White Paper: Bridging the gap between surveillance data and antimicrobial stewardship in the outpatient sector—practical guidance from the JPIAMR ARCH and COMBACTE-MAGNET EPI-Net networks

Whi e Pape : B idging he gap be ween su eillance da a and an imic obial s ewa dship in he ou pa ien sec o —p ac ical guidance om he JPIAMR ARCH and COMBACTE-MAGNET EPI-Ne ne wo ks Fabiana A ie i 1 †, Si i Go¨pel 2,3 †, Ma cella Sibani 1 *, Elena Ca a a 1 , Ma ia Dile a Pezzani 1 , Ri a Mu i 4 , Nico T. Mu e s 5 , Lo ena Lo`pez-Ce e o 6 , And eas Voss 7 , Robe o Cauda 4 and E elina Tacconelli 1,2,3 on behal o he ARCH wo king g oup‡ 1 In ec ious Diseases Sec ion, Depa men o Diagnos ics and Public Heal h, Uni e si y o Ve ona, Ve ona, I aly; 2 In ec ious Diseases, Depa men o In e nal Medicine I, Tu¨bingen Uni e si y Hospi al, Tu¨bingen, Ge many; 3 Ge man Cen e o In ec ion Resea ch (DZIF), Clinical Resea ch Uni o heal hca e associa ed in ec ions, Tu¨bingen, Ge many; 4 Ins i u e o In ec ious Diseases, Fondazione Policlinico Uni e si a io A. Gemelli IRCCS, Uni e si a´ Ca olica del Sac o Cuo e, Rome, I aly; 5 Ins i u e o Hygiene and Public Heal h, Bonn Uni e si y Hospi al, Bonn, Ge many; 6 Mic obiology and In ec ious Diseases Uni , Uni e si y Hospi al Vi gen Maca ena, Se illa, Spain; 7 Depa men o Clinical Mic obiology and In ec ious Diseases, Canisius-Wilhelmina Hospi al, Nijmegen, The Ne he lands *Co esponding au ho . E-mail: ma cella.sibani@uni .i †Equally con ibu ing i s au ho s. ‡Membe s a e lis ed in he Acknowledgemen s sec ion. Backg ound: The ou pa ien se ing is a key scena io o he implemen a ion o an imic obial s ewa dship (AMS) ac i i ies, conside ing ha o e consump ion o an ibio ics occu s mainly ou side hospi als. This publica- ion is he esul o a join ini ia i e by he JPIAMR ARCH and COMBACTE-MAGNET EPI-Ne ne wo ks, which is aimed a o mula ing a se o a ge ac ions o linking su eillance da a wi h AMS ac i i ies in he ou pa ien se ing. Me hods: A scoping e iew o he li e a u e was ca ied ou in h ee esea ch a eas: AMS leade ship and accoun - abili y; an imic obial usage and AMS; an imic obial esis ance and AMS. Consensus on he ac ions was eached h ough a RAND-modi ied Delphi p ocess in ol ing o e 40 expe s in in ec ious diseases, clinical mic obiology, AMS, e e ina y medicine o public heal h, om 18 low-, middle- and high-income coun ies. Resul s: E idence was e ie ed om 38 documen s, and an ini ial 25 a ge ac ions we e p oposed, di e en ia - ing be ween essen ial o desi able a ge s acco ding o clinical ele ance, easibili y and applicabili y o se ings and esou ces. In he i s consul a ion ound, p elimina y ag eemen was eached o all a ge s. Fu he o a se- cond e iew, 6 s a emen s we e e-conside ed and 3 we e dele ed, leading o a inal lis o 22 a ge ac ions in he o m o a p ac ical checklis . Conclusions: This Whi e Pape is a p agma ic and lexible ool o guide he de elopmen o calib a ed su eillance-based AMS in e en ions speci ic o he ou pa ien se ing, which is cha ac e ized by subs an ial in- e - and in a-coun y a iabili y in he o ganiza ion o heal hca e s uc u es, main aining a global pe spec i e and aking in o accoun he easibili y o he a ge ac ions in low- esou ce se ings. In oduc ion An imic obial s ewa dship (AMS) in he ou pa ien se ing is a c i ic- al aspec wi hin a global scena io o he con inuous inc ease in an imic obial esis ance (AMR) and o e consump ion o an ibio ics, which mainly occu s (app oxima ely 80%–90%) ou side hospi- als. 1–3 Hence, i is impossible o hypo hesize any AMS in e en ion in he ou pa ien se ing wi hou he abili y o adequa ely ack an imic obial use (AMU) and AMR. This p ocess can be done in se - e al ways, om single p esc ibing uni s o la ge e i o ial a eas, and should be able o gua an ee eedback o indi idual p esc ibe s and allow benchma king wi h egional and na ional da a. Due o V CThe Au ho (s) 2020. Published by Ox o d Uni e si y P ess on behal o he B i ish Socie y o An imic obial Chemo he apy. This is an Open Access a icle dis ibu ed unde he e ms o he C ea i e Commons A ibu ion Non-Comme cial License (h p://c ea i ecom mons.o g/licenses/by-nc/4.0/), which pe mi s non-comme cial e-use, dis ibu ion, and ep oduc ion in any medium, p o ided he o iginal wo k is p ope ly ci ed. Fo comme cial e-use, please con ac [email p o ec ed] ii42 J An imic ob Chemo he 2020; 75 Suppl 2: ii42–ii51 doi:10.1093/jac/dkaa428 Downloaded om h ps://academic.oup.com/jac/a icle/75/Supplemen _2/ii42/6024988 by gues on 10 Feb ua y 2025 he ele ance o hese da a, many e o s ha e been unde aken a he in e na ional le el (WHO, ESAC ECDC, Canadian An imic obial Resis ance Su eillance Sys em, Japanese An imic obial Consump ion Su eillance) o s anda dize epo ing. Howe e , he he e ogenei y o me ics o AMU su eillance, espe- cially o he ou pa ien se ing, makes i di icul o o mula e clea ecommenda ions on which me ic should bep e e ed. 4 While many AMS in e en ions ocus on educing consump ion, i is impo an o poin ou ha in many se ings he AMS p o- g amme is de eloped o educe AMR. In he ou pa ien se ing, a numbe o ini ia i es (i.e. educa ional ools and awa eness cam- paigns) ha e been p o ed o be success ul in enhancing app op i- a eness o p esc ip ions. Howe e , al hough good examples o bo om-up AMS ini ia i es in eg a ed in o ou pa ien daily clinical p ac ice a e inc easingly being desc ibed, 5 high-quali y e idence da a showing he impac o such ini ia i es on mic obiological ou - comes a e s ill limi ed, mainly because o sca ce and he e oge- neous epo ing o da a. 6 Indeed, when i comes o he o he pilla o AMS in e en ions (i.e. moni o ing AMR), he ou pa ien se ing is e en mo e challenging because mos he apeu ic decisions a e made empi ically. Mic obiological da a, when a ailable, a e di i- cul o in e p e and a e a ely ep esen a i e o he gene al popula ion. Despi e he a ailabili y o guidelines o implemen a ion and managemen o AMS p og ammes in he communi y (CDC Co e Elemen s and Field Guide, SHEA MITIGATE o Eme gency Depa men and U gen Ca e, Join Commission An imic obial S ewa dship Ambula o y Ca e), p ac ical ecommenda ions on how p esc ibe s should ela e o local mic obiological and con- sump ion da a o imp o e p esc ip ions a e a ely discussed. Undoub edly, in a con ex whe e each coun y has i s own legisla- ion egula ing bo h an ibio ic policies and ou pa ien en i ies, i is di icul o issue widely applicable ecommenda ions. The ou - pa ien se ing can be an elusi e concep o ou line and se e al de ini ions a e ound in he li e a u e (Table1); addi ionally, i s o - ganiza ion has been con inuously and apidly changing in ecen decades, e en in low- and middle- income coun ies (LMICs). 