Optimizing antibiotic prescribing: collective approaches to managing a common-pool resource

Abstract

Background: Antimicrobial resistance (AMR) is one of the greatest threats in 21st century medicine. AMR has been characterized as a social dilemma. A familiar version describes the situation in which a collective resource (in this case, antibiotic efficacy) is exhausted due to over-exploitation. The dilemma arises because individuals are motivated to maximize individual payoffs, although the collective outcome is worse if all act in this way. Objectives: We aim to outline the implications for antimicrobial stewardship of characterizing antibiotic overuse as a social dilemma. Sources: We conducted a narrative review of the literature on interventions to promote the conservation of resources in social dilemmas. Content: The social dilemma of antibiotic over-use is complicated by the lack of visibility and imminence of AMR, a loose coupling between individual actions and the outcome of AMR, and the agency relationships inherent in the prescriber role. We identify seven strategies for shifting prescriber behaviour and promoting a focus on the collectively desirable outcome of conservation of antibiotic efficacy: (1) establish clearly defined boundaries and access rights; (2) raise the visibility and imminence of the problem; (3) enable collective choice arrangements; (4) conduct behaviour-based monitoring; (5) use social and reputational incentives and sanctions; (6) address misalignment of goals and incentives; and (7) provide conflict resolution mechanisms. Implications: We conclude that this theoretic analysis of antibiotic stewardship could make the problem of optimizing antibiotic prescribing more tractable, providing a theory base for intervention development.

Social dynamics of a population-level dashboard for antimicrobial stewardship: A qualitative analysis

“…Antibiotic stewards must confront what many would call a "social dilemma," insofar as providers' antibiotic prescribing to achieve short-term health outcomes for individual patients may be at odds with longer-term individual and public health needs. [6][7][8][9] Moreover, because AS programs are tasked to motivate individual clinicians and departments to change their prescribing behavior, they must grapple with subtle, often tacit aspects of clinical norms and organizational culture in their local context. 6,[10][11][12][13] Decision support tools intended to bridge individual clinicians' decision-making needs and organizational quality improvement (QI) goals have unique design requirements.…”

Exploring the social ecology for appropriate antibiotic prescribing and stewardship in primary care: presenting the VALUE driven model of practice derived from qualitative analysis of public and private care settings in Singapore

“…Collective and coordinated antibiotic stewardship efforts in primary care (both public and private practice) would improve appropriate antibiotic prescribing in primary care clinics at a national level [42]. Our study highlighted opportunities for national interventions to improve antibiotic prescribing in primary care, particularly in private practices which manages the bulk of primary care acute conditions in Singapore.…”

Balancing conflicting demands: factors influencing vets’ choice of antimicrobial agent

“…5 Prudent AMU in animals and people, therefore, involves a trade-of between these competing demands in order to select an antimicrobial that will be clinically efective while also minimising the risk of AMR. 6,7 The factors inluencing vets' decisions regarding prescribing antimicrobial agents in pig production have been explored using both qualitative [8][9][10] and quantitative [11][12][13] approaches. In a paper summarised on p 798 of this issue of Vet Record, Eriksen and colleagues have built upon this existing knowledge by quantifying and comparing the inluence of the factors identiied in previous studies on the choice of antimicrobial in the speciic context of intestinal diseases in weaner pigs in Denmark, providing valuable insight into how vets balance the competing considerations they face when selecting an antimicrobial agent.…”

“…Conversely, the primary responsibility of the vet is to safeguard the health, welfare and productivity of their clients’ animals (ie, as much as necessary) 5 . Prudent AMU in animals and people, therefore, involves a trade‐off between these competing demands in order to select an antimicrobial that will be clinically effective while also minimising the risk of AMR 6,7 …”