Action Plan — The Focus Areas:
II. Prevention and Control (Issue A)

Prevention and control of drug-resistant infections require measures to promote the appropriate use of antimicrobial drugs and prevent infection transmission. The concept of appropriate use may be expressed in various other ways, e.g., good antimicrobial stewardship or judicious, prudent, or rational use. In this Action Plan, appropriate antimicrobial drug use is defined as use that maximizes therapeutic impact while minimizing toxicity and the development of resistance. In practice, this means prescribing antimicrobial therapy when and only when beneficial to a patient; targeting therapy to the desired pathogens; and using the appropriate drug, dose, and duration. Appropriate antimicrobial drug use should not be interpreted simply as reduced use because these drugs offer valuable benefits when used appropriately. It is overuse and misuse that must be decreased to reduce the selective pressure favoring the spread of resistance.

Appropriate use can be facilitated in various ways, e.g., by promoting informed prescribing by clinicians, informing consumers about the proper use and limitations of antimicrobial drugs, and improving diagnostic techniques. The challenge facing public health organizations is to work with partners to identify effective methods of promoting appropriate antimicrobial drug use and to translate these interventions into routine medical practice.

Measures to prevent infection transmission, whether drug-resistant or not, are also very important in controlling AR. These measures include the appropriate use of vaccines and infection control, sanitation, hygiene measures, and other safe behaviors, e.g., safe sexual practices. Efforts to control drug-resistant infections must become part of everyday practice in health care settings across the nation, as well as in other settings (e.g., agriculture and veterinary medicine) in which antimicrobial drugs are used. Partners in many sectors of society and the general public will need to be involved in this effort.

A. Issue: Appropriate use of antimicrobial drugs can offer great benefits to patients, but overuse and misuse of these drugs can hasten the development of resistance and shorten the drug's useful life.