7,8 Fo he pu poses o his esea ch pape , JPIAMR ARCH and COMBACTE-MAGNET EPI-Ne 9,10 ha e ha monized e o s o ou line a s uc u ed app oach ha p o ides a se o ac ions o acili a e an ibio ic policy in e en ions and d i e he link be ween su eillance da a on AMR and an ibio ic consump ion and imple- men a ion o AMS ac i i ies. The in e na ional expe panel has p oduced a se ies o Whi e Pape s ocused on ou di e en se ings: hospi al; ou pa ien ; long- e m ca e acili ies (LTCFs); and e e ina y. The esea ch ques ions ha cons i u e he e idence base o he ecommenda- ions ocused on h ee main a eas: (i) leade ship commi men , accoun abili y and AMS eam; (ii) AMU and AMS; and (iii) AMR and AMS. The inal lis o a ge ac ions summa izes he epidemiologic- al, mic obiological and an imic obial da a ha a e essen ial o an ibio ic p esc ibing and policy. The en i e p ocess was unde - pinned by a s ong ocus on he easibili y o he ac ions and he One Heal h app oach. This pape ocuses on he ou pa ien se ing, namely any ca e se ice p o ided o pa ien s who a e no admi - ed oa hospi al o LTCF, anging om immedia e ea men o an acu e and o en se ious illness (e.g. eme gency ou pa ien clinics) o ou pa ien special y clinics and p ima y heal h ca e acili ies ha p o ide p e en i e and cu a i e se ices (Table 1). The in ended audience o his Whi e Pape is heal hca e p o essionals and leade s wo king in ou pa ien clinics in high-income coun ies who a e willing o es ablish o implemen an e ec i e AMS p o- g amme; howe e , speci ic e e ences o LMICs a e also p o ided whene e easible and ele an . The checklis s p oduced a e a ailable o download on he ARCH websi e, 9 and can be used as p ac ical ools by heal h p o essionals and policymake s o es ab- lish and/o moni o s ewa dship ac i i ies. Dissemina ion will be ensu ed by he ne wo ks in ol ed in he JPIAMR ARCH p ojec ha a e lis ed in Table 1o he i s pape in his se ies. 11 Me hods Using a One Heal h app oach, he p esen p ojec was concei ed o de elop expe consensus based on e alua ion o he a ailable li e a u e and guid- ance documen s on AMS and su eillance. This was ollowed by he de el- opmen o a i s d a o a ge s and a RAND-modi ied Delphi p ocess o he de ini i e alida ion o a ge s (p o ocola ailable a he ARCHwebsi e). 9 The en i e p ocess is desc ibed in he i s pape o his se ies, which ocuses on he hospi al se ing. 11 B ie ly, he p ocess in ol ed he ollowing: de el- opmen o key esea ch ques ions (lis ed in Table3o he i s Whi e Pape o his se ies) de i ing om a sys ema ic e iew p e iously de eloped o p o ide guidance on he AMR su eillance modali ies ha a e bes sui ed o d i ing s ewa dship in e en ions in hospi als (EPI-Ne COACH p ojec ); 12 a na a i e e iew o he a ailable e idence; he p oduc ion o a i s d a o a ge s p o ided o he expe s in a web-based su ey in which ag eemen was exp essed on a nine-poin Like scale; a 2 day ace- o- ace mee ing held a he end o Oc obe 2019. Fo he li e a u e sea ch, ele an publica- ions in English, published in he las 10yea s, we e sc eened wi h a s ep- wise app oach: i s , guidance ( om scien i ic socie ies, in e na ional and na ional au ho i ies) and documen s included in he EU-JAMRAI eposi- o y 13 we e assessed, and hen he sea ch was ca ied ou using MEDLINE (Na ional Lib a y o Medicine, Be hesda, MD, USA) wi h a combina ion o he ollowing e ms: an imic obial, consump ion, ou pa ien , an imic obial d ug esis ance and su eillance. Nex , du ing he ace- o- ace mee ing, he expe s we e p esen ed wi h a summa y o he e idence, discussed he esul s o he online su ey and inalized he lis o a ge s. Recommenda ions, s a e o he a , and o iginal app oaches we e e alua ed by ocusing on easibili y and adap abili y o di e en economic and heal hca e con ex s o compile a lis o ‘essen ial’ and ‘desi able’ a ge s. Ta ge s we e ecognized as ‘essen ial’ when widely Table 1. De ini ions o ou pa ien se ings Re e ence De ini ion 59 An ou pa ien is a pe son who goes o a heal hca e acil- i y and who lea es he acili y wi hin 3 h o he s a o consul a ion. An ou pa ien is no o mally admi ed o a acili y. 60 Ca e p o ided in acili ies whe e pa ien s do no emain o e nigh (e.g. hospi al-based ou pa ien clinics, non-- hospi al-based clinics and physician o ices, u gen ca e cen es, ambula o y su gical cen es e c.). 61 a Any ca e se ice p o ided o pa ien s who a e no admi - ed as inpa ien s o a hospi al. a Fo he pu poses o his documen , we conside ed his b oad de ini ion o ou pa ien se ing; howe e , mos o he e idence ound in he li e a- u e e iew was ela ed o GP clinics, amily physician clinics and paedia - ic clinics. Linking su eillance wi h AMS in he ou pa ien se ing JAC ii43 Downloaded om h ps://academic.oup.com/jac/a icle/75/Supplemen _2/ii42/6024988 by gues on 10 Feb ua y 2025 p ac icable i no al eady b oadly accomplished, and ‘desi able’ in he case o limi ed easibili y o esou ce cons ain s. Topics o which mo e e idence was equi ed in o de o d aw up ecommenda ions we e de inedas p io i y opics o u u e esea ch. A o al o 40 expe s om 18 coun ies and 30 ne wo ks de eloped he p o ocol, con ibu ed o eaching a consensus and app o ed he inal lis o indica ions (see i s pape in his se ies). Resul s A o al o 38 documen s we e included o he app aisal, 2,6,14–49 co e ing all egions wo ldwide; howe e , he majo i y (32, 84%) we e om Eu ope, No h Ame ica o he Eas Asia and Paci ic egions. Mos o he e idence was e ie ed om guidelines, sys- ema ic e iews, p ac ical guides o ools, s udies and su eillance epo s, mos ly encompassing adul and paedia ic se ings. A limi ed numbe o expe opinion and s udy p o ocol documen s we e also included. E idence o he leade ship commi men , accoun abili y and AMS eam esea ch a ea was e ie ed om 10 guidelines, 3 sys- ema ic e iews and 1 s udy p o ocol, while e idence ela i e o AMU and AMS was ob ained om 8 guideline documen s, 6 e iews, 13 s udy a icles o epo s, 3 p ac ical ools and 1 expe opinion. No guidelines speci ically add essing AMR and AMS we e iden i ied, and e idence o his opic was e ie ed om eigh documen s, including e iews, s udies, a ew p ac ical ools and expe opinion. P elimina y s a emen s o he h ee a eas o esea ch (leade - ship commi men , accoun abili y and AMS eam; AMU and AMS; and AMR and AMS) we e es ablished. Twen y expe s a ed he ini- ial s a emen s h ough an online su ey and ag eemen was eached o all o hem; howe e , du ing he ace- o- ace mee ing (Oc obe 2019) some aspec s we e discussed u he : 6 s a e- men s we e e-conside ed and e-ph ased and 3 we e dele ed, leading o a lis o 22 a ge ac ions ha we e app o ed in hei