ONLINE POST in ENGLISH, commissioned | AMP Student 2017;5
Sir Alexander Fleming, the founder of penicillin, said “the thoughtless person playing with penicillin treatment is morally responsible for the death of the man who succumbs to infection with a penicillin resistant infection!” How true is this prophecy. This is illustrated by the fact that in human prescribing, 50% of antibiotics are unnecessary or incorrectly prescribed and we are witnessing increased mortality due to drug resistant infections (1).
The medical student, as a key member of the healthcare professional team, has a professional and moral duty to learn about and practice good antimicrobial prescribing – the cornerstones of antimicrobial stewardship. Today our clinical practice in infection is challenged by the spectre of antimicrobial multi-resistance (AMR) and morbidity and mortality from drug resistant infections. Our ability to treat many infections is compromised. Antimicrobial Stewardship Programmes (ASP) have been created with the goals of improving clinical outcomes, increasing patient safety, reducing ecological harm such as resistance [e.g MRSA], reducing infections such as C.difficile and reducing costs (2).
To achieve this, educating prescribers to ensure that the right drug, dose, route and duration is prescribed is key (3). Educating prescribers in stewardship is a difficult task because every doctor is a potential antimicrobial prescriber unlike other drugs reserved to some medical settings. Furthermore, dentists, veterinarians, and some non- medical personal (nurses, pharmacists) are also authorized to prescribe (4).
As we recognize the importance of shaping prescribing behavior, the WHO commends that education should be extended to medical and other health students as an integral part of ASP (5).
Many studies (6-11) have identified the educational needs of medical students in stewardship. For example, one of the identified needs refers to combination therapy and dose selection (7, 8). There are many examples across the globe of how countries or regions have attempted to address this. In Scotland with the support of SAPG (Scottish Antimicrobial Prescription Group) stewardship was included in the content of “The Scottish doctor” (medical school’s curriculum) and e-learning resources have been extensively available for undergraduate and postgraduate doctors (12). Also, in the UK, a web based learning resource for undergraduate students was created – PAUSE (Prudent Antibiotic Use) – with teaching materials based on patient focus and reflective learning (13). The Netherlands offers different approaches, with the University of Rotterdam developing a one-week module on several aspects of stewardship in the second year of the curriculum, and in Nijmegen an elective module in the third year (4). The US CDC and the Association of American Medical Colleges developed an Antimicrobial Stewardship Curriculum for Medical Students that is freely available online (14). More recently medical students are participating in the Massive Open Online Course (MOOC) on stewardship (www.futurelearn.com/courses/antimicrobial-stewardship). This is now also available in an unfacilitated form and with Chinese language translation.
The future impact on prescribing practice and outcomes of improved medical student training remains to be seen. This should not stop us from ensuring that we continue to guarantee that students are adequately and appropriately trained and that they are empowered to maintain and develop good prescribing skills as they enter into clinical practice. Apart from simply acquiring knowledge, as medical students enter into the clinical years they will have the opportunity to be involved in the team’s clinical decision making process and practice. Here the students should be encouraged to actively participate in ensuring that good prescribing is done. This could be achieved by asking the right questions or even questioning practice if deemed inappropriate.
Moreover, students and their supervisors should actively engage with evaluating practice, through reflective case discussions, quality improvement projects and audits (https://www.ahspartnership.org.uk/quality-and-safety/ihi-dundee) and so on. This is a powerful tool for further learning and changing practice. It is at the heart of the reflective learner. Finally, introduction of students to basic research, that may be ongoing in the department or new opportunities, should also be encouraged as it will further enhance good practice.
In conclusion, medical students should get involved in antimicrobial stewardship not just as passive learners but also as active members of the medical team, since the commitment to give our patients the best care should start in the beginning of medical education and not after graduation.
1. Dellit TH, et al. Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America guidelines for developing an institutional program to enhance antimicrobial stewardship. Clin Infect Dis. 2007 Jan 15;44(2):159-77.
2. MacDougall C, Polk RE. Antimicrobial stewardship programs in health care systems. Clin Microbiol Rev. 2005 Oct;18(4):638 56.
3. Ohl CA, Luther VP. Health care provider education as a tool to enhance antibiotic stewardship practices. Infect Dis Clin North Am. 2014 Jun;28(2):177-93.
4. Pulcini C, Gyssens IC. How to educate prescribers in antimicrobial stewardship practices. Virulence. 2013 Feb 15;4(2):192-202. doi: 10.4161/viru.23706.
5. World Health Organization. The evolving threat of antimicrobial resistance. Options for action.
6. Scaioli G, Gualano MR, Gili R, Masucci S, Bert F, Siliquini R. Antibiotic use: a cross-sectional survey assessing the knowledge, attitudes and practices amongst students of a school of medicine in Italy. PLoS One. 2015 Apr 1;10(4):e0122476.
7. Abbo LM, et al. Medical students' perceptions and knowledge about antimicrobial stewardship: how are we educating our future prescribers? Clin Infect Dis. 2013 Sep;57(5):631-8.
8. Dyar OJ, Pulcini C, Howard P, Nathwani D; ESGAP (ESCMID Study Group for Antibiotic Policies). European medical students: a first multicentre study of knowledge, attitudes and perceptions of antibiotic prescribing and antibiotic resistance. J Antimicrob Chemother. 2014 Mar;69(3):842-6.
9. Khan A K A, Banu G, K K R. Antibiotic Resistance and Usage-A Survey on the Knowledge, Attitude, Perceptions and Practices among the Medical Students of a Southern Indian Teaching Hospital. J Clin Diagn Res. 2013 Aug;7(8):1613-6.
10. Suaifan G ARY, Shehadeh M, Darwish DA, Al-ljel H, Yousef AM, Darwish RM. A cross-sectional study on knowledge, attitude, and behavior related to antibiotic use and resistance, among medical and nonmedical university students in Jordan. Afr J Pharm Pharacol. 2012; 6(10): 763–770.
11. Thriemer K, Katuala Y, Batoko B, Alworonga JP, Devlieger H, Van Geet C, et al. Antibiotic prescribing in DR Congo: a knowledge, attitude and practice survey among medical doctors and students. PloS One. 2013; 8(2): e55495.
12. Nathwani D,et al. Scottish Antimicrobial Prescribing Group (SAPG): development and impact of the Scottish National Antimicrobial Stewardship Programme. Int J Antimicrob Agents. 2011 Jul;38(1):16-26.
13. British Society for Antimicrobial Chemotherapy, European Society of Clinical Microbiology and Infectious Disease. Prudent Antibiotic User (PAUSE). http://www.pause-online.org.uk/
14. Luther VP, Ohl CA, Hicks LA. Antimicrobial stewardship education for medical students. Clin Infect Dis. 2013 Nov;57(9):1366.
Bianca Branco Ascenção: Infectious Diseases Department, Centro Hospitalar de Setúbal, Portugal
Dilip Nathwani: Infection Unit, Ninewells Hospital and Medical School, Dundee, United Kingdom