Dilip Nathwani, Dundee (UK) and Cèline Pulcini, Nice (France)
In March 2012 a Policy Statement on Antimicrobial Stewardship by the Society for Healthcare Epidemiology of America (SHEA), the Infectious Diseases Society of America (IDSA), and the Pediatric Infectious Diseases Society (PIDS) was published . One of the key recommendations was that “ SHEA, IDSA, and PIDS believe that significant knowledge deficits in the areas of antimicrobial resistance and antimicrobial stewardship are prevalent among healthcare providers in the United States.
- Educational programs that teach about the science behind, the principles of, and the tools essential for the practice of effective antimicrobial stewardship should be developed for those in training programs as well as for all prescribing clinicians.
- Education about antimicrobial resistance and stewardship should be incorporated into curriculum requirements for medical students and postgraduate residents and fellows. It is crucial that currently practicing clinicians become proficient in these areas.
- In addition to ensuring that these areas are included in curricula and programs for those in training, there are a number of ways in which proficiency may be accomplished for practicing clinicians, including partnering with specialty societies and the Food and Drug Administration (FDA) to provide educational resources.
- Moreover, as a part of the drug-review process, pharmaceutical sponsors should include a plan to educate healthcare providers about both the optimal use of the drug and precautions that reduce the emergence of antimicrobial resistance.
- Individual facilities should be responsible for supporting the education of the members of the antimicrobial stewardship team.
- Antimicrobial stewardship is a patient safety issue and a public health issue and must be taken seriously in all aspects of the continuum of patient care.
- Additionally, because of the gravity of the problems with antimicrobial resistance that confront society and the paucity of readily available clinical solutions, SHEA, IDSA, and PIDS support appropriations to fund these education initiatives”. Other stewardship strategies, including that from the EU  recognise and support the principles outlined in the above document.
An outcomes based approach for delivering training for medical undergraduates had also been proposed by the British Society for Antimicrobial Therapy in 2005 . This led to the development of the PAUSE website supported by BSAC & ESCMI and this approach has been adapted into a learning module for all foundation training grade doctors in Scotland.
In the Australian guidelines for Antimicrobial stewardshipthe educational requirements and competency of prescriber’s are described in more detail and are worthy of attention. Of particular interest are examples of different types of available educational resources. Many more are likely to be out there. However, access to them can be challenging due to variation in quality, language, local relevance, applicability, IT access, lack of ownership or ability to keep them updated, bias due to organisational and pharmaceutical sponsoring and so on.
2. ESGAP position
ESGAP believes that the education challenges faced by health care professional are immense. Supporting education for stewardship is one of the key ESGAP objectives. ESGAP recognises the relevance and value of these statements to all stewardship programmes. This module aims to :
1. Highlight the importance of education in changing prescribing attitudes and behaviour
2. Synthesize the evidence base to support the effectiveness a range of these educational interventions
3. Provide readers with some helpful resources to support medical [undergraduate and postgraduate training] education, pharmacy training and nursing education in stewardship. These will be done by providing links to available resource that is free to access. We hope that this will continue to be updated over time. We would encourage you as readers to send us appropriate links to educational material. We would ask you to review the quality of the material using the following 10 point checklist.
Education, through the acquisition of knowledge, is considered to be an essential element of any program designed to inﬂuence prescribing behaviour. It can provide a foundation of knowledge that will enhance and increase the acceptance of antibiotic stewardship strategies.
- However, education alone, without incorporation of active intervention, is only marginally effective in changing antimicrobial prescribing practices and has not demonstrated a sustained impact. .
- Indeed, the Cochrane systematic evaluation of the impact of interventions to improve antibiotic prescribing practices for hospital inpatients  included a range of educational interventions from distribution of educational materials; educational meetings; local consensus processes; educational outreach visits; local opinion leaders to reminders provided verbally, on paper or on computer and audit and feedback under the umbrella term of persuasive interventions. These measures were compared to more restrictive measures, such as pre-prescription approval, aimed at controlling use. The first review concluded that restrictive methods has a more immediate impact than persuasive interventions although an update of the Cochrane review [2012 in press] appears to indicate, as one may expect, that persuasive intervention have a more sustained impact when effective.
The types of educational interventions that are most effective also require some consideration:
- Passive educational interventions produce minimal change in physician behaviour, and lectures or presentations with little audience interaction or discussion were ineffective.
- Interactive sessions that included techniques to enhance physician participation (e.g., role-play, discussion groups, hands-on training, problem solving, case solving) showed somewhat more successful results than traditional lecture-based learning. 