inal e sion by he en i e panel. Tables2–4, espec i ely, lis he ecommended a ge s o he h ee a eas o esea ch. Due o lack o e idence o expe ag eemen , i was no possible o o mula e a ge s on one esea ch ques ion o AMU and AMS and on h ee esea ch ques ions o AMR and AMS, highligh ing he gaps in he li e a u e and expanding he lis o esea ch p io i ies (Table 5). Discussion Leade ship commi men , accoun abili y and an imic obial s ewa dship eam The ou pa ien se ing is cha ac e ized by consis en in e - and in a-coun y a iabili y in he o ganiza ion o heal hca e s uc- u es, which e lec s he complexi y in he design o AMS p og ammes. Ne e heless, i is c ucial o iden i y a clea leade (o leade s) o guide he AMS eam and ac i i ies. 19,50 In la ge ad- minis a i e se ings such as ou pa ien clinics, an o ganiza ional s uc u e ollowing he ‘hub and spoke’ model can be conside ed. Fo example, in he case o an ou pa ien se ice linked o a hos- pi al, esou ces such as he mic obiology labo a o y, pha macy, IT s uc u e and guidance by in ec ious disease specialis s can be used o d i e AMS ac i i ies, while in low-income coun ies exis ing p og ammes such as hose o HIV, mala ia and ube culosis can be in eg a ed wi h AMS o sa e esou ces. By con as , in he case o smalle p esc ibing uni s such as single GPs, den is s o o he special ies, a clea AMS leade should be iden i ied o each uni . The wo king g oup highligh ed he c ucial ole o se e al di e en p o essionals wi hin he ou pa ien se ing. GPs a e necessa ily he pi o s o mos AMS ac i i ies in his se ing; howe e , depending on he esou ces and speci ic cha ac e is ics, leading oles can be assigned o o he physicians, a physician’s assis an , an ad anced p ac ice egis e ed nu se o a pha macis . The inclusion o a dis ic pha macis can be a key elemen o deli e messages o pa ien s and physicians, 21,51 especially, bu no only, in low- esou ce se - ings and in coun ies wi h a high p opo ion o unp esc ibed Table 2. Leade ship commi men , accoun abili y and an imic obial s ewa dship eam in he ou pa ien se ing Pa icipan s in he an imic obial s ewa dship eam 1.1. Essen ial The AMS eam should be mul idisciplina y. Co e membe s should include leade s wi h expe ience in AMS and su eillance, a ep esen a i e o pha - macies in he local dis ic and a ep esen a i e o gene al p ac i ione s. 1.2. Desi able Include addi ional igu es in he co e g oup acco ding o he se ing, esou ces and ype o in e en ion (i.e. o he specialis s om a ge wa ds, in ec- ion con ol nu ses and IT expe s). Ins i u ional suppo o he o ganiza ion and managemen o an imic obial s ewa dship p og ammes: legal amewo k 1.3. Essen ial Regula e and p omo e AMS ac i i ies a e e y le el o heal hca e o ganiza ion wi h well-de ined oles, esponsibili ies and a clea go e nance s uc u e. Ins i u ional suppo o he o ganiza ion and managemen o an imic obial s ewa dship p og ammes: s a ing pe sonnel 1.4. Essen ial Include dedica ed ime and speci ic sala y suppo o AMS ac i i ies as pa o AMS p og ammes. 1.5. Essen ial Alloca e ull- ime equi alen s acco ding o na ional equi emen s o he di e en se ings and le el o in e en ion, whe e a ailable. A ie i e al. ii44 Downloaded om h ps://academic.oup.com/jac/a icle/75/Supplemen _2/ii42/6024988 by gues on 10 Feb ua y 2025 an ibio ic sales whe e pha macies and o he p i a e d ug s o es ep esen he p ima y access poin s o an imic obials. 52 O he po- en ial pa ne s, especially in he case o smalle adminis a i e uni s, can be local heal hca e depa men s, heal h insu ance com- panies, heal hca e p o essional socie ies, local mic obiology labo- a o ies and LTCFs. In LMICs, he in eg a ion o AMS e o s in o Table 3. An imic obial usage and an imic obial s ewa dship in he ou pa ien se ing Which an ibio ics should be moni o ed? 2.1. Essen ial Include as minimum equi emen s o moni o ing: - o e all consump ion o an ibio ics - IV and o al an ibio ics used in high olumes o acco ding o he local anking (5–10 mos used agen s) - an imic obials included in he Wa ch and Rese e ca ego ies WHO Essen ial D ug Lis AWARE index - an ibio ics used o ea ing in ec ions caused by locally clinically ele an esis an pa hogens as de ined by he AMS eam 2.2. Desi able Moni o he o al consump ion o sys emic an imic obials (ATC J01 class), bo h IV and o al o mula ions, as o e all agg ega ed da a and as sub- classes o indi idual agen s. 2.3. Desi able S a i y da a by p esc ibing medical special y (i.e. gene al p ac i ione , paedia ician, den is ) o allow o benchma king. Ta ge indica ions/ synd omes o which an ibio ics should be moni o ed: - Respi a o y ac in ec ion (RTI), including uppe and lowe RTI - U ina y ac in ec ion - Dia hoea (depending on local epidemiology and ele ance) - Sexually ansmi ed diseases - Skin and so issue in ec ions Which me ics should be employed? 2.4. Essen ial Fo na ional/ egional su eillance, moni o DDDs pe 1000 inhabi an s pe day and numbe o p esc ip ions pe 1000 inhabi an s pe yea 2.5. Essen ial Fo su eillance a he p esc ibe le el, moni o numbe o p esc ip ions ei he pe 100 pa ien s/yea o 100 pa ien con ac s/yea 2.6. Desi able Fo na ional/ egional su eillance, moni o numbe o p esc ip ions pe 100 physician con ac s/yea 2.7. Desi able Fo su eillance a he p esc ibe le el, moni o DDD pe 100 pa ien s pe yea 2.8. Desi able Fu he me ics should be based on logis ics and he ypes o An imic obial S ewa dship in e en ions ha will be implemen ed; o in e en ions a - ge ing o e -p esc ip ion o speci ic diagnoses, moni o p esc ip ion a e o speci ic diagnoses [p esc ip ion/indica ion/p esc ibe /yea (mon h)]. Repo deli e y 2.9. Essen ial Make local agg ega ed da a a ailable o physician ne wo ks and speci ic p esc ibing uni s. S a i ica ion by special y o indica ion should be done whene e possible. 2.10. Desi able I consump ion da a b oken down by single p esc ibe ac i i y (i.e. numbe o DDDs o p esc ip ions a ibu able o each indi idual gene al p ac i ione o o he p esc ibe s) a e a ailable, deli e hem o he speci ic p esc ibing uni s, making hem a ailable o p esc ibe s and ca egi e s, bu also o adminis a ion. Pe o m u he agg ega ion by special y o s a i ica ion by indica ion whene e possible. Which ime in e al should be used o epo ing? 2.11. Essen ial P o ide an imic obial consump ion da a on a egula basis, a leas annually. 