiotics in children [4]. Children may respond differently to antibiotics compared to adults. Finally, immunisation initiatives should be included in AMS programmes as a preventive strategy in both in- and outpatient paediatric settings, in order to decrease the likelihood of serious illness and to decrease AMR. Therefore, other core members of the paediatric AMS team, like the microbiologist, paediatric infectious disease specialist and clinical pharmacist, should receive training focused on the unique medical needs of the paediatric patient [16, 19]. In addition, future paediatricians should be skilled in taking leadership roles in AMS initiatives and develop practical solutions rooted in the general principles of AMS, as it is important to further expand AMS activities from the hospital to paediatric offices and communities [14].

Keep antibiotics working

Limiting the further spread of AMR is one of EAP’s child health priorities for 2017–2018. We will work together with the European Centre for Disease Prevention and Control to raise awareness about the relevance and benefits of cost-effective AMS policies [21] and training in child health and to advocate for sustained implementation of these across Europe. Europe would greatly benefit from a uniform adoption of AMR and infection prevention best practice across countries. This includes harmonisation and simplification of the various treatment guidelines that currently exist across Europe. Moreover, there is an urgent need to conduct research on new antibiotic (classes) for critical multi-drug-resistant pathogens and on the effects of AMS programmes in low-income countries in which emerging resistance are particularly alarming [1]. In addition, limited access to high-quality antibiotics is particularly of concern in these countries. Continuous education and training of health care professionals on appropriate antibiotic use is crucial. We therefore welcome the new European Action Plan, which was launched this summer. The European Commission intends, among others, to develop training programmes on AMR for health professionals through the ECDC and the EU health programme [8].

Conclusion

Prevention of AMR needs rigorous actions in the community, at practice, ward, institutional, national and international levels. Best practices should be applied cross-border and healthcare institutions and communities should collaborate regionally and internationally, in order to fight AMR successfully. Effective Europe-wide implementation and sustained use of cost-effective antimicrobial policies can consequently lead to improved safety and quality of care while contributing to more sustainable healthcare. Ideally, all communities, hospitals and health regions in Europe should have AMS programmes that serve all patient types, including children. This includes adult academic and community hospitals and outpatient care centres that primarily care for children. Therefore, the EAP is interested to discuss interdisciplinary approaches of education with other stakeholders.

Prudent use of antibiotics is very important to address the global challenges posed by AMR. We all have the responsibility to ensure that existing antibiotics remain effective.

Notes

Authors’ contributions

Lenneke Schrier initiated the EAP statement (together with HJD), wrote the draft and agrees on its final wording. Adamos Hadjipanayis commented on the draft and agrees on its final wording. Stefano del Torso commented on the draft and agrees on its final wording. Tom Stiris commented on the draft and agrees on its final wording. Marieke Emonts commented on the draft and agrees on its final wording. Hans Juergen Dornbusch initiated the EAP statement (together with LS), commented on the draft and agrees on its final wording.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

This article does not contain any studies with human participants or animals performed by any of the authors and therefore neither ethical approval nor informed consent applies.

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© The Author(s) 2017

Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.

Authors and Affiliations

  1. 1.European Academy of PaediatricsBrusselsBelgium
  2. 2.Willem-Alexancer Children’s HospitalLeiden University Medical CenterLeidenThe Netherlands
  3. 3.Paediatric DepartmentLarnaca General HospitalLarnacaCyprus
  4. 4.European University Medical SchoolNicosiaCyprus
  5. 5.Pediatra di FamigliaPaduaItaly
  6. 6.Department of Neonatal Intensive CareOslo University HospitalOsloNorway
  7. 7.Institute of Cellular MedicineNewcastle UniversityNewcastle upon TyneUK
  8. 8.Department of Paediatric Immunology and Infectious DiseasesNewcastle upon TyneUK
  9. 9.Hospital Foundation TrustGreat North Children’s HospitalNewcastle upon TyneUK
  10. 10.Medical University of GrazGrazAustria

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