- Previous research has suggested that the use of multidisciplinary teams, rather than individual “physician champions,” is the most successful strategy for creating a change in a hospital environment.  The concept of team based learning, often through inter-professional education, delivered in the workplace, is gaining a lot of support in terms of effectively implementing good clinical practice, although more studies are required to assess their true value.  SHEA also recently critiqued the evidence for educational strategies to support antimicrobial stewardship. 
- Active educational programmes such as discussion groups for health professionals working in same facility, personal visit by trained health professional, educational outreach visits and academic detailing, interactive role-playing, hands-on-training, problem and case solving, educational workshops or conferences outside provider’s setting. sequenced or repetitive or spaced education sessions (learn-work-learn methods were all deemed probably more effective than passive educational programmes.
Whilst many guidelines, formularies and policies exist on the website access to teaching and training material is much more difficult. Here are some examples of what may be available and we would be keen to hear from you with more suggestions. Please e-mail me: firstname.lastname@example.org
A) Overall approach
- How to educate prescribers in antimicrobial stewardship practices: This nice review article is an excellent overview of the strategies for education in relation to stewardship. The learning outcomes for stewardship education and course are clearly defined.
- PAUSE : UK, BSAC and ESCMID supported; English only. Online resource for undergraduates and doctors in training, case studies available to download with assessment, access to all through registration and password and free of charge; last updated 2011 – plans for review in 2013
- European medical students: a first multicentre study of knowledge, attitudes and perceptions of antibiotic prescribing and antibiotic resistance. (JAC 2013) An analysis of European medical student knowledge and perceptions in relation to antibiotic prescribing and resistance.
C) Postgraduate, Public, Patients
- NPS prescribe: Australia, NPS, English, on line 28 inter-active case studies, mainly for Australian healthcare professionals, course registration through guest access free of charge but have to e-mail email@example.com for information , updated 2010
- SWAB: The Dutch Working Party on Antibiotic Policy (SWAB) in cooperation with ECDC has set up an e-learning module which includes e-learning activities to teach different medical specialists in antimicrobial resistance.
- CDC get smart campaign: Patient, carer and healthcare professional educational resources about antibiotic use ; English, 2012, videos/podcasts, paper and other resource, downloadable, free of charge and no registration required.
- e-bug : E- bugs is a free educational resource for teachers and in the home. It aims for Public Schools: to assist in educating primary and secondary school pupils on microbes, hygiene and infection control. These resources would also be useful for healthcare workers in dealing the public, carers and other healthcare workers. Health Protection Agency England, English, free access, 2012, range of interactive material
- Policy Statement on Antimicrobial Stewardship by the Society for Healthcare Epidemiology of America (SHEA), the Infectious Diseases Societyof America (IDSA), and the Pediatric Infectious Diseases Society (PIDS). Society for Healthcare Epidemiology of America; Infectious Diseases Society of America; Pediatric Infectious Diseases Society. Infection Control and Hospital Epidemiology Vol. 33, No. 4, Special Topic Issue: Antimicrobial Stewardship (April 2012) (pp. 322-327)
- Allerberger F, et al. Antibiotic stewardship implementation in the EU: the way forward. Expert Rev Anti-Infect Ther 2009; 7. :1175-1183.
- Lorraine A. Paterson Davenport, Peter G. Davey, Jean S. Ker and on behalf of the BSAC Undergraduate Education Working Party. An outcome-based approach for teaching prudent antimicrobial prescribing to undergraduate medical students: report of a Working Party of the British Society for Antimicrobial Chemotherapy. J. Antimicrob. Chemother. (July 2005) 56(1): 196-203
- 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):159–177.
- Davey P, Brown E, Fenelon L, et al. Interventions to improve antibiotic prescribing practices for hospital inpatients. Cochrane Database Syst Rev. 2005;(4):CD003543.]
- Davis D, O’Brien MA, Freemantle N, Wolf FM, Mazmanian P, Taylor-Vaisey A. Impact of formal continuing medical education: do conferences, workshops, rounds, and other traditional continuing education activities change physician behavior or health care outcomes? JAMA. 1999;282(9):867–874.
- Grimshaw JM, Thomas RE, MacLennan G, et al. Effectiveness and efficiency of guideline dissemination and implementation strategies. Health Technol Assess. 2004;8(6):iii–iv,1–72.
- Reeves S, Zwarenstein M, Goldman J, Barr H, Freeth D, Hammick M, Koppel I. Interprofessional education: effects on professional practice and health care outcomes. Cochrane Database of Systematic Reviews 2008, Issue 1. Art. No.: CD002213. DOI: 10.1002/14651858.CD002213.pub2.]