2.12. Desi able The da a should be agg ega ed a leas qua e ly o allow o desc ibing seasonal a ia ion in ends in high-usage indica ions o espi a o y in ec ions. Linking su eillance wi h AMS in he ou pa ien se ing JAC ii45 Downloaded om h ps://academic.oup.com/jac/a icle/75/Supplemen _2/ii42/6024988 by gues on 10 Feb ua y 2025 well-es ablished s uc u es o su eillance and ea men o com- municable diseases such as HIV, mala ia and ube culosis was iden i ied by he panel as a s a egy o use in he implemen a ion o AMS ac i i ies. In e ms o ins i u ional suppo h ough a legal amewo k, he a ailable li e a u e mos ly ocuses on he ele ance o he commi men o public heal h au ho i ies in p omo ing AMS and communica ing wi h pa ien s and heal hca e p o essionals, iden i ying AMS coo dina o s a a local le el and including AMS- ela ed du ies wi hin job desc ip ions. 19,22,25,50 Some coun ies, o example, ha e implemen ed inancial incen i es o p ima y ca e p o ide s. Pay- o -pe o mance sys ems a e implemen ed wi hin he UK’s Na ional Heal h Se ice, he na ional heal h se ice in F ance and he heal hca e sys em in he USA. An imic obial usage and an imic obial s ewa dship The a ailable guidance on AMS in he ou pa ien se ing sugges s moni o ing p esc ip ions o condi ions ypically associa ed wi h a high a e o inapp op ia e p esc ibing wi hou indica ing speci ic pha maceu ical ca ego ies. Cu en ly, mos high-income coun ies and an inc easing numbe o LMICs ha e da a lows om eim- bu semen o sales eco ds ha can p o ide da a o na ional o in e na ional su eillance sys ems. Pe iodic epo s o elec onic ools allow open consul a ion o hese su eillance da a a he coun y o egional le el, 27,31 wi h he addi ional possibili y o acking consump ion o sys emic an ibio ics (ATC J01) in dis inc hospi als and communi ies. In some cases, he da a can be also b oken down o J01 subg oups o o single agen s and p esen ed as absolu e consump ion o single classes o as he a io o b oad- spec um an ibio ics o o al consump ion. An imic obials o he han an ibio ics (e.g. an imycobac e ials, an ipa asi ics) may also be a ailable insome cases. The AWARE index, in oduced by he WHO, appea s o be a p omising globally o ien ed app oach o da a s a i ica ion and e alua ion o pe o mance. 53,54 Mos na ional ac ion plans, as well as he WHO ‘adop AWaRe’ ini ia i e, es ablish goals in e ms o desi able shi s in consump ion (i.e. educ ion o inc ease in con- sump ion o speci ic agen s, classes o o he de ined ca ego ies). Conside ing he in insic need o benchma king and imp o e- men s in acking, he a ge s p oposed by he expe panel a e in ended o p omo e alignmen be ween local and e e al AMU da a. T acking consump ion a he ATC J01 subclass o agen le el ep esen s he mos desi able op ion, bu i s easibili y is es ic ed o well-s uc u ed con ex s such as hospi al ou pa ien clinics o coun ies whe e p ima y ca e se ices a e o ganized on a local basis and include a cen alized pha macy se ice ha is able o main ain a comple e and upda edda a low. Consis en wi h o he human se ings, o he ou pa ien se ing he expe s p oposed a less demanding, bundle app oach as an essen ial a ge , which equi es moni o ing, beyond o e all consump ion, o he mos e- quen ly p esc ibed agen s, including hose in he Wa ch and Rese e ca ego ies o he WHO AWaRe index and o he an ibio ics speci ically indica ed by he AMS eam, conside ing local epidemi- ology (Table3).Thein oduc iono moni o ingo IVan ibio ics (Table 3, a ge 2.1) inds i s a ionale in he g owing implemen a- ion o se ices o IV adminis a ion wi hou hospi al s ay h ough communi y-based managemen , such as ou pa ien pa en e al an imic obial he apy (OPAT). Fo su eillance pu poses, consump- ion in he communi y se ing is epo ed as DDDs pe 100 o 1000 inhabi an s. A p e ious consensus e o , aiming o de elop a se o quan i a i e AMS me ics o be employed in ou pa ien s, highligh ed he need o combine mo e han one me ic o o e - come in insic pi alls and op imize in e p e a ion. 39 Conside ing di e en AMS o ganiza ions and le els o in e en ion, he expe panel p o ides dis inc s epwise app oaches (Table 3, a ge s 2.4– 2.8). Whe e a cen alized pha macy se ice is in place, DDD-based me ics a e easy o ob ain and can be ou inely calcula ed o moni o ing o consump ion, handling cos s and eimbu semen s; in his con ex , ob aining he numbe o p esc ip ions equi es add- i ional wo k and dedica ed esou ces. When ini ia i es o AMS Table 4. An imic obial esis ance and an imic obial s ewa dship in he ou pa ien se ing Which esis an pa hogens should be a ge ed? 3.1. Essen ial Iden i y and moni o mos p edominan esis ance pa e ns among u ina y ac cul u es. How should esis ance be moni o ed? 3.2. Desi able All samples (ob ained inside and ou side he hospi al) should be clea ly ca ego ized in heal hca e-associa ed o communi y-acqui ed samples o allow o isk s a i ica ion and di ec empi ical he apy in ou pa ien and hospi al se ings. Wha ime in e al should be used o epo ing an imic obial esis ance su eillance da a? 3.3. Essen ial P o ide esis ance su eillance da a a leas yea ly, epo ing only da a o which 30 o mo e isola es a e a ailable. Should he epo be deli e ed o heal hca e p o essionals o he han he an imic obial s ewa dship eam? 3.4. Essen ial Deli e a epo o p esc ibing uni s, making hem a ailable o p esc ibe s and ca egi e s, bu also o adminis a ion. 3.5. Desi able Deli e a epo o p esc ibe s wi h a commen a y; conside highligh ing speci ic da a ha migh equi e e-e alua ion o he apeu ic guidelines. A ie i e al. ii46 Downloaded om h ps://academic.oup.com/jac/a icle/75/Supplemen _2/ii42/6024988 by gues on 10 Feb ua y 2025 e o s come om small p esc ibing uni s, simple da abases can eco d he numbe o p esc ip ions o e ime. As a u he s ep, he panel encou ages da a s a i ica ion based on p esc ibe speciali y, and sugges s he acking o p esc ip ions (o e all olumes as well as ela i e consump ion o speci ic an imic obial agen s/classes) ackling high-p io i y condi ions, such as hose o which an ibio ics a e o e p esc ibed (e.g. acu e b onchi is, i al pha yngi is) o a e likely o be ine ec i e due o inc easing esis ance a es [e.g. u in- a y ac in ec ions (UTIs) and sexually ansmi ed diseases]. Al hough his app oach equi es de ailed eco ding o p esc ibing indica ions ha is a ely in place, i s implemen a ion would allow meaning ul benchma king andda a acking imp o emen s. The da a collec ed should be egula ly dissemina ed o admin- is a o s and p esc ibe s (Table 3 a ge s 2.9–2.12). The a o emen- ioned s a i ica ion should be employed o ailo epo s, which should also conside he speci ic in e en ion o be imple- men ed and goals o be pu sued. Regional o local, agg ega ed, popula ion-based da a should be p o ided o inc ease awa eness o p esc ibe s and adminis a o s ega ding he dis ance om bes p ac ice and p og ess made o e ime, as well as o p omo e sha ed e o s wi hin he same a ea and ac oss he con inuum o ca e (e.g. e e al hospi als and