1.	Goal: Identify effective methods for promoting appropriate antimicrobial use.
	a.	Action Items
		21.	Identify factors that promote or impede appropriate drug use in hospitals, extended care facilities, and outpatient settings in collaboration with partners (b). Coordinator: CDC Collaborators: FDA, AHRQ, DVA, DoD Timeline: Initiated
		22.	Develop appropriate drug use policies and evaluate the impact (including on prescribing patterns, resistance rates, patient outcome, and cost) of implementing these policies in hospitals and other health care delivery settings. Identify ways to increase adherence to appropriate use policies proven to be beneficial in collaboration with partners (b). Coordinator: CDC Collaborators: AHRQ, FDA, DVA, DoD, HCFA Timeline: Initiated
		23.	Evaluate the relationship between prescribing behavior and specific antimicrobial drug marketing and promotional practices. Assess the public health effects of these practices in collaboration with partners (b). Coordinators: CDC, FDA Timeline: Begin within three to five years
		24.	Help individual hospitals and health care systems analyze how the availability of AR data and computer-assisted decision support systems influences prescriber behavior, health outcomes, and costs. This plan may include the provision of computer software and the establishment of projects that involve the Medicare Peer Review Organizations (PROs). Coordinator: CDC Collaborators: HCFA, DVA, DoD Timeline: Begin within three to five years
2.	Goal: Promote appropriate antimicrobial use through educational and behavioral interventions found to be effective.
	a.	Action Items
		25.	TOP PRIORITY ACTION ITEM — Conduct a public health education campaign to promote appropriate antimicrobial use as a national health priority. The campaign should involve many partners (b). Elements of this campaign may include:
				Culturally appropriate educational and behavioral interventions implemented through community-based programs that target patients and selected populations and communities, such as daycare centers and schools;
				Strategies to improve patient adherence to appropriate therapies;
				A clearinghouse for educational materials (e.g., booklets and CD-ROM presentations) on appropriate drug use and AR prevention;
				A periodically updated priority list of drug-resistant microorganisms in humans and animals; and
				A glossary disseminated through CDC Website that defines technical words commonly used in discussions of AR issues. Coordinators: CDC, FDA Collaborators: USDA, HCFA Timeline: Begin within one to two years
		26.	TOP PRIORITY ACTION ITEM — In collaboration with many partners (b), develop and facilitate the implementation of educational and behavioral interventions that will assist clinicians in appropriate antimicrobial prescribing. Examples may include:
				Educational curricula and training modules for all prescribing clinicians, health professions students, trainees, and senior health care administrators as part of quality assurance programs;
				Clinical guidelines that address appropriate antimicrobial use;
				Informatics technology (e.g., computer-assisted decision support) to assist in point-of-care prescribing and patient outcome monitoring;
				Culturally appropriate materials and methods to help clinicians explain to patients the benefits and limitations of antimicrobial drugs and the importance of appropriate use of these drugs; and
				Material that could be included in licensing, board certification, and credentialing examinations. Coordinators: CDC, FDA
				Consider ways that results of periodic drug use surveys could be made available to food animal producers and veterinarians to encourage participation in data collection Coordinators: CDC, FDA Collaborators: DoD, DVA, HRSA, HCFA Timeline: Initiated
3.	Goal: Promote appropriate antimicrobial use through regulatory changes and public policy actions.
	a.	Action Items
		27.	Explore ways to integrate appropriate use information into antimicrobial package inserts and promotional materials, to provide such information to patients with each prescription, and to provide clear guidance to industry to ensure that promotion of antimicrobials directed towards consumers encourages appropriate use and discourages inappropriate use. Coordinator: FDA Collaborator: CDC Timeline: Initiated
		28.	Articulate factors that support the current approach of requiring prescription-only dispensing for all systemic (i.e., nontopical) antimicrobial drugs used in clinical medicine. Coordinator: FDA Collaborator: CDC Timeline: Begin within one to two years
		29.	Periodically review and update antimicrobial drug susceptibility information included in drug labeling, with input from stakeholders and other experts, e.g., the National Committee for Clinical Laboratory Standards (NCCLS) and CDC. Coordinator: FDA Timeline: Begin within one to two years
		30.	Convene an advisory panel or other expert group involving stakeholders and partners (b) to consider issues related to resistant pathogens that cause serious infections for which available treatment options are very limited or nonexistent. Issues include:
				Criteria for designating such drug-pathogen combinations;
				Compiling and updating a list of such drug-pathogen combinations;
				Recommendations for diagnosis and management of patients with suspected or documented infection, including where appropriate that selected important drugs be preferentially used for the treatment of conditions associated with organisms that are resistant to other drugs;
				Publicizing and facilitating access to clinical trials or compassionate use of investigational therapies;
				Recommendations for preventing infection transmission;
				Recommendations for performance and reporting of susceptibility test results for selected important drugs by clinical laboratories including possibly that they be reported to clinicians only on request if an organism is sensitive to other appropriate drugs;
				Monitoring the use of selected important drugs, with consideration of changes in product labeling by FDA and in recommendations for use if increased resistance is detected; and
				Labeling by FDA of selected important drugs with the recommendation that they be preferentially used for the treatment of conditions associated with organisms that are resistant to other drugs. (Related Action Item: This item will also be considered in conjunction with Product Development #80.) Coordinators: FDA, CDC Timeline: Begin within one to two years
		31.	Convene a working group to examine the impact of federal reimbursement policies for home parenteral antimicrobial treatment, appropriate antimicrobial use, and appropriate use of antimicrobial susceptibility testing. Where needed, the working group will make recommendations for modifying these policies. Coordinator: HCFA Collaborators: CDC, HRSA Timeline: Begin within one to two years
		32.	Develop and submit measures for appropriate antimicrobial use to the National Committee for Quality Assurance for inclusion in Health Plan Employer Data and Information Set (HEDIS), which provides comparative data on managed care organizations. Coordinator: CDC Collaborator: HCFA Timeline: Initiated

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