Antibiotic stewardship: prescribing social norms

With a burgeoning world population, expansions in medical intervention, and intensifi ed agriculture, the need for antibiotic stewardship is increasingly clear. Declining effi cacy of antimicrobial prophylaxis for surgery or chemotherapy, and emergence of pan-resistant pathogens, warn of a post-antibiotic era. In the evolutionary arms race of antimicrobial resistance, rejuvenating the neglected pipeline for new agents provides only a partial solution. The key challenge worldwide is translating awareness of resistance into eff ective stewardship. In the past decade, the UK has made notable progress. A high media profi le has provided political leverage to advance antimicrobial resistance up national health agendas, and surveillance systems for antibiotic consumption and resistance have been established. National targets to reduce broad-spectrum antibiotic use have been associated with declines in Clostridium diffi cile and meticillin-resistant Staphylococcus aureus. However, declining sensitivities to substitute antibiotics suggest that without reducing total antibiotic consumption, we might be replacing rather than eliminating resistances. Sustaining progress will require a major shift in prescribing and consumption norms. A particular challenge in reducing antibiotic use is the disconnect between individual behaviour and populationlevel resistance. Avoiding overuse of a global common good requires making a diff use and unrecognised Published Online February 18, 2016 http://dx.doi.org/10.1016/ S0140-6736(16)00007-6