su ounding LTCFs). The impo - ance o complemen ing da a dissemina ion wi h s uc u ed edu- ca ional ac i i ies o os e unde s anding and enhancing desi able p esc ibing p ac ice is u he s essed by he panel. De ailed da a o single p esc ibing uni s (small p esc ibe g oups, ambula o y ca e) o indi idual p esc ibe s allow pee compa isons o pe o mance, an app oach ha has been demon- s a ed o be highly e ec i e in ou pa ien AMS. 55,56 To p o ide meaning ul and close- o-p ac ice da a, annual epo ing is sug- ges ed. Qua e ly agg ega ed da a and co esponding epo ing, when olume o use is la ge enough o p o ide eliable da a, has he po en ial o e eal seasonal ends ha wa an u he in es iga ion o speci ic coun e measu es. Sel -medica ion and o e - he-coun e dis ibu ion we e also acknowledged by he membe s o he panel as issues ha can ha e an impo an impac on AMR, especially (bu no only) in LMICs whe e policies egula ing he sale o an imic obials, includ- ing he equi emen o a p esc ip ion o human use, a e no in place. 57,58 Es ima ing he amoun o his dispensing ou e was deemed o be o alue. Howe e , conside ing ha local and na- ional heal hca e au ho i ies a e esponsible o his a he han single p ac i ione s o a local AMS eam ac ing in small p esc ibing uni s, a e discussion he a ge was dele ed om he lis and ou lined as a opic o u u e esea ch (Table 5). An imic obial esis ance and an imic obial s ewa dship Wi h ega d o AMR su eillance, e idence on speci ic pa hogens o be a ge ed in he ou pa ien se ing is limi ed. The majo i y o guidance documen s sugges he acking o an ibio ic esis ance ends among ‘common ou pa ien pa hogens’, communi y- associa ed Clos idioides di icile in ec ions and in ec ion a es wi h ‘mul id ug- esis an o ganisms’ wi hou speci ying which pa ho- gens. 22,38,47,48 This limi a ion is mainly ela ed o he ac ha , in Table 5. Resea ch p io i ies •De elop s anda dized and eliable su eillance de ini ions and ou come da a Ra ionale While c i e ia o disc imina e hospi al- om communi y-acqui ed in ec ions exis , mic obiological samples submi ed om ou pa ien se ings may no e lec he ue o igin o in ec ions. Resis ance a e in he communi y could be o e es ima ed when o e ep esen a ion o samples om pa ien s wi h speci ic isk ac o s (e.g. exposu e o heal hca e acili ies such as day se ice p ac ices, indwelling de ice ca ie s, ecu en in ec ions, e c.) occu s. S anda dized de ini ions allowing unambiguous iews o he mos p obable se ing o in ec ion acquisi ion, u he pa ien -based s a i ica ion c i e ia (e.g. age, gende , speci ic isk ac o ) and he es ablishmen o he minimum numbe o isola es necessa y o p o ide consis - en da a, would help in collec ing mo e eliable su eillance da a o in o m p esc ibing p ac ice and empi ical he apy. •App aise and es ablish new s a egies o AMU su eillance in communi y Ra ionale As cu en me ics and o ma s o AMU moni o ing we e de eloped o su eillance no di ec ly conside ing AMS goals and s a egy, he mos e ec i e me hods o an imic obial consump ion da a collec ion in he communi y se ing s ill ha e o be iden i ied, especially in ega d o i s co - ela ion wi h an imic obial esis ance ends. The easibili y/ eliabili y o poin p e alence su eys (PPSs) o an ibio ic use in he communi y se ing ha e been poo ly explo ed un il now. The assessmen o sel -medica ion and o e - he-coun e dispensing a na ional, egional and local le els ( h ough PPSs o o he sui able me hodologies) would no only p o ide essen ial da a o co ec ly es ima e ac ual an imic obial consump ion, bu would also guide policymake s in es ablishing an imic obial dispensing egula ions. •Gene a e e idence o unde s and he ole o accina ion in AMS Ra ionale Many AMR egula o y documen s and AMS guidance poin ou accina ion as a p omising s a egy o limi AMR. E en hough he a ional o his en- do semen appea s clea , limi ed s udies ha e analysed an imic obial consump ion and esis ance end a ia ions as di ec e ec s o accina ion campaigns o he associa ion be ween accina ion co e age and an imic obial usage and esis ance a e. Mo e e idence is needed on he e ec o accines on an ibio ic use and esis ance. Solid s a is ical ools and adequa e s udy designs o assess such a link should be e alua ed and implemen ed. Linking su eillance wi h AMS in he ou pa ien se ing JAC ii47 Downloaded om h ps://academic.oup.com/jac/a icle/75/Supplemen _2/ii42/6024988 by gues on 10 Feb ua y 2025 he ou pa ien con ex , mic obiological analysis o a ious speci- mens o de e mine pa hogens and ela ed suscep ibili ies is o en imp ac ical. Some e iew documen s ocus on he mos common in ec ions, such as espi a o y ac in ec ions (RTIs) and UTIs. Consequen ly, he mos ele an pa hogens a e S ep ococcus pneumoniae,Haemophilus in luenzae,Mo axella ca a halis, Mycoplasma pneumoniae and En e obac e iaceae. 47 Acknowledging he di icul ies associa ed wi h sample collec ion, he panel conside ed ha moni o ing RTI esis ance in ou pa ien s is no easible, as only a ew samples a e no mally submi ed o mic obiological analysis. Acco dingly, i was decided o ocus on synd omes displaying a g ea e bu den o esis ance, sugges ing ha esis ance be moni o ed only o UTIs (Table 4, a ge 3.1). Ne e heless, he impo ance o ca ego izing all samples (ob ained bo h in and ou o hospi al) in heal hca e-associa ed o communi y-acqui ed se ings o allow isk s a i ica ion and di ec empi ical he apy in ou pa ien and hospi al se ings was unde - lined. Fu he s a i ica ions by gende , age and isk ac o s we e discussed, bu hey we e no included in he inal a ge s due o lack o easibili y and eliabili y. On AMR epo ing, he expe panel ag eed on he ac ha he epo should be deli e ed o all p esc ibing uni s and heal hca e au ho i ies. I should be made a ailable o adminis a ion, p e- sc ibe s, ca egi e s and nu ses o all uni s. The expe panel u he s essed he impo ance no only o passi ely deli e ing a epo , bu also o linking dissemina ion o su eillance da a wi h s uc- u ed educa ional ac i i ies o imp o e unde s anding and d i e clinical p ac ice. Howe e , conside ing possible esou ce con- s ain s, his was held o be desi able and no essen ial ( a ge 3.5). I was also sugges ed ha an English e sion o he epo be included o os e he sha ing o in o ma ion be ween coun ies. Mo eo e , as p e iously ad oca ed, 58 he panel highligh ed he ac ha educa ional e o s should a ge no only physicians, bu also unde g adua e s uden s. In his con ex , he unde g adua e cu iculum could be expanded o allow eaching o he p inciples o mic obiology, in ec ious diseases and clinical pha macology wi h emphasis on AMR and p uden p esc ibing. The a ailable li e a u e did no allow he de elopmen o de ailed indica ions on a ew impo an ques ions ela ed o AMU epo ing and AMR moni o ing and epo ing in he ou pa ien se - ing. The esea ch ques ion ini ially o mula ed o opic 2, ‘Which c i e ia should be used o de ine a anking o an ibio ic use?’, and he esea ch ques ions o opic 3, ‘Should non-clinical samples (e.g. sc eening) be moni o ed?’, ‘Should speci ic h esholds be es ab- lished o d i ing AMS ecommenda ions o empi ical he apy?’ and‘Which s a i ica ion should be used o d i eselec i e epo ing o an ibiog ams?’, should he e o e be conside ed p io i ies o u- u e esea ch. Th ee main esea ch p io i ies including inpu s o policymake s a e summa ized in Table5. Las ly, he panel dis- cussed he impo ance o expanding a simila lis o consensus a - ge s o ube culosis and o he pa hogens ( ungi and i uses) in he u u e. Conclusions The 22 a ge s de eloped he ein we e concep ualized as a lis o p agma ic and b oadly applicable ac ions o guide de elopmen o an AMS p og amme in he ou pa ien se ing. Despi e he in insic limi a ions gi en by he subjec i e na u e o expe opinion me hodology, one s eng h o his wo k is ha he a ge ac ions ha e been p oposed by a b oad panel o p o essionals, encom- passing human and e e ina y medicine in a One Heal h app oach. Ano he s eng h o his wo k is he ca ego iza ion o he a ge ac ions as essen ial (conside ed as he minimum equi emen s) and desi able (ac ions o be conside ed o he u he and op imal implemen a ion o an AMS plan), aking in o accoun low- esou ce se ings, including hose cha ac e ized by lack o quali ied pe son- nel and labo a o y in as uc u e due o budge cons ain s. Acknowledgemen s We a e e y g a e ul o Ru h Joanna Da is o he suppo in he man- agemen o he p ojec , and o Michaela Ha diman and Nadine Conzelmann o hei adminis a i e suppo . Membe s o he ARCH wo king g oup Ayola Akim Adegnika, Cen e de Reche ches Me´dicales de Lamba e´ne´ (CERMEL), Lamba e´ne´, Gabon, and Ins i u u¨ T openmedizin and Ge man Cen e o In ec ion Resea ch, pa ne si e Tu¨bingen, Uni e si a¨ sklinikum, Wilhelms aße, Tu¨bingen, Ge many; Fabiana A ie i, In ec ious Diseases Sec ion, Depa men o Diagnos ics and Public Heal h, Uni e si y o Ve ona, Ve ona, I aly; Ni hya Babu Rajend an, In ec ious Diseases, Depa men o In e nal Medicine I, Tu¨bingen Uni e si y Hospi al, Tu¨bingen, Ge many, and Ge man Cen e o In ec ion Resea ch (DZIF), Clinical Resea ch Uni o heal hca e associa ed in ec- ions, Tu¨bingen, Ge many; Julia Bielicki, Pedia ic In ec ious Diseases, Uni e si y Child en’s Hospi al Basel, Basel, Swi ze land, and Pedia ic In ec ious Disease Resea ch G oup, Ins i u e o In ec ion and Immuni y, S Geo ge’s Uni e si y o London, London, UK; S e en Bo mann, Cen e de Reche ches Me´dicales de Lamba e´ne´ (CERMEL), Lamba e´ne´, Gabon, and Ins i u u¨ T openmedizin and Ge man Cen e o In ec ion Resea ch, pa ne si e Tu¨bingen, Uni e si a¨ sklinikum, Wilhelms aße, Tu¨bingen, Ge many; Elena Ca a a, In ec ious Diseases Sec ion, Depa men o Diagnos ics and Public Heal h, Uni e si y o Ve ona, Ve ona, I aly; Robe o Cauda, Ins i u e o In ec ious Diseases, Fondazione Policlinico Uni e si a io A. Gemelli IRCCS, Uni e si a` Ca olica del Sac o Cuo e, Rome, I aly; Monica Comp i, In ec ious Diseases Sec ion, Depa men o Diagnos ics and Public Heal h, Uni e si y o Ve ona, Ve ona, I aly; Giulia De Angelis, Dipa imen o di Scienze Bio ecnologiche di base, Cliniche In ensi ologiche e Pe iope a o ie, Uni e si a` Ca olica del Sac o Cuo e, Rome, I aly; Raquel Du o, Uni o he P e en ion and Con ol o In ec ion and An imic obial Resis ance, Cen o Hospi ala Uni e si a´ io de S~ ao Jo~ ao, Opo o, Po ugal; Isabel F os , Cen e o Disease Dynamics, Economics & Policy, New Delhi, India; Facul y o Medicine, Depa men o In ec ious Disease, Impe ial College, London, UK; Liliana Galia, In ec ious Diseases Sec ion, Depa men o Diagnos ics and Public Heal h, Uni e si y o Ve ona, Ve ona, I aly; Pe a Gas meie , Ge man Cen e o In ec ion Resea ch Associa ion (DZIF), B aunschweig, Ge many, and Ins i u e o Hygiene and En i onmen al Medicine, Cha i e´ - Uni e si a¨ smedizin Be lin, Ge many, co po a e membe o F eie Uni e si a¨ Be lin, Humbold -Uni e si a¨ zu Be lin, and Be lin Ins i u e o Heal h; Ch is ian Giske, Depa men o Clinical Mic obiology, Ka olinska Uni e si y Hospi al, S ockholm, Sweden; Depa men o Labo a o y Medicine, Ka olinska Uni e si y Hospi al, S ockholm, Sweden; Si i Go¨pel, In ec ious Diseases, Depa men o In e nal Medicine I, Tu¨bingen Uni e si y Hospi al, Tu¨bingen, Ge many, and Ge man Cen e o In ec ion Resea ch (DZIF), Clinical Resea ch Uni o heal hca e associa ed in ec- ions, Tu¨bingen, Ge many; He man Goossens, Depa men o Medical Mic obiology, Vaccine & In ec ious Disease Ins i u e, Uni e si y o An we p, An we p, Belgium; Gunna Kahlme e , Depa men o Clinical Mic obiology, Va¨xjo¨ Cen al Hospi al, Va¨xjo¨, Sweden; Souha S. Kanj, A ie i e al. ii48 Downloaded om h ps://academic.oup.com/jac/a icle/75/Supplemen _2/ii42/6024988 by gues on 10 Feb ua y 2025 Di ision o In ec ious Diseases, Depa men o In e nal medicine, and In ec ion Con ol and P e en ion P og am, and An imic obial S ewa dship P og am, Ame ican Uni e si y o Bei u Medical Cen e , Bei u , Lebanon; Tomisla Kos yane , Depa men o Medical Mic obiology, Vaccine & In ec ious Disease Ins i u e, Uni e si y o An we p, An we p, Belgium; Leona d Leibo ici, Medicine E, Rabin Medical Cen e , Beilinson Hospi al, Pe ah Tik a, Is ael, and Facul y o Medicine, Tel-A i Uni e si y, Tel-A i , Is ael; Jean-Ch is ophe Luce , In ec ion Con ol Uni , Bicha -Claude Be na d Hospi al, AP-HP, Pa is, F ance; IAME, UMR 1137, DeSCID eam, Uni e si e´ Pa is Dide o , So bonne Pa is Ci e´, Pa is, F ance; Lo ena Lo´pez-Ce e o, Mic obiology and In ec ious Diseases Uni , Uni e si y Hospi al Vi gen Maca ena, Se illa, Spain; Rodolphe Made , Uni e si y o Lyon, F ench Agency o Food, En i onmen al and Occupa ional Heal h and Sa e y (ANSES), Labo a o y o Lyon, An imic obial Resis ance and Bac e ial Vi ulence Uni , Lyon, F ance; Ful ia Mazza e i, In ec ious Diseases Sec ion, Depa men o Diagnos ics and Public Heal h, Uni e si y o Ve ona, Ve ona, I aly; Elena Mazzolini, Depa men o Epidemiology, Is i u o Zoop o ila ico Spe imen ale delle Venezie, Legna o, Padua, I aly; Ma c Mendelson, Di ision o In ec ious Diseases and HIV Medicine, Depa men o Medicine, Uni e si y o Cape Town, Cape Town, Sou h A ica; Ri a Mu i, Ins i u e o In ec ious Diseases, Fondazione Policlinico Uni e si a io A. Gemelli IRCCS, Uni e si a` Ca olica del Sac o Cuo e, Rome, I aly; Nico T. Mu e s, Ins i u e o Hygiene and Public Heal h, Bonn Uni e si y Hospi al, Bonn, Ge many; Mical Paul, Diseases Ins i u e, Rambam Heal h Ca e Campus, Ru h and B uce Rappapo Facul y o Medicine, Technion - Is ael Ins i u e o Technology, Hai a, Is ael; Ma ia Dile a Pezzani, In ec ious Diseases Sec ion, Depa men o Diagnos ics and Public Heal h, Uni e si y o Ve ona, Ve ona, I aly; Elisabe h P es e l, Eu opean Commi ee on In ec ion Con ol, Basel, Swi ze land, and Depa men o In ec ion Con ol and Hospi al Epidemiology, Medical Uni e si y o Vienna, Vienna, Aus ia; Hanna Renk, Uni e si y Child en’s Hospi al Tu¨bingen, Depa men o Paedia ic Ca diology, Pulmology and In ensi e Ca e Medicine, Tu¨bingen, Ge many; Oana Sandulescu, Depa men o In ec ious Diseases I, Facul y o Medicine, Ca ol Da ila Uni e si y o Medicine and Pha macy, Bucha es , Na ional Ins i u e o In ec ious Diseases ‘P o . D Ma ei Bals¸’ Bucha es , Romania; Le Huu Song, Vie namese Ge man Cen e o Medical Resea ch, Hanoi, Vie nam, and 108 Mili a y Cen al Hospi al, Hanoi, Vie nam; Mau izio Sanguine i, Dipa imen o di Scienze Bio ecnologiche di base, Cliniche In ensi ologiche e Pe iope a o ie, Uni e si a` Ca olica del Sac o Cuo e, Rome, I aly, and Dipa imen o di Scienze di Labo a o io e In e i ologiche, Fondazione Policlinico Uni e si a io A. Gemelli IRCCS, Rome, I aly; Remco Sch ij e , Ve E ecT, Bil ho en, The Ne he lands; Luigia Scudelle , Scien i ic Di ec ion o IRCCS Ca’ G anda Ospedale Maggio e Policlinico di Milano, Milano, I aly; Mike Sha land, Paedia ic In ec ious Diseases Resea ch G oup, Ins i u e o In ec ion and Immuni y, S Geo ge’s Uni e si y o London, London, UK; Ma cella Sibani, In ec ious Diseases Sec ion, Depa men o Diagnos ics and Public Heal h, Uni e si y o Ve ona, Ve ona, I aly; E elina Tacconelli, In ec ious Diseases Sec ion, Depa men o Diagnos ics and Public Heal h, Uni e si y o Ve ona, Ve ona, I aly, and In ec ious Diseases, Depa men o In e nal Medicine I, Tu¨bingen Uni e si y Hospi al, Tu¨bingen, Ge many, and Ge man Cen e o In ec ion Resea ch (DZIF), Clinical Resea ch Uni o heal hca e associa ed in ec ions, Tu¨bingen, Ge many; Didem To umkuney, In e na ional Fede a ion o Pha maceu ical Manu ac u e s and Associa ions (IFPMA), Gene a, Swi ze land; Thi umalaisamy P. Vela an, Ins i u e o T opical Medicine, Uni e si a¨ sklinikum Tu¨bingen, Ge many, and Vie namese Ge man Cen e o Medical Resea ch, Hanoi, Vie nam, and Facul y o Medicine, Duy Tan Uni e si y, Da Nang, Vie nam; And eas Voss, Depa men o Medical Mic obiology, Radboud Uni e si y Medical Cen e, Nijmegen, The Ne he lands. Funding This esea ch p ojec has ecei ed unding om he Inno a i e Medicines Ini ia i e Join Unde aking unde g an ag eemen No. 115737, esou ces o which a e composed o inancial con ibu ion om he Eu opean Union Se en h F amewo k P og amme (FP7/2007-2013) and Eu opean Fede a ion o Pha maceu ical Indus ies and Associa ions (EFPIA) companies in-kind con ibu ion, and he Ge man Fede al Minis y o Educa ion and Resea ch (BMBF) (P ojec ID 01KI1830) unde he Join P og amme Ini ia i e on An imic obial Resis ance (JPIAMR) 2018 call. T anspa ency decla a ions The au ho s ha e none o decla e. Pa ick Moo e o Ad ia ic Heal h Communica ions p o ided medical w i ing se ices o he edi ing and p oo ing o his pape . This a icle o ms pa o a Supplemen . Re e ences 1Ashi u-O edope D, Hopkins S. An imic obial s ewa dship: English Su eillance P og amme o An imic obial U iliza ion and Resis ance (ESPAUR). J An imic ob Chemo he 2013; 68: 2421–3. 2SudaKJ,HicksLA,Robe sRMe al. An ibio ic expendi u es by medica ion, class, and heal hca e se ing in he Uni ed S a es, 2010-2015. Clin In ec Dis 2018; 66: 185–90. 3English Su eillance P og amme o An imic obial U ilisa ion and Resis ance (ESPAUR) Repo 2018–2019. h ps://asse s.publishing.se ice.go . uk/go e nmen /uploads/sys em/uploads/a achmen _da a/ ile/843129/ English_Su eillance_P og amme_ o _An imic obial_U ilisa ion_and_ Resis ance_2019.pd . 4Mo is AM, Calde wood MS, F idkin SK e al. Resea ch needs in an ibio ic s ewa dship. In ec Con ol Hosp Epidemiol 2019; 40: 1334–43. 5Rod iguez-Bano J, Pe ez-Mo eno MA, Penal a G e al. Ou comes o he PIRASOA p og amme, an an imic obial s ewa dship p og amme imple- men ed in hospi als o he Public Heal h Sys em o Andalusia, Spain: an eco- logic s udy o ime- end analysis. Clin Mic obiol In ec 2020; 26: 358–65. 6D ekonja DM, Filice GA, G ee N e al. An imic obial s ewa dship in ou - pa ien se ings: a sys ema ic e iew. In ec Con ol Hosp Epidemiol 2015; 36: 142–52. 7Be man P. O ganiza ion o ambula o y ca e p o ision: a c i ical de e min- an o heal h sys em pe o mance in de eloping coun ies. Bull Wo ld Heal h O gan 2000; 78: 791–802. 8Cox JA, Vlieghe E, Mendelson M e al. An ibio ic s ewa dship in low- and middle-income coun ies: he same bu di e en ? Clin Mic obiol In ec 2017; 23: 812–8. 9JPIAMR ARCH. h ps://a chne -su eillance.eu/. 10 COMBACTE-MAGNET EPI-Ne . h ps://www.epi-ne .eu. 11 Pezzani MD, Ca a a E, Sibani M e al. Whi e Pape : B idging he gap be ween human and animal su eillance da a, an ibio ic policy and s ewa d- ship in he hospi al sec o —p ac ical guidance om he JPIAMR ARCH and COMBACTE-MAGNET EPI-Ne ne wo ks. JAn imic obChemo he 2020; 75 Suppl 2: ii20–ii32. 12 Pezzani MD, Mazza e i F, Comp i M e al. Linking an imic obial esis ance su eillance o an ibio ic policy in heal hca e se ings: he COMBACTE-Magne EPI-Ne COACH p ojec . J An imic ob Chemo he 2020; 75 Suppl 2: ii2–ii19. 13 Eu opean Join Ac ion An imic obial Resis ance and Heal hca e- Associa ed In ec ions. Deli e able 7.1 (Re 01) Websi e wi h E alua ed Tools and In o ma ion, Guidelines, Tools and Implemen a ion Me hods o An ibio ic S ewa dship. h ps://ec.eu opa.eu/ esea ch/pa icipan s/documen s/down loadPublic?documen Ids=080166e5bed42157&appId=PPGMS Linking su eillance wi h AMS in he ou pa ien se ing JAC ii49 Downloaded om h ps://academic.oup.com/jac/a icle/75/Supplemen _2/ii42/6024988 by gues on 10 Feb ua y 2025 14 Aus alian Commission on Sa e y and Quali y in Heal h Ca e. An imic obial S ewa dship in Aus alian Heal h Ca e. h ps://www.sa e yand quali y.go .au/si es/de aul / iles/mig a ed/AMSAH-Book-WEB-COMPLETE.pd . 15 EU Guidelines o he P uden Use o An imic obials in Human Heal h. h ps://eu -lex.eu opa.eu/legal-con en /EN/TXT/?u i=CELEX%3A52017XC0 701%2801%29 16 Eu opean Cen e o Disease P e en ion and Con ol. P oposal o EU Guidelines on he P uden Use o An imic obials in Humans. h ps://www.ecdc. eu opa.eu/si es/de aul / iles/media/en/publica ions/Publica ions/EU-guide lines-p uden -use-an imic obials.pd . 17 Bielicki J, Lundin R, Pa el S e al. An imic obial s ewa dship o neona es and child en: a global app oach. Pedia In ec Dis J 2015; 34: 311–13. 18 Heal h: Republic o Sou h A ica. Guidelines on Implemen a ion o he An imic obial S a egy in Sou h A ica: One Heal h App oach & Go e nance. h p://nah .co.za/wp-con en /uploads/An imic obial-S ewa dship-Guidelines- Go e nance_June2017.pd . 19 Sanchez GV, Fleming-Du a KE, Robe s RM e al. Co e elemen s o ou - pa ien an ibio ic s ewa dship. MMWR Recomm Rep 2016; 65:1–12. 20 Kilgo e JT, Smi h MJ. Ou pa ien pedia ic an ibio ic use: a sys ema ic e- iew. Cu In ec Dis Rep 2019; 21:14. 21 Saha SK, Hawes L, Mazza D. E ec i eness o in e en ions in ol ing pha - macis s on an ibio ic p esc ibing by gene al p ac i ione s: a sys ema ic e iew and me a-analysis. J An imic ob Chemo he 2019; 74: 1173–81. 22 Cen e s o Disease Con ol and P e en ion. A Field Guide o An ibio ic S ewa dship in Ou pa ien Se ings. h ps://qiop og am.o g/si es/de aul / iles/edi o s/141/C310_Field_Guide_20180730_FNL.pd . 23 Minis y o Heal h Malaysia. P o ocol on An imic obial S ewa dship P og am in Heal hca e Facili ies. h ps://www.pha macy.go .my/ 2/en/docu men s/p o ocol-an imic obial-s ewa dship-p og am-heal hca e- acili ies. h ml. 24 Collie s A, Coenen S, Philips H e al. Op imising he quali y o an ibio ic p esc ibing in ou -o -hou s p ima y ca e in Belgium: a s udy p o ocol o an ac ion esea ch p ojec . BMJ Open 2017; 7: e017522. 25 Ze s RM, S oesz A, Smi h BA e al. Ou pa ien an ibio ic use and he need o inc eased an ibio ic s ewa dship e o s. Pedia ics 2018; 141: e20174124. 26 Na hwani D; B i ish Socie y o An imic obial Chemo he apy. An imic obial S ewa dship om P inciple o P ac ice. 2018. h p://www.bsac. o g.uk/an imic obials ewa dshipebook/BSAC-An imic obialS ewa dship- F omP inciples oP ac ice-eBook.pd . 27 The Cen e o Disease Dynamics, Economics & Policy. The S a e o he Wo ld’s An ibio ics. h ps://cddep.o g/wp-con en /uploads/2017/06/swa_ edi s_9.16.pd . 28 Eu opean Su eillance o An imic obial Consump ion Ne wo k. An imic obial Consump ion—Annual Epidemiological Repo . h ps://www. ecdc.eu opa.eu/si es/de aul / iles/documen s/an imic obial-consump ion-an nual-epidemiological- epo -2017.pd . 29 Johnson AP, Mulle -Pebody B, Budd E e al. Imp o ing eedback o su eil- lance da a on an imic obial consump ion, esis ance and s ewa dship in England: pu ing he da a a you Finge ips. J An imic ob Chemo he 2017; 72: 953–6. 30 An imic obial Use and Resis ance in Aus alia. Thi dAus alianRepo on An imic obial Use and Resis ance in Human Heal h. h ps://www.sa e yand quali y.go .au/si es/de aul / iles/2019-06/AURA-2019-Repo .pd . 31 Schweicke B, Feig M, Schneide M e al. An ibio ic consump ion in Ge many: i s da a o a newly implemen ed web-based ool o local and na- ional su eillance. J An imic ob Chemo he 2018; 73: 3505–15. 32 Sha land M, Pulcini C, Ha ba h S e al. Classi ying an ibio ics in he WHO Essen ial Medicines Lis o op imal use—be AWaRe. Lance In ec Dis 2018; 18: 18–20. 33 F os HM, Kneppe BC, Shihadeh KC e al. A no el app oach o e alua e an ibio ic u iliza ion ac oss he spec um o inpa ien and ambula o y ca e and implica ions o p io i iza ion o an ibio ic s ewa dship e o s. Clin In ec Dis 2020; 1675–82. 34 Yada K,Meeke D,Mis yRDe al. A mul i ace ed in e en ion imp o es p esc ibing o acu e espi a o y in ec ion o adul s and child en in eme - gency depa men and u gen ca e se ings. Acad Eme g Med 2019; 26: 719–31. 35 Ge manos GJ, T au ne BW, Zoo ob RJ e al. No clinical bene i o ea ing male u ina y ac in ec ion longe han se en days: an ou pa ien da abase s udy. Open Fo um In ec Dis 2019; 6: o z216. 36 Guzik J, Pa el G, Ko ha i P e al. An ibio ic p esc ibing o acu e espi a o y in ec ions in New Yo k Ci y: a model o collabo a ion. In ec Con ol Hosp Epidemiol 2018; 39: 1360–6. 37 Jaggi P, Wang L, Gleeson S e al. Ou pa ien an imic obial s ewa dship a ge s o ea men o skin and so - issue in ec ions. In ec Con ol Hosp Epidemiol 2018; 39: 936–40. 38 Klepse ME, Dobson EL, Pogue JM e al. A call o ac ion o ou pa ien an i- bio ic s ewa dship. J Am Pha m Assoc (2003) 2017; 57: 457–63. 39 Ve spo en A, Gyssens IC, Pulcini C e al. Me ics o assess he quan i y o an ibio ic use in he ou pa ien se ing: a sys ema ic e iew ollowed by an in e na ional mul idisciplina y consensus p ocedu e. JAn imic obChemo he 2018; 73: i59–66. 40 Wo ldHeal hO ganiza ion.Moni o ing Global P og ess on Add essing An imic obial Resis ance: Analysis Repo o he Second Round o Resul s o AMR Coun y Sel -Assessmen Su ey. h ps://apps.who.in /i is/handle/10665/ 273128. 41 Zweigne J, Meye E, Gas meie P e al. Ra e o an ibio ic p esc ip ions in Ge man ou pa ien ca e - a e he guidelines ollowed o a e hey s ill exceeded? GMS Hyg In ec Con ol 2018; 13: Doc04. 42 Howa d P, Hu ne B, Beo ic B e al. ESGAP in en o y o a ge indica o s assessing an ibio ic p esc ip ions: a c oss-sec ional su ey. J An imic ob Chemo he 2017; 72: 2910–14. 43 Wang S, Pulcini C, Rabaud C e al. In en o y o an ibio ic s ewa dship p og ams in gene al p ac ice in F ance and ab oad. Med Mal In ec 2015; 45: 111–23. 44 Halli S, Zah eddine L, Saleh N e al. P ac ice o pa en s and pha macis s ega ding an ibio ics use in pedia ics: a 2017 c oss-sec ional s udy in Lebanese communi y pha macies. JE alClinP ac 2020; 26:181–9. 45 Ande son M, Cli C, Schulze K e al. Eu opean Obse a o y Policy B ie s. Copenhagen, Denma k: WHO, 2019. 46 O ganisa ion o Economic Co-ope a ion and De elopmen . E idence Syn hesis Summa y: In e en ions o Add ess An imic obial Use. h ps://www. canada.ca/con en /dam/phac-aspc/documen s/se ices/publica ions/d ugs- heal h-p oduc s/in e en ions-add ess-an imic obial-use/ echnical- epo - in e en ions-eng.pd . 47 Ga au J, Nicolau DP, Wull B e al. An ibio ic s ewa dship challenges in he managemen o communi y-acqui ed in ec ions o p e en ion o escala ing an ibio ic esis ance. J Glob An imic ob Resis 2014; 2: 245–53. 48 Williams PCM, Isaacs D, Be kley JA. An imic obial esis ance among chil- d en in sub-Saha an A ica. Lance In ec Dis 2018; 18: e33–44. 49 Bosso JA, Sieg A, Mauldin PD. Compa ison o hospi alwide and cus om an ibiog ams o clinical isola es o Pseudomonas ae uginosa.Hosp Pha m 2013; 48: 295–301. 50 Aus alian Commission on Sa e y and Quali y in Heal h Ca e. An imic obial S ewa dship in Aus alian Heal h Ca e. 2018. h ps://www.sa e yandquali y.go .au/ou -wo k/an imic obial-s ewa dship/an imic obial-s ew a dship-aus alian-heal h-ca e-2018. 51 Essack S, Bell J, Shepha d A. Communi y pha macis s—leade s o an i- bio ic s ewa dship in espi a o y ac in ec ion. JClinPha mThe 2018; 43: 302–7. A ie i e al. ii50 Downloaded om h ps://academic.oup.com/jac/a icle/75/Supplemen _2/ii42/6024988 by gues on 10 Feb ua